Home and Community-Based Services for Persons with Intellectual and/or Developmental Disabilities Waiver Programs & Targeted Case Management for Home and Community-Based Services Waiver Programs

• Program Overview: Home and Community-Based Services
  • Persons with Intellectual and/or Developmental Disabilities Waiver (HCBS-DD)
  • Supported Living Services (SLS)
  • Children's Extensive Support (CES)
  • Program Overview: Targeted Case Management (TCM)
• Prior Authorization Requests (PARs)
  • PAR Submission
  • Consumer-Directed Attendant Support Services (CDASS)
• Claim Submission
• HCBS-DD Procedure Code Table
• HCBS-SLS Procedure Code Table
• CES Procedure Code Table
• TCM Procedure Code Table
• HCBS- CES, CHRP, DD and SLS Paper Claim Reference Table
• Timely Filing
• HCBS IDD and TCM for HCBS Waiver Programs Manual Revisions Log

Return to Billing Manuals Web Page

Program Overview: Home and Community-Based Services (HCBS)

The Home and Community-Based Services (HCBS) waiver programs provide Health First Colorado (Colorado's Medicaid program) members who meet special eligibility criteria access to additional services in their homes and communities as an alternative to institutional care. The Home and Community-Based Services programs for persons with intellectual and/or developmental disabilities include:

• Home and Community-Based Services for Persons with Intellectual and/or Developmental Disabilities Waiver (HCBS-DD)
• HCBS-Supported Living Services (HCBS-SLS)
• HCBS-Children's Extensive Support (HCBS-CES)

Level of care determinations are made annually by Contracted Case Management Agencies. Members must meet financial and medical eligibility, as well as program-specific criteria to access services under a waiver. The applicant must be at risk of transition to a nursing facility, hospital, or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). To access waiver benefits, members must be willing to receive services in their homes or communities. A member who receives services through a waiver is also eligible for all basic Health First Colorado covered services except nursing facility, ICF/IID, and long-term hospital care. When a member chooses to receive services under a waiver, the services must be provided by certified Health First Colorado providers.

Applicants may apply for more than one waiver but may only receive services through one waiver at a time.

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Persons with Intellectual and/or Developmental Disabilities Waiver (HCBS-DD)

The HCBS-DD Waiver provides persons with intellectual and/or developmental disabilities access to services and supports 24 hours a day to allow them to a live safely and participate in their community. Services include:

• Residential Habilitation
• Day Habilitation Services and Supports
  • Specialized Habilitation
  • Supported Community Connections
• Prevocational Services
• Supported Employment Services
• Benefits Planning
• Non-Medical Transportation Services
• Behavioral Services (for individuals 21 years of age and older)
• Specialized Medical Equipment and Supplies
• Dental Services (for individuals 21 years of age and older)
• Vision Services (for individuals 21 years of age and older)

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Supported Living Services (SLS)

The HCBS-SLS Waiver provides services and supports to assist persons with intellectual and/or developmental disabilities to live in the person's own home, apartment, family home, or rental unit that qualifies as an SLS setting. Services include:

• Personal Care
• Respite
• Homemaker
  • Basic
  • Enhanced
• Consumer Directed Attendant Support Services (CDASS)
• Mentorship
• Day Habilitation Services
  • Specialized Habilitation
  • Supported Community Connections
  • Prevocational Services
• Supported Employment Services
• Non-Medical Transportation
• Behavioral Services (for individuals 21 years of age and older)
• Professional Services
  • Hippotherapy
  • Movement Therapy
  • Massage Therapy
• Personal Emergency Response System (PERS)
• Home Accessibility Adaptations
• Vehicle Modifications
• Assistive Technology
• Dental Services (for individuals 21 years of age and older)
• Vision Services (for individuals 21 years of age and older)
• Specialized Medical Equipment and Supplies
• Home Delivered Meals
• Life Skills Training
• Peer Mentorship
• Transition Setup
• Remote Supports
• Benefits Planning

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Children's Extensive Support (CES)

The HCBS-CES Waiver is for children ages birth to 18 with intellectual and/or developmental disabilities or for children ages four (4) and under who are at risk of a developmental delay. Services include:

• Respite
• Youth Day Services
• Homemaker
  • Basic
  • Enhanced
• Community Connector
• Professional Services
  • Movement Therapy
  • Massage Therapy
• Specialized Medical Equipment and Supplies
• Adapted Therapeutic Recreational Equipment and Fees
• Home Accessibility Adaptations
• Vehicle Modifications
• Assistive Technology
• Caregiver Education

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Program Overview: Targeted Case Management (TCM)

Targeted Case Management (TCM) is an optional Health First Colorado benefit for members who have been determined by a Contracted Case Management Agency to meet eligibility criteria and are actively enrolled in one of the programs listed below. Member eligibility for this benefit is dependent on whether the member is receiving case management from one of the Department of Health Care Policy & Financing's (the Department) Contracted Case Management Agencies.

Members, by Waiver, eligible for TCM when billed by a Contracted Case Management Agency:

• Brain Injury Waiver (HCBS-BI)
• Children's Extensive Support (HCBS-CES) Waiver
• Children’s Home and Community-Based Services (HCBS-CHCBS) Waiver
• Children with Life Limiting Illness (HCBS-CLLI) Waiver
• Children's Residential Habilitation Program (HCBS-CHRP) Waiver
• Community Mental Health Supports Waiver (HCBS-CMHS)
• Complementary and Integrative Health Waiver (HCBS-CIH)
• Persons with Intellectual and/or Developmental Disabilities (HCBS-DD) Waiver
• Elderly, Blind, and Disabled Waiver (HCBS-EBD)
• Supported Living Services (HCBS-SLS) Waiver

TCM - Per Member/Per Month (PM/PM) services

A component of TCM is paid on a PM/PM basis and requires that Contracted Case Management Agencies must document the provision of a billable activity in the Care and Case Management (CCM) System within ten (10) business days of the provision of that service, ensuring the date of contact is entered correctly. Billable activities include, but are not limited to, the following:

• Development and implementation of a Person-Centered Support Plan,
• Prior Authorization of services identified through assessment and service planning process,
• Development and revision as needed of a Person-Centered Service Plan,
• Referral and related activities to help a member obtain needed services.
• Monitoring and monitoring follow-up activities that are necessary to ensure the Person-Centered Service Plan is implemented and adequately addresses the member's needs.
• Exclusions for TCM include administrative tasks such as mass physical or electronic mailings, as well as automated telephone calls.
• Billing for TCM activities that are paid for by contractual payments are considered duplicative and should be excluded.
• Activities that are not documented within the required timeframes above should not be billed as TCM.

TCM - Monitoring Visits

A separate component of TCM encompasses face-to-face and remote monitoring the quality of services to ensure the member is receiving services in accordance with the service plan, ensure member satisfaction with services, and to ensure the health, safety, and welfare of the member. Rural travel add-ons may only be billed with one of the required, quarterly face-to-face visits if performed in person. Rural travel add-ons may be billed for members residing in counties designated as rural or frontier. Rural add-on may not be billed in conjunction with telephone/virtual monitoring.  This work includes monitoring the effective and efficient provision of services across multiple funding sources.

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Prior Authorization Requests (PARs)

Unless otherwise noted, all HCBS services require prior approval before they can be reimbursed by Health First Colorado. Contracted Case Management Agencies complete the Prior Approval and/or Over Daily PAR requests for their specific programs according to instructions published in regulations. Refer to Appendix A located on the Billing Manuals web page under the Appendices drop-down for the telephone numbers for the aforementioned departments.

Contracted Case Management Agencies transmit electronic HCBS PAR information to the Medicaid Management Information System (interChange) for the HCBS Waivers- through the Bridge subsystem of the interChange.

The CMAs’ responsibilities include, but are not limited to:

• Informing members and/or legal guardian of the functional and target waiver eligibility process.
• Submitting a copy of the approved Level of Care Certification to the County department of human/social services for a Health First Colorado member identification number.
• Developing the appropriate Prior Approval and/or Service Accommodation Request for approval.
• Submitting a copy of the Prior Authorization and/or Cost Containment document to the authorizing agent. Refer to Appendix D located on the Billing Manuals web page under the Appendices drop-down for a list of authorizing agents. 
• Assessing the member's health and social needs.
• Arranging for face-to-face contact with the member within the following timeframes:     
  • Two (2) days for a referral from a hospital
  • Five (5) days for a nursing facility
  • 10 days for all other referrals for long-term services and supports
• Monitoring and evaluating services.
• Reassessing each member.
• Demonstrating continued cost-effectiveness whenever services increase or decrease.

Approval of prior authorization does not guarantee Health First Colorado payment and does not serve as a timely filing waiver. Prior authorization only assures that the approved service is determined to be necessary and is considered a benefit of the Health First Colorado. All claims, including those for prior authorized services, must meet eligibility and claim submission requirements (e.g., timely filing, provider information completed appropriately, required attachments included, etc.) before payment can be made.

Prior approvals must be completed thoroughly and accurately. If an error is noted on an approved request, it should be brought to the attention of the member's case manager for corrections. Procedure codes, quantities, etc., may be changed or entered by the member's case manager at any time during the individual's plan year.

The authorizing agent or Contracted Case Management Agency is responsible for timely submission and distribution of copies of approvals to agencies and providers contracted to provide services.

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PAR Submission

All PARs are submitted via the Bridge, which directly interfaces with the Colorado interChange Medicaid Management Information System. Access to the Bridge is afforded to case managers only and is accomplished via the Medicaid Enterprise User Provisioning System (MEUPS).

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Consumer Directed Attendant Support Services (CDASS)

For members authorized to receive CDASS, case managers will need to enter the data into one of the web-based systems in addition to sending a PAR to the Department's fiscal agent. Members have the option to receive Financial Management Services (FMS) from one (1) of two (2) FMS vendors:

• Palco
• Public Partnerships, LLC (PPL)

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Claim Submission

Submission of claims for services rendered must not be duplicative. Providers cannot be reimbursed for delivering the same service to the same member on the same day at the same time, whether such services are billed on the same claim or on multiple/different claims. Additionally, providers are barred from billing services that share or have overlapping service definitions but are described by different procedure codes on the same day to the same member. Collectively referred to as duplicate claims, reimbursement for such claims requires clear documentation of the necessity of the service and that there was not duplicative service delivery. 

Refer to the service definitions on the Colorado Code of Regulations website to identify if claims are duplicative based on services rendered. Refer to the provider specialty code enrollment requirements on the HCBS Provider Specialty Code List web page to identify services that may be provided by an individual provider. Providers may only bill for services approved in the members’ service plans.

In any instance in which duplicate claim submission results in Medicaid reimbursement, the Department has the authority to recoup funds from providers.

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for general billing information, including claims submission.

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HCBS-DD Procedure Code Table

Providers may bill the following procedure codes for HCBS-DD services:

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HCBS-SLS Procedure Code Table

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CES Procedure Code Table

Providers may bill the following procedure codes for HCBS-CES services:

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TCM Procedure Code Table

Eligible Case Management Agencies may bill the following procedure codes for TCM services. Note that the maximums per service plan year are cumulative.

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HCBS- CES, CHRP, DD and SLS Paper Claim Reference Table

The following paper form reference table describes required fields for the paper CMS 1500 claim form for HCBS-CES, HCBS-CHRP, HCBS-DD and HCBS-SLS claims:

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

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HCBS IDD and TCM for HCBS Waiver Programs Manual Revisions Log