Home and Community Based Services (HCBS) Complementary and Integrative Health (CIH) Manual

The Spinal Cord Waiver (SCI) Waiver changed to the Complementary and Integrative Health (CIH) Waiver July 1, 2022. The use of the term “the SCI Waiver” will be retained in the Benefits Utilization System (BUS), the Colorado Benefits Management System (CBMS), the Bridge, and eligibility verification/benefit plan information maintained in the Colorado interchange Medicaid Management Information System (MMIS) until Phase II of the Care and Case Management system goes live.

• General Information
• Prior Authorization Requests (PARs)
  • PAR Submission
  • PAR Form Instructional Reference Table
• Consumer Directed Attendant Support Services (CDASS)
• Claim Submission
  • Complementary and Integrative Health (CIH) Manual
  • Procedure Code Table
• Paper Claim Reference Table
  • Complementary and Integrative (CIH) Waiver Services
• Timely Filing
• HCBS CIH Manual Revisions Log

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General Information

Waiver programs provide additional Health First Colorado (Colorado's Medicaid program) benefits for specific populations who meet special eligibility criteria.

Level of care determinations are made annually by the case management agencies (aka Single-Entry Points). Members must meet financial, medical, and program criteria to access services under a waiver. The applicant must be at risk of placement in a nursing facility, hospital, or ICF/IID (Intermediate Care Facility for Individuals with an Intellectual Disability). To utilize 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 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 or by a Health First Colorado contracting managed care organization (MCO).

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

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Prior Authorization Requests (PARs)

Unless otherwise noted, all HCBS services require prior approval before they can be reimbursed by the Health First Colorado. Case management agencies/single entry points complete the Prior Approval and/or Cost Containment requests for their specific programs according to instructions published in the regulations for the Department of Health Care Policy and Financing (the Department).

Refer to Appendix A located on the Billing Manuals web page under the Appendices drop-down for telephone numbers.

For the Home and Community Based Services Complementary and Integrative Health (HCBS-CIH) waiver, the following services must be submitted by the case management agency (CMA)/Single-Entry Point (SEP) to the Department for approval:

• All services above cost containment

Providers may contact the CMA/SEP for the status of the PAR or inquire electronically through the Health First Colorado Online Portal.

The CMAs/SEPs responsibilities include, but not limited to:

• Informing members and/or legal guardian of the eligibility process.
• Submitting a copy of the approved Enrollment Form to the County department of human/social services for a Health First Colorado member identification number.
• Developing the appropriate Prior Approval and/or Cost Containment Record Form of services and projected costs for approval.
• Submitting a copy of the Prior Authorization and/or Cost Containment document to the HCPF 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 10 calendar days of receipt of the referral.
• Monitoring and evaluating services.
• Reassessing each member.
• Demonstrating continued cost effectiveness whenever services increase or decrease.

Approval of a 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 a medical necessity and is considered a benefit of 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.

The authorizing agent or case management agency/single entry point 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

The HCBS-CIH forms are electronically filed via the "Bridge" which directly interfaces with the Colorado interChange System. Access to the Bridge is accomplished via the Medicaid Enterprise User Provisioning System (MEUPS). Only case managers may access the Bridge.

This is an electronic process. Paper documents cannot be submitted.

Note: If submitted to the Department's fiscal agent, the following correspondence will not be returned to case managers, outreach will not be performed to fulfill the requests, and all such requests will be recycled: 1) Paper PAR forms 2) PAR revision requests. Should questions arise about what fiscal agent staff can process, contact the appropriate Department benefits manager.

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PAR Form Instructional Reference Table

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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. Duplicate claims are any claims paid across more than one claim number for the same beneficiary, date, procedure code and service state by the same provider. Duplicate claims can include different procedure codes but with overlapping service definitions. Duplicates claims also include a single provider offering more than one service simultaneously. All overlapping services rendered and subsequent billing claims must have supporting documentation that clearly identifies the necessity and non-duplication of overlapping services to verify these services were provided separately and independently of one another.

Refer to the service definitions on the Colorado Code of Regulations website to identify if claims are duplicative. Refer to the provider specialty code enrollment requirements on the HCBS Provider Specialty Code List web page to identify services that must be provided by an individual provider.

In any instance in which duplicate billings result in Medicaid reimbursement, a recovery shall be made by the Department against the provider.

Refer to the General Provider Information Manual for general billing information and claim submission information.

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Complementary and Integrative Health (HCBS-CIH)

The Home and Community-Based Services Complementary and Integrative Health (HCBS-CIH) waiver program provides a variety of services to qualified members with spinal cord injury, brain injury, spina bifida, multiple sclerosis, muscular dystrophy, and cerebral palsy with the inability for independent ambulation as an alternative to an inpatient hospital or nursing facility placement. Members meeting program eligibility requirements are determined functionally eligible for the HCBS-CIH waiver by the case manager.

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Procedure Code Table

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

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Paper Claim Reference Table

The following paper form reference table gives required and/or conditional fields for the paper CMS 1500 claim form for CIH claims:

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Complementary and Integrative (CIH) Waiver Services

The HCBS-CIH waiver program provides a variety of services to eligible members with a spinal cord injury, brain injury, spina bifida, multiple sclerosis, muscular dystrophy, and cerebral palsy with the inability for independent ambulation as an alternative to inpatient hospital and nursing facility placement. Members meeting program eligibility requirements are certified by the case management agency/single entry point as medically eligible for this HCBS waiver program. This waiver offers all of the following services:

• Adult Day Services (Basic) - Services delivered on a tiered basis.
  • Tier I - Services provided virtually or in-person in an outpatient setting to include parks or other community-based locations. Meal provision not required if services are not provided in person or over the lunch hour. Service can be provided up to three hours per day.
  • Tier II - Services provided between three (3) - five (5) or more hours per day as approved by the case manager and in the context of the member's health, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care would be provided as component parts of this service if such services are not being provided in the participant's home.
  • Tier III - Services provided over a full day as approved by the case manager and in the context of the member's health, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care would be provided as component parts of this service if such services are not being provided in the participant's home. Tier I Adult Day Services cannot be provided in conjunction with this service.
• Adult Day Services (Specialized) - Services provided between three (3) - five (5) or more hours per day as approved by the case manager and in the context of the member's health, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care would be provided as component parts of this service if such services are not being provided in the participant's home. Tier I Adult Day Services cannot be provided in conjunction with this service.
• Complementary and Integrative Health Services - Services are limited to Acupuncture, Chiropractic Care, and Massage Therapy. Services are to be delivered under direction of a care plan approved by a Complementary and Integrative Health Service Provider. There is a yearly cap that allows for no more than 408 total units of any combination of services.
• Electronic Monitoring (Personal Emergency Response Systems) - An electronic device, which enables certain individuals at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable help" button to allow for mobility. The system is connected to the person's phone and programmed to signal a response center once a help" button is activated. Monitoring of the device is included in the PERS service. The response center is staffed by trained professionals.
• Electronic Monitoring (Medication Reminder) - Medication reminders are devices, controls, or appliances which enable an individual at high risk of institutionalization to increase their abilities to perform activities of daily living, such as medication administration. Medication reminders shall include devices or items that remind or signal the member to take prescribed medications. Medication reminders may include other devices necessary for the proper functioning of such items and may also include durable and non-durable medical equipment not available as a State plan benefit.
• Homemaker - Services consisting of general household activities (meal preparation and routine household care) provided by a trained homemaker. Provided when the individual regularly responsible for these activities is temporarily absent or unable to manage the home and care for him or herself or others in the home.
• Home Modification - Specific modifications, adaptations or improvements in an eligible member's existing home setting which, based on the member's medical condition are necessary to ensure the health, welfare and safety of the member, enable the member to function with greater independence in the home, are required because of the member's illness, impairment or disability, as documented on the ULTC-100.2 form and the care plan and prevents institutionalization of the member. There is a lifetime cap of $14,000 per member.
• Personal Care - Assistance with eating, bathing, dressing, personal hygiene, activities of daily living. These services may include assistance with preparation of meals but does not include the cost of the meals themselves. When specified in the service plan, this service may also include such housekeeping chores as bed making, dusting and vacuuming. Services are incidental to the care provided or are essential to the health and welfare of the individual, rather than the individual's family. Payment will not be made for services provided to a minor by the child's parent (or stepparent), or to an individual by the person's spouse.
• Relative Personal Care - Personal Care providers may be members of the individual's family. The number of Health First Colorado personal care units for provided by any single member of the member's family shall not exceed the equivalent of 444 personal care units per annual certification. Payment will not be made for services provided to an individual by an individual's spouse employed by a Personal Care agency.
• Remote Supports - Remote Supports service provides live, two (2)-way virtual coaching, supervision and cues from a virtual attendant for everyday activities of daily living that do not require hands-on assistance to be completed safely. These supports can help a member live more independently in their home and community. Services may include prompts and reminders for such needs as dressing, cooking support, overnight support and fall detection. Remote Supports Technology is included to purchase and install devices that support the delivery of Remote Supports.
• Respite - Services provided to an eligible member on a short-term basis because of the absence or need for relief of those persons normally providing the care. The unit of reimbursement shall be a unit of one day for care provided in an Alternative Care Facility. Individual respite providers shall bill according to an hourly rate or daily institutional rate, whichever is less.
• Non-Medical Transportation - Service offered in order to enable individuals served on the waiver to gain access to waiver and other community services, activities and resources, specified by the service plan. This service is offered in addition to medical transportation required under 42 CFR 431.53 and transportation services under the State Plan, defined at 42 CFR 440.170 (a) (if applicable), and shall not replace them. Non-Medical Transportation is limited to two (2) roundtrips per week. Trips to and from Adult Day programs are not subject to this cap.
• Home Delivered Meals - Includes nutritional counseling, planning, preparation, and delivery of meals. Must demonstrate need for the service in Service Plan: demonstrated need for nutritional counseling, meal planning, and preparation, dietary restrictions or specific nutritional needs, unable to prepare their own meals, limited or no outside assistance, inability to access and prepare nutritious meals demonstrates a need-related risk to health, safety or institutionalization. Home Delivered Meals are limited to two (2) meals per day up to 14 meals per week, up to 365 days post-transition.
• Home Delivered Meals - Post Hospitalization – expands the availability of home delivered meals following a 24hr hospitalization providing up to 30 days of meals post discharge two times within a certification period. Members have up to 30 days post discharge to opt in to receive this benefit.
• Life Skills Training - Individualized training, provided in member's residence, the community, or group living situations, that is designed and directed with member to develop and maintain the ability to independently sustain himself/herself in the community. Must demonstrate need for the service in Service Plan: need for training to sustain self in the community, skills for which training is needed and that without poses a risk to the health, safety, or ability to live in the community, without training individual could not develop the skills needed, with training ability to acquire these skills within 365 days. Life Skills Training is limited to up to 24 units per day with no more than 160 units per week, up to 365 days post-transition.
• Peer Mentorship - Provided by peers to promote self-advocacy and encourage community living by instructing and advising on issues and topics related to community living, describing real-world experiences as examples, and modeling successful community living and problem-solving. Must demonstrate the need for the service in Service Plan: need for soft skills, insight, or guidance from a peer, without service may experience a health, safety, or institutional risk, no other services or resources available to meet the need. Peer Mentorship is limited to 24 units per day for 365 days post-transition.
• Transition Setup - Coordination and coverage of one-time, non-recurring expenses to establish a basic household upon transition from nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or Regional Center to a community living arrangement not operated by the state. [Note: This is not available for transition to provider-owned settings (e.g., ACF, Host Home, Group Home, or SLP. This is not available in a community-to-community transition.] Units limited to 40, up to 30 days post-transition.

The HCBS-CIH program also offers the following participant-directed service delivery options:

• Consumer Directed Attendant Support Services (CDASS) - CDASS is a service delivery option that offers HCBS-CIH members the opportunity to direct services that assist an individual in accomplishing activities of daily living including personal care, homemaker and health maintenance tasks. Members may also designate an authorized representative to direct these activities on their behalf. The member, or the authorized representative, is responsible for hiring, training, recruiting, setting wages, scheduling, and in other ways managing the attendant.
• In-Home Support Services (IHSS) - IHSS includes health maintenance activities, support for activities of daily living or instrumental activities of daily living, personal care service and homemaker services. Such services are provided under the direction of the member, or an authorized representative who is designated by the member. Additionally, IHSS providers are required to provide the core independent living skills.

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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 CIH Manual Revisions Log

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