Below are frequently asked questions (FAQ) that the Department of Health Care Policy and Financing (HCPF) has received regarding the Health First Colorado Home Health Benefit.
As we receive additional inquiries from stakeholders, questions of common interest will be added to this webpage with their responses. Please continue to send your questions to HomeHealth@state.co.us or call 303-866-5638.
Page Updated: April 10, 2024
Q: What is the Health First Colorado Home Health Benefit and what does it cover? (4/10/2024)
- A: Health First Colorado is Colorado’s Medicaid program. The Home Health Benefit for Health First Colorado members includes services provided by a licensed and certified Home Health Agency (HHA) to members who need acute or long-term Home Health services. The Health First Colorado Home Health Benefit includes:
- Skilled Nursing provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN)
- Certified Nurse Aide (CNA) services (may also be referred to as a Certified Nursing Assistant or Home Health Aide)
- Physical Therapy (PT)
- Occupational Therapy (OT)
- Speech/Language Pathology (SLP) services or Speech Therapy (ST)
- The need for these services must be documented appropriately by the HHA to be paid as a Health First Colorado Home Health Benefit.
Q: What is the difference between Acute and Long-Term Home Health services under the Health First Colorado Home Health Benefit? (4/10/2024)
- A: Acute Home Health services are skilled and intermittent services provided to members who experience an acute medical condition with a rapid onset and a short duration, such as a new diagnosis, care after a hospital discharge, or an acute incident of a chronic condition. These services are allowed without prior authorization for up to 60 calendar days or until the acute condition is resolved, whichever comes first. A member's primary care provider must send a referral for Home Health services to an HHA of the member's choosing to begin the evaluation and admission process. To find a Home Health Agency (HHA) in your area, search the Find A Doctor webpage by filtering the provider type to “Home Health.”
Long-term Home Health services are skilled services provided to members who require continual Home Health services beyond the acute period for chronic and ongoing conditions. Prior authorization is required for Long-Term Home Health services.
Q: Can I get therapy services in my home? (4/10/2024)
- A: Yes. Therapy services are available for adults age 21 and older during an acute home health episode of care. Pediatric members aged 20 and under may receive long-term home health therapy services when medically necessary. Therapy services can include physical therapy, occupational therapy, and speech therapy that are on the physician-ordered plan of care.
Q: What is the difference between the Health First Colorado Home Health Benefit and the Health First Colorado Private Duty Nursing (PDN) Benefit? (4/10/2024)
- A: The Home Health Benefit provides services to members who need intermittent Home Health services. Intermittent means visits that have a distinct start time and stop time and are task-oriented to meet a member’s specific needs for that visit. These visits include skilled nursing care, Certified Nurse Assistant care, or therapy services. The Private Duty Nursing (PDN) benefit offers skilled nursing services for Health First Colorado members who require more continuous care than what is available with intermittent Home Health services. The Home Health Benefit and the Private Duty Nursing Benefit are available to all ages.
Q: How do Health First Colorado Members get Long-Term Home Health (LTHH) services? (4/10/2024)
A: For adult members 21 or older requiring LTHH services (services required for longer than 61 days), members must work with their local case management agency (CMA) to determine eligibility. Members can collaborate with their case manager to see what other programs, such as non-skilled care (i.e., cooking, cleaning, transportation) they may qualify for.
Children ages 20 and under who are Health First Colorado members can access LTHH services by working with an HHA of their choice. Services available to the pediatric member are determined by completing the Pediatric Assessment Tool (PAT) and working in coordination with their physician to determine a care plan.In addition, members can contact their assigned Regional Accountable Organization which can assist with care coordination and finding resources.
Q: Do I have to be homebound to get Health First Colorado Home Health Benefits? (4/10/2024)
- A: No. Home Health services can be provided in the member’s residence or in any setting where normal life activities occur. This includes at work, in the community, at Assisted Living or Alternative Care Facilities, or hotels or temporary accommodations while traveling.
Q: Can Health First Colorado Home Health visits be done through telemedicine? (4/10/2024)
A: Yes. Telemedicine visits can be provided in addition to what is being provided in person. Telemedicine visits cannot be used if services are needed in-person or hands-on assessments as described in the care plan.
The requirements for certain assessments, such as admissions assessments or recertifications, including home safety evaluation, the condition of the patient, and the identification of care needs and services, cannot be assessed virtually. Supervisory visits are also required to be performed by the Home Health Agency for staff working in the home and must be performed in person.
More information on telemedicine requirements can be found in the Telemedicine Billing Manual. For details about telehealth monitoring under the Home Health Benefit, please review the Home Health Billing Manual and/or the Home Health rules for telehealth 10 CCR 2505-10 8.520.5.D.
Q: Are prior authorizations required for the Health First Colorado Home Health Benefit? (4/10/2024)
- A: Yes. A Prior Authorization Request, or PAR, is the process by which a Home Health Agency (HHA) receives validation that the requested services are medically necessary and appropriate for a particular member and that the service category is covered. PARs are required to ensure Health First Colorado complies with Federal and State regulations, which require states to pay only for services that are Medicaid benefits and medically necessary.
While Acute Home Health does not require a PAR, conditions warranting Home Health services for 61 days or more are considered Long-Term Home Health and require a PAR.
Q: Can I still have Health First Colorado Home Health services if I am on a Home and Community-Based Services (HCBS) waiver? (4/10/2024)
A: Yes. Home Health services are a benefit of the State plan and are available to all Health First Colorado Members who qualify. HCBS waiver services cannot duplicate services available under Colorado’s State Plan, including Home Health services.
Members who utilize Consumer Directed Attendant Support Services (CDASS) on any HCBS waiver are not eligible for Long-Term Home Health services but may utilize Acute Home Health services should the medical need arise.
Certified Nursing Assistant (CNA) services are included in the rate for Group Residential Support Services (GRSS) and Individual Residential Services and Supports (IRSS) are not reimbursable under the Health First Colorado Home Health Benefit.
Q: What tasks are NOT included under the Health First Colorado Home Health Benefit? (4/10/2024)
- A: While we can not provide a list of every task that may or may not be included under the benefit, below are examples of tasks and/or services that are commonly requested and found not to be a part of the Home Health Benefit.
- Nursing or CNA visits that are provided in a shift (visits lasting more than 4.5 hours in a row).
- Nursing or CNA visits for the purpose of psychiatric counseling, behavior management, or protective oversight.
- CNA visits for the purpose of providing only unskilled personal care and/or homemaking services.
- Tasks that are considered as personal care or homemaking services.
- Nursing visits that are for the sole purpose of providing supervision of the CNA or other HHA staff and/or completing administrative tasks such as agency paperwork.
- Long-Term Home Health nursing visits for the sole purpose of teaching the member or their family member/caregiver.
- Long-Term Home Health nursing visit to assess a stable member.
- Two HHA staff during one visit; except when required to perform a procedure safely.
- Adult members using Home Health services have a daily cap of services that can be provided in the home. That amount can be found on the Fee Schedule listed under Home Health.
Q: Can I be the Certified Nurse Assistant (CNA) for my own child? (4/10/2024)
A: Yes. This arrangement is allowed under the Health First Colorado Home Health Benefit. This allowance is not a separate program under the benefit. Colorado allows family members who meet the qualifications and are licensed as CNAs to be hired by a Home Health Agency to provide approved care for a member.
A parent who is also the nurse or CNA for their child must meet requirements as outlined in the Colorado Code of Regulations 10 CCR 2505-10 8.520 and include:
- Have a license and/or credential active with the Department of Regulatory Agencies (DORA) as an RN/LPN or a CNA.
- Be employed with a Home Health Agency that is enrolled as a Health First Colorado provider.
- Parents must only be reimbursed for services that exceed the usual responsibilities of the family member.
- A child must be enrolled and eligible for Health First Colorado to qualify for services. Additionally, the child must qualify for the Home Health Benefit in order to receive CNA and/or nursing services. See How do Health First Colorado Members get LTHH services?
- For additional resources, visit the CDPHE website or the Home Health webpage.
Q: Where can I find information regarding tax exemptions for family caregivers? (4/10/2024)
A: On January 3, 2014, the Internal Revenue Service issued Notice 2014-7, 2014-4 I.R.B. 445. Certain income tax exclusions in this notice were outlined but are specific to waiver payments. The Health First Colorado Home Health Benefit, which includes CNA services, can be received in the home as part of Colorado's State Plan and is not exclusive of a specific waiver. Colorado does not currently have an exemption under any SSA provisions for non-waiver programs.
The Health First Colorado Home Health Benefit is available to all Health First Colorado members who qualify. Members who receive Home Health may also be enrolled on other waivers. Whether the IRS will treat income as excludable depends on the nature of the payments and the program's purpose in which services are provided. Therefore, qualifications for this IRS exclusion depend on each member's situation.
Additional information can be found on the IRS website.Note that HCPF cannot provide tax advice or interpret IRS guidelines for specific member situations.
Q: Can my child receive Synagis® injections at home? (4/10/2024)
A: Home administration of Synagis® is limited to members approved for the Health First Colorado Home Health Benefit, including those newly enrolled or members already receiving Home Health services. This means that members cannot get Synagis® under the Health First Colorado Home Health Benefit unless they would otherwise qualify for this service, absent the need for Synagis®.
The Home Health Agency (HHA) administration of the Synagis® injections is done in compliance with Colorado Rules and Regulations. The number of visits the HHA provides to administer Synagis® should equal the number of Synagis® doses the physician or allowed practitioner has ordered. The HHA will bill for administration, not for Synagis® itself. Synagis® will be billed through the pharmacy. These visits cannot exceed five (5) standard registered nurse (RN) visits.
Q: What is the Pediatric Assessment Tool and why was it developed? (4/10/2024)
- A: The Pediatric Assessment Tool (PAT) was developed in response to stakeholder feedback that objective criteria were needed to assess pediatric Home Health service needs. The tool was crafted with input from a team of developmental pediatricians and tailored to capture pediatric-specific service needs. The PAT determines which service needs are medically necessary. HCPF worked with members, families, Home Health Agencies, and other stakeholders to develop this tool to determine medical necessity to meet federal requirements.
Q: What does “Medical Necessity” mean? (4/10/2024)
- A: The terms “Medical Necessity,” and “Medically Necessary,” have the same meaning. Medical necessity means goods or services that are:
- For the purpose of evaluating, diagnosing, or treating an illness, injury, disability, disease, or its symptoms;
- Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease; and
- Not primarily for the economic benefit or convenience of the member, member’s family, physician, or other providers; and
- For the purposes of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living.
- Additional information on medical necessity definitions can be found in Program Integrity Rules 10 CCR 2505-10 8.076.1.8. This is further defined for children 20 and younger to include the requirements outlined in the EPSDT rules 10 CCR 2505-10 8.280.1.
Q: What's the difference between "medically necessary services" and "unskilled services"? (4/10/2024)
- A: Medical Necessity means a Medical Assistance program good or service as defined in Program Integrity rules 10 CCR 2505-10 8.076.1.8. For children 20 and younger, this is further defined to include the requirements outlined in the Early and Periodic Screening, Diagnosis, and Treatment rules 10 CCR 2505-10 8.280.1. To summarize these rules, medically necessary Home Health services are skilled medical services that must be provided by licensed/registered medical personnel, such as Certified Nursing Assistants (CNAs) or nurses. The medical service provided is to treat a medical condition, not for personal support.
Unskilled services or personal care services are not medical services to treat a medical condition; instead, they help support the individual in other ways. They can be provided by non-medical personnel. These services do not require the supervision of a nurse and do not require a physician’s order. Unskilled services include services such as protective oversight and precautionary measures taken to prevent harm or injury and assisting with tasks that members can do with minimal to no assistance. More information on these services can be found in the Personal Care rules 10 CCR 2505-10 8.489.11.