November 13, 2024
Over the past year, issues emerged that impacted member eligibility and provider payments. We want to acknowledge the negative impact of these issues on those who receive Long-Term Services and Supports (LTSS) and thank members, advocates, and providers for swiftly identifying them.
Our LTSS system was impacted by several challenges at the same time, including:
- County workload demands for medical assistance renewals and new applications for the Supplemental Nutrition Assistance Program (SNAP);
- Issues with the implementation of IT system changes have resulted in additional workload and frustration for case managers; and
- Unanticipated complications with the transition of members to new case management agencies (CMAs) to achieve conflict-free case management.
The impact of all three occurring at once - which was not intended - caused short-term challenges to member eligibility, provider reimbursement, CMA processing and member service response time. The IT innovations and case management redesign modernizations will ultimately create a better system for members, providers and CMAs. In partnership with our stakeholders, the work achieved over the last year to resolve the short-term challenges has significantly moved us closer to this vision.
Our top priority is ensuring ongoing coverage for LTSS members while mitigating payment delays for LTSS providers so members can access needed services. We have identified and put in place short- and long-term solutions to address the most pressing issues. This webpage is updated on a monthly to six week basis to provide stakeholders with information about what has been implemented and what is currently in process to resolve any ongoing challenges.
Protecting Coverage for LTSS Members
- Expedited Backlog Processing
- Approving Eligibility When an LOC is not Current
- Temporarily Pausing Terminations and Mitigating Future Terminations
- Missing Documentations and Verifications
- Address Delays in Disability Determination
Paying Providers Timely to Protect Access to Services
- Provisional Provider Payments
- Prior Authorization Request (PAR) Extension
- Benefit Plan Extension
- Fill in Eligibility Gaps
Identifying and Resolving Known Issues in the CCM
- Known Issue Identification
- Case Management Support Structure
Reducing Case Management and County Backlog
- Address County Backlog
- Implement County Monitoring
- Implement Case Management Agency Monitoring
- Distribute CMA Stabilization Funds
- Allow for Case Management Policy and Program Flexibility
Addressing Appeals and Escalations Backlog
- Address Appeals Backlog
- Address Escalations Backlog
- Improve the Escalation Webform
Protecting Coverage for LTSS Members
Expedited Backlog Processing and Manually Processing Level of Care (LOC) Assessments: In May 2024, the Department of Health Care Policy and Financing (HCPF) started sending unprocessed Level Of Care (LOC) assessments from the Care and Case Management System (CCM) to the eligibility system (CBMS). The unprocessed LOCs are those that were not previously sent from the CCM to CBMS. In addition, we directed our county eligibility partners to request a missing LOC if that LOC was not received through the automated interface with the CCM system. In September 2024, HCPF completed a system change to process the backlog of LOC certification entries in CBMS. Further, in October 2024, HCPF provided a list of all cases that were protected to our county partners so they could request missing information or resolve the case to complete the eligibility process.
Approving Eligibility When an LOC is Not Current: HCPF has implemented a system change to approve eligibility if current members do not have an active Level of Care (LOC) in the eligibility system. HCPF has applied a 12-month extension in our eligibility system to all Long-Term Care (LTC) LOC end dates that are ending as of March 1, 2024 or later. This solution went into effect on April 13, 2024.
Temporarily Pausing Terminations and Mitigating Future Terminations: HCPF temporarily paused terminations for most reasons for LTSS members for two months past the member’s original termination date unless the termination is for a member who has moved out of state or has passed away. Then in March 2024, HCPF began to reinstate eligibility and prevent impacted members from being terminated from Medicaid.
- In January 2025, HCPF will no longer use the manual process that has been in place since March 2024 to reinstate eligibility for all LTSS members when their eligibility is set to end.
- Effective January 1, 2025, HCPF will begin to implement terminations with a temporary pause for 60 days after the termination date for Long-Term Care (LTC), Buy-In Program for Working Adults with Disabilities (WAwD), and Buy-In Program for Children with Disabilities (CBwD).
- This 60-day extension will apply to most termination reasons, not just procedural ones, allowing members extra time to submit their renewal packets with supporting documents and to work with their eligibility technician to resolve any issues with their case. However, there are specific termination reasons that will not be eligible for this 60-day extension, which include:
- Death
- No longer a Colorado resident
- Withdrawal from the program
- Incarceration
- During this period, an initial letter will be sent to members informing them that their termination has been paused, explains the reasons for this pause, and what they need to do.
- Additionally, HCPF will automatically re-evaluate eligibility in the second month of the extension. If a member meets all eligibility requirements and submits the necessary documentation, their ongoing eligibility will be approved. If they do not meet the requirements or fail to provide the required information, their eligibility will terminate at the end of the 60 days.
- Before the end of the 60-day period, members will receive a formal Notice of Action that outlines whether they remain eligible or if their eligibility will end, along with information about their appeal rights.
- If the member is determined to no longer meet eligibility, they are entitled to a 90-day reconsideration period, which begins at the end of eligibility (after the end of the 60-day extension). During this 90-day reconsideration period, if the member is able to submit all of the required paperwork or work with their eligibility technician to resolve any issues with their case and is then deemed eligible, their eligibility will be reinstated for their original termination date.
Missing Documentations and Verifications: If the member's eligibility is still pending due to missing documentation or verifications, county workers may manually implement a pause by applying a Good Faith Extension, further delaying termination until the member’s case can be fully reviewed.
- HCPF reissued guidance to county workers on the Good Faith Extension on March 1, 2024 and will be monitoring this closely to watch for any inappropriate terminations and work to reverse those identified.
Address Delays in Disability Determination: HCPF is addressing backlogs and issues related to obtaining medical records to make disability determinations.
- Action Review Group (ARG) is the contracted vendor partner for the purpose of reviewing and determining Colorado state Disability Determination Applications. ARG has been experiencing a significant backlog of applications for some time. Once made aware of the depth of the situation, HCPF moved quickly to work closely with ARG to bring them into compliance. Both a timeframe and process requirements have been set for ARG to move to a regular cadence of meeting the 60-day contractually required processing time for the elements of the process that are within their control.
- In addition to working with the disability determination vendor, HCPF has also implemented the following strategies:
- HCPF has worked with hospitals to speed up the release of medical records. Electronic fund transfer has been established to expedite payments for medical records needed from hospitals.
- A partnership is also being established with the Regional Accountable Entities (RAEs) to help get medical records for disability applications.
- HCPF launched a new back office team that assists with entering completed determinations to help address the backlog.
Paying Providers Timely to Protect Access to Services
Provisional Provider Payments: HCPF put in place a Provisional Provider Payment to assist providers who were seeing an increase in denied or suspended claims resulting in a lack of payment.
Prior Authorization Request (PAR) Extension: HCPF has implemented a temporary system edit that allows providers to bill for previously approved services even if there is not an active PAR in the system.
- HCPF has instructed providers to bill for all services they have provided to LTSS members back to July 1, 2023, even if an active PAR is not in the HCPF Provider Portal.
- When information is available, HCPF is manually extending PARs for LTSS-eligible members who do not have current PARs.
Benefit Plan Extension: In addition, HCPF is manually creating member benefit plans (e.g., HCBS BI - Brain Injury Waiver) when they are missing. This allows HCPF’s claims payment system to continue to pay for services even if the Case Management Agency has not had the opportunity to provide that information.
- HCPF is pursuing an additional solution to automate updates to the benefit plan which will decrease the system errors that are occurring when there is a mismatch between the information on the benefit plan and the PAR.
Fill in Eligibility Gaps: HCPF manually filled in eligibility gaps for members so providers may be paid. There were approximately 1,200 members who were on Long-Term Care (LTC), had a gap of days to months, then went back to LTC.
- Gaps were due to either losing coverage completely or moving to a lower category and then back to LTC.
- As of June 10, 2024, gaps in coverage for all members who were identified as having a gap have been closed.
Identifying and Resolving Known Issues in the CCM
There are a number of known issues within the newly launched Care and Case Management System (CCM) that are not directly impacting member eligibility or provider payments, but are adding to case managers' workload and contributing to the backlog.
Known Issue Identification: HCPF has identified known issues in the CCM system and is working with the CCM vendor to implement the system changes to ensure the changes meet user requirements and needs.
- Additional funding has been provided to the CCM vendor so they may increase training support, call center staffing, and development staff to help implement system changes faster.
Case Management Support Structure: HCPF implemented an improved Case Management Systems Support structure that will improve the way system changes are communicated, identified and work through open issues quickly. HCPF is partnering with case management agencies to improve overall outcomes for LTSS members and business needs for case managers.
Reducing Case Management and County Backlog
Due to the overlap of all of these converging initiatives and the challenges they have presented, there are significant capacity issues within the Case Management Agencies (CMAs) and county human services agencies. These capacity concerns resulting in backlogs are primarily being experienced in large urban areas.
Address County Backlog: HCPF implemented and is monitoring backlog reduction plans at five large counties (accounting for over 70% of the renewal backlog).
- Backlog reduction plans have an end date of December 2024.
- HCPF will continue to monitor the implementation of these plans to ensure follow-through.
- Three of the five initial counties have made significant progress on their backlogs, with the remaining two continuing their focus on catching up. Additionally, HCPF is now reviewing other counties to ensure they are keeping up with timely renewals and not accumulating backlogs.
Implement County Monitoring: HCPF will monitor county performance against new application contract measures and implement formal improvement action plans as necessary.
Case Management Agency Monitoring - Backlog Reduction: HCPF is monitoring CMA stabilization through monthly data collection and review meetings. Colorado’s largest CMAs, Rocky Mountain Human Services (RMHS), Developmental Pathways (DP), and The Resource Exchange (TRE), each are experiencing a backlog in required case management activities. HCPF has worked with these three CMAs with backlogs to approve individual agency Backlog Reduction Action Plans. View the CMA Backlog Reduction Plans Update for more information about case management backlogs, what HCPF is doing to support CMAs to reduce their backlogs, and to review the three agency’s backlog reduction plans.
Distribute CMA Stabilization Funds: HCPF distributed stabilization funds to support CMAs while they have increased workload and limited capacity.
- More than $27 million was appropriated to support the 15 CMAs who were selected via the formal Request For Proposal (RFP) solicitation process.
- HCPF paid over $23 million directly to CMAs in May 2024 and the remaining payments of $4 million were distributed to the final transitioned CMAs in July 2024.
Allow for Case Management Policy and Program Flexibility: Where possible, HCPF has and will continue to provide flexibility in the requirements of case managers to increase capacity and allow them to prevent or catch up on their backlog.
- HCPF has allowed for virtual assessments to address and mitigate the backlog of Level of Care (LOC) certifications.
Addressing Appeals and Escalations Backlog
The compounding issues listed above are impacting both members’ eligibility and access to services and providers' ability to get paid. HCPF’s ability to manage and address member and provider-specific issues has been impacted by the unexpected and rapidly growing number of appeals and escalation requests. View escalation form
Address Appeals Backlog: HCPF has shifted internal staff responsibilities to increase capacity in appeals.
- Training has been provided to internal staff to be able to handle the intake of new appeals. HCPF is also hiring temporary staff to support the accounting team.
- A new workflow has been designed to help with processing the backlog of decisions from the Office of Administrative Courts.
Address Escalations: HCPF has leveraged the American Rescue Plan Act (ARPA) Home and Community Based Services funds to increase escalations support.
Improve the Escalation Webform: HCPF is working to make updates to the form to make it more member-friendly, and to improve the functionality.
- The Member Grievance form is now available in Spanish. In the webform click “Para espanol, por favor haga clic aqui” to translate.