Medicaid Sustainability and Colorado's LTSS System

• Set in statute to sunset next year, this payment was in place to supplement wages prior to the minimum wage in nursing facilities rising above $15.00/hour.
• With this change, the department will end the distribution of the funds one year early.
• Nursing Facility rates will not be impacted by the 1.6% across-the-board (ATB) reduction.

Implementation Date: August 28, 2025 - payments will not go out in Spring 2026

• HCPF will post the updated rate tables on the Provider Rates and Fee Schedule page as soon as possible.
• The historic average Across the Board (ATB) increase in provider reimbursements before COVID, and the related introduction of federal stimulus dollars, averaged 0.62% annually. The ATB provider rate increases from FY 2021-22 to FY 2024-25 ranged from 2-3%, or about 3 to 5 times higher than typical, historic annual ATB rate increases. The 1.6% ATB increase was 2.5 times higher than historic averages.
• Eliminating the 1.6% ATB increase after 3 months (effective October 1) approximates a 0.4% ATB annual increase, which is more in line with the historic 0.62%.

Implementation Date: October 1, 2025

• HCPF is aligning rates based on service scope, training requirements, and comparability to similar services to ensure the sustainability of Colorado’s Medicaid program. (Community Connector has different training requirements than certain licensed services; the rate is being aligned accordingly.)
• Further details are available in Informational Memo 25-025

Expected Implementation Date: January 1, 2026

• Individual Residential Services and Supports (IRSS) is a service available exclusively in the Developmental Disabilities (DD) waiver, offering access to 24/7 residential services.
• IRSS may be provided by rotating shift staff, with a higher rate to account for a higher cost of service provision, or by a primary caregiver who resides with the member, at a lower rate to account for the lower cost of service provision.
• Currently, some providers, due to conflicting Department guidance, are billing the higher rate when the primary caregiver residing with the member is family, even though the cost to provide the service is lower and therefore should be billed at the lower rate.
• The Department intends to change rules to clarify that IRSS provided by a family member who is the primary provider and resides with the member must be billed at the lower rate.
• This change will ensure consistency and equity in how this service is reimbursed.

Expected Implementation Date: After Rules are passed, expected in March 2026

• HCPF will delay the implementation of the LTSS Presumptive Eligibility program, which would have allowed individuals who appear eligible for LTSS to begin receiving a limited number of community-based services while their full Medicaid eligibility determination is pending. Our federal partners have signaled that they will need an additional year to review our proposal; therefore, the Department is leveraging the delay to revert savings.
• This action temporarily postpones program startup and associated expenditures. Given that it has not yet been implemented, there will be no service impacts to members.

Expected Implementation Date: Delay starting October 31, 2025; anticipate final implementation of the program in Summer 2027

• This reduction ends automatic youth-to-adult Developmental Disabilities (DD) waiver transitions for members aging out of Children’s Extensive Supports (CES) or Children’s Habilitation Residential Program (CHRP).
• This change to youth transitions does not affect authorizations onto the DD Waiver through Emergency Enrollment, transfers from institutions, or through child welfare services.

Expected Implementation Date: Pending federal approval; Summer 2026

• This reduction will pause churn enrollments in the DD waiver, reducing them by 50%, resulting in members staying on the waitlist and continuing to receive services under their existing waiver until the pause is lifted.
• This reduction in churn enrollments does not affect authorizations onto the DD Waiver through Emergency Enrollment, transfers from institutions, or child welfare services.

Expected Implementation Date: Pending federal approval; Summer 2026

• HCPF will apply Post-Eligibility Treatment of Income (PETI) for Members enrolled in the DD waiver, bringing it into alignment with other HCBS residential waivers, where Members contribute part of their income toward service costs.
• Aligning the cost sharing requirements in the DD waiver with the income requirements of other HCBS residential waivers will create more equity across residential waivers and contribute to the cost savings needed to sustain Medicaid programs.

Expected Implementation Date: Pending federal approval; Summer 2026

• HCPF will implement a cap on Personal Care, Homemaker, and Health Maintenance Activities (HMA) that will cap annual utilization at approximately 19,000 units for HMA (about 13 hours per day), 10,000 units for Personal Care (about 6.8 hours per day), and 4,500 units for Homemakers (about 3 hours per day).
• There will be an exceptions process for individuals who have a demonstrated need for services above the cap.

Expected Implementation Date: Pending federal approval; Spring 2026

• This reduction will limit paid caregiving services for a member to a maximum of 56 hours per week (8 hours per day) for a single caregiver. The current 16-hour-per-day cap per caregiver will remain in place.
• This limit will impact Home Health Aide, Personal Care, Homemaker, HMA, and Nursing services.

Expected Implementation Date: Pending federal approval; Spring 2026

• This will reduce the homemaker service cap for legally responsible persons from 10 to 5 hours per week.
• Reducing the cap on this service will better align the hours of allowable services with what would be considered outside the typical responsibility of a legally responsible person, better ensuring long-term availability of the option.

Expected Implementation Date: Pending federal approval; Spring 2026

• This reduction will align Movement Therapy rates with the Department’s standardized rate-setting methodology.                                                                                       
• These rate adjustments will ensure consistency with statewide rate review methodologies.

Expected Implementation Date: Pending federal approval; Spring 2026

• HCPF will remove Equine Services from all HCBS waivers due to ongoing system issues delaying implementation.
• Members may still access services through Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) through State Plan and Movement & Expressive Therapies in HCBS waivers.

Expected Implementation Date: Pending federal approval; Summer 2026

• This action will reduce Community Connector's reimbursement to align with the Tier 3 Supported Community Connections rate—approximately $7.71 per 15-minute unit.
• HCPF views the rate cut as necessary for Medicaid cost control, sustainability of the benefit, and more equitable alignment with comparable direct care services.

Expected Implementation Date: Pending federal approval; Spring 2026

• HCPF will reduce the annual cap on Community Connector services by 50%, lowering the maximum allowable units from 2,080 to 1,040 per support plan year under the Children’s Extensive Support (CES) and Children’s Habilitation Residential Program (CHRP).
• This change will reduce Medicaid expenditures associated with excessive utilization while maintaining member access to the service.

Expected Implementation Date: Pending federal approval; Spring 2026

• HCPF requests in R-17 to remove access to Community Connector services for members under six years of age.                                         
• For children under age 6 community engagement is a typical parental responsibility.

Expected Implementation Date: Pending federal approval; Spring/Summer 2026

• HCPF requests in R-15 to implement an acute care period for the Private Duty Nursing (PDN) service.
• In connection with hospital discharges and new admissions to services, PDN may be provided for up to 60 days without a PAR in place.

Expected Implementation Date: Pending federal approval; Early 2027

• HCPF requests in R-15 to update and innovate the Private Duty Nursing (PDN) service by establishing a per-diem blended rate.
• The hourly unit, as well as the individual and group rates, will remain available for use where appropriate. Per diem rates will be utilized when services are provided 24/7. These rates will be based on a blending of RN and CNA components.

Expected Implementation Date: Pending federal approval; Early 2027

• HCPF requests in R-15 to convert LTHH, including CNA and therapy services to new billing durations to better align with actual utilization.
• For Long-Term Home Health, the Department requests to convert LTHH - CNA to a 15-minute billing unit and PT, OT, and SLP/ST services to 30-minute billing units to better align payments with the actual duration of services provided.

Expected Implementation Date: Pending federal approval; Early 2027

• HCPF requests in R-15 to establish group rates for the following services and service delivery options: IHSS, Personal Care, and Homemaker within CFC, and CNA within LTHH.
• This change will allow a single Direct Care Worker (DCW) and/or CNA to serve multiple members of the same household or setting simultaneously.

Expected Implementation Date: Pending federal approval; Early 2027

• HCPF requests in R-15 to develop and implement a new strategy for services that have negotiated rates for the Developmental Disabilities (DD) residential waiver and the Children’s Habilitation Residential Program (CHRP) waiver.

Expected Implementation Date: Spring and Fall 2026

• The state has developed a single assessment tool, the Colorado Single Assessment (CSA), and a corresponding Person Centered Support Plan (PCSP) for all individuals seeking or receiving long-term services and supports (LTSS).
• HCPF is requesting in R-08 ongoing funding for the assessment to true up SB 16-192, which provided the Department with funding for only the first year of the CSA. Because the current roll out plan for the CSA and PCSP is gradual over the first year, this request includes a reduction in funds for year one and a request for funds in subsequent years.

Expected Implementation Date: FY 2026-27