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Money Follows the Person (MFP)

MFP Demonstration     Referral Process     Capacity Building Grant     Transitions Stakeholder Advisory Council     Resources     Contact Us

Money Follows the Person (MFP) is a Federal grant program that creates a path to community living for people living in Medicaid Long-Term Care (LTC) facilities. In August 2023, HCPF received an award of a $43 million Money Follows the Person (MFP) demonstration grant from the Centers for Medicare and Medicaid Services (CMS). This award represents a culmination of efforts that include the State’s former MFP demonstration, Colorado Choice Transitions (CCT), and the implementation of permanent Transition Services resulting from House Bill 18-1326 in January 2019. In collaboration with local, State, and Federal partners, the Department of Health Care Policy and Financing (HCPF) will implement the new MFP demonstration to expand services and supports available to people who wish to live in the community.

To be eligible for MFP a person must reside in a Medicaid Nursing Facility (NF), Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID), or Regional Center (RC) for 60 days or more with a desire to move to the community. 

Colorado MFP Demonstration

The demonstration grant offers HCPF a unique opportunity to build upon existing Transition Services by expanding Targeted Case Management-Transition Coordination (TCM-TC) and adding MFP Supplemental Services to holistically address social determinants of health. Demonstration of TCM-TC will offer the resource to members for 365 days following discharge from an LTC facility. Currently, members receive TCM-TC for a limited time following discharge based on need and service authorization limits. Where one unit equals fifteen minutes, TCM-TC members will be eligible to receive 360 units per transition. The goal of the demonstration is to increase continuity of care, lessen isolation, and ensure the long-term success of community living.

MFP Supplemental Services will offer person-centered support to address social determinants of health and help members acclimate to community living while they still reside in an LTC facility. The MFP Supplemental Services created under Colorado’s demonstration will include:

  • Environmental Adaptations to provide home modifications prior to discharge
    • Allows a member to enhance accessibility to their home through modifications such as widened doorways, the construction of ramps, or adaptations to the bathroom or kitchen
       
  • Peer mentorship prior to discharge
    • Provides members with support from someone with lived experience to build awareness of resources available to assist with community living
       
  • Short-term rental assistance
    • Provides members with rental support including rental arrears, utility start-up costs, security deposits, etc.
       
  • Pre-tenancy support 
    • Helps members learn about the requirements to access and maintain community housing
       
  • Short-term food assistance
    • Provides members with payment for food pantry items for up to 30 days following discharge
       
  • Operational Protocol Final HCPF Response
    • The Operational Protocol is a required document for the Money Follows the Person Demonstration. It provides information for CMS, other federal or State officials, and external stakeholders to understand the operation of the demonstration.
       
  • MFP Award Letter

 

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MFP Referral Process

The process to access and participate in the MFP demonstration begins with Options Counseling. Options Counseling provides a thorough review of the resources available for community living and initiates the referral to MFP for those interested in transitioning to the community from an LTC facility. HCPF administers contracts with local contact agencies (LCA) to provide Options Counseling to residents in the State’s Medicaid Nursing Facilities.

There are several ways to initiate a referral to a local contact agency for Options Counseling.

HCPF’s Medicaid Transition to Community Request Form provides an online platform for referrals to be submitted to the LCA by the member, professional organizations, or anyone acting on the member’s behalf. The form is also available on the Transition Services website. When completed correctly, referrals are automatically routed to the appropriate LCA for Options Counseling.

The Minimum Data Set (MDS), is a Federally mandated comprehensive assessment conducted with all NF residents. The assessment includes a section that addresses whether a member is interested in community living, and if the response is ‘Yes’ a referral is made to the LCA for Options Counseling.

Outside of administration of the MDS, referrals can be made on behalf of the member by the nursing facility. This may occur if the member communicates to NF staff or the social worker that they are interested in community living, and referrals can be made by submitting the Medicaid Transition to Community Request Form or directly to the LCA.

Community referrals can also come from a variety of sources. A family member, friend, advocate, provider, or someone else involved in the member’s life can all make referrals on the member's behalf. They can do so by completing the Medicaid Transition to Community Request Form, contacting the NF social worker to initiate a referral, or contacting an LCA directly. Pre-Admission Screening and Resident Review Program or PASRR is a federally required tool used in Nursing Facility admissions. In Colorado, it is used as a referral point for Transition Services.
 

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MFP Capacity Building Grant

In August 2021, HCPF was awarded $5 million by the Centers for Medicare and Medicaid Services (CMS) under the Money Follows the Person (MFP) Supplemental Capacity Building grant. This grant represents further investment in the services and supports implemented under HB 18-1326 by HCPF. Colorado’s grant proposal is designed to focus on innovative solutions that streamline access to Health First Colorado benefits.

A core component of Colorado’s proposal is the creation of a Capacity Building Grant made available to eligible transition services agencies. This is a competitive grant opportunity for community organizations to focus on streamlining access to services, increasing service capacity, and developing innovative solutions to overcome local barriers. 

The request for application (RFA) process ended in February 2024. Submissions were reviewed, and awardees selected. Organizations will have one year to implement solutions and work with the State to inform recommendations for long-term policy solutions. Grant closeout will include final reports from awardees that will be leveraged by HCPF while making policy decisions related to program and/or systems improvements.

Grantee Monthly Check-In Meetings

Meetings occur monthly on the third Tuesday of the month from 10 to 11 a.m.

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Transitions Stakeholder Advisory Council (TSAC)

The Transitions Stakeholder Advisory Council (TSAC) is a public forum convened monthly to discuss MFP and transition-related issues. The meeting comprises representation from individuals and stakeholders throughout the statewide LTSS community. The council is co-chaired by a representative from the community to promote council goals that are shared and community-driven. 

The TSAC goal is to build program awareness, support ongoing collaboration, identify gaps, and discuss recommendations to manage shared resources effectively. The agenda is planned in advance and shared each month via email to the Office of Community Living’s Constant Contact List. If you are interested in attending the meeting or joining the council as a member or public participant, please email hcpf_accessunit@state.co.us for more information.

Sign up to receive Office of Community Living Communications
 

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Resources

Contact Us

hcpf_accessunit@state.co.us

The MFP demonstration is supported by Funding Opportunity Number 1LICMS330819 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
 

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