Transition Services FAQ

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What are Transition Services?

A: Transition Services helps any Health First Colorado member who qualifies for services to live effectively in their communities.

Who Qualifies for Transition Services?

A: A Health First Colorado (Colorado's Medicaid Program) member aged 18 or older who lives in a Long-Term Care facility and wishes to return to their community.

Additionally, a Health First Colorado member who is enrolled in one of the six adult Home and Community Based Services (HCBS) Waivers is eligible to participate in Transition Services. For those already enrolled in one of the six HCBS Waiver programs, a qualifying life event is a requirement for eligibility.

What types of facilities are considered long-term care facilities under the Transition Services benefit?

A: A qualified long-term care facility is defined as a nursing home, a Regional Center, or an Intermediate Care Facility for Individuals with Intellectual Disabilities.

What types of settings are considered community settings under the Transition Services benefit?

A: Community settings include a family home, individual home, assisted living residence, group home, host home, or supportive living program. For a member who lives in one of these settings, a qualifying life event is required for eligibility.

What qualifies as a life event for eligibility if a member is not transitioning from a long-term care facility?

A: When a member is experiencing a life transition in a community setting, they will need to access the benefits by working with their HCBS Case Manager. Examples of life transitions include, but are not limited to, the following:

• Person's primary caregiver is no longer able to care for the person receiving HCBS services.
• Person is moving to a less restrictive environment, such as from a group home or Alternative Care Facility, to their own apartment or into a family home.
• Person is moving out of parent's home to live independently in their own apartment.
• Person has recently aged out of the Medicaid programs for children.

The purpose of Transition Services is to support the person in becoming more independent during a period of transition. If this applies to the member's situation, their first step will be to reach out to their HCBS Case Manager to start the conversation about Transition Services.

What services and benefits are available to a member in a long-term care facility?

A: A member interested in moving from a long-term care facility to live independently in the community can access the following State Plan Benefits and HCBS benefits. The HCBS benefits are available after a member has transitioned to the community.

Targeted Case Management - Transition Coordination (TCM-TC)

• Transition Coordination is a Health First Colorado (Colorado's Medicaid Program) State Plan benefit under Targeted Case Management.
• Transition Coordination services are activities essential to move a member from a nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or Regional Center and establish a community-based residence. Services are provided by a Transition Coordination Agency (TCA).
• TCM-TC services facilitate a process to complete a community needs evaluation to identify supports and services the member needs to return to the community from placement in a qualified facility and to aid the member in attaining their transition and independent living goals.

Expanded HCBS Transition Services

• If an individual is eligible for HCBS Waivers once they return to the community, they can access the following expanded HCBS benefits:
  • Life Skills Training: training to help meet a member's physical, emotional, social and economic needs.
  • Home Delivered Meals: meal planning, preparation and delivery, as well as nutrition counseling.
  • Peer Mentorship: support from peers to help a member during their transition to the community.
     
• For a member who is moving from a qualified long-term care facility and is NOT moving into a provider owned setting (group home, host home, assisted living facility, or supportive living program), an additional service called Transition Setup is available. This service can help with one-time expenses to get a member set up in their new household when they transition to a community living arrangement.

Please note, not all services are available under every waiver. The chart below identifies which services are available under each adult waiver. If an HCBS Transition Service is not available under a specific waiver it is because that waiver already has a similar benefit available to waiver participants for the duration of their enrollment in the waiver and is not time limited.

What if a member does not have a place to return to in the community after being in a long-term care facility?

A: The Transition Coordination benefit can help an eligible member apply for rental assistance vouchers through the Colorado Division of Housing (DOH). In addition to help applying for vouchers, a member who qualifies can access housing navigation services to support them in the search for housing in the community that meets their needs.

What services and benefits are available to a member in the community?

Expanded HCBS Transition Services

• A member experiencing a qualifying life event can access the following HCBS benefits:
  • Life Skills Training: training to help meet a member's physical, emotional, social and economic needs.
  • Home Delivered Meals: meal planning, preparation and delivery as well as nutrition counseling.
  • Peer Mentorship: support from peers to help a member during their transition to the community.

Please note, not all services are available under every waiver. The chart below identifies which services are available under each adult waiver. If an HCBS Transition Service is not available under a specific waiver it is because that waiver already has a similar benefit available to waiver participants for the duration of their enrollment in the waiver and is not time limited. The Transition Setup benefit of Transitions Services is not available to any member residing in the community.

Can someone enrolled in the Program of All-Inclusive Care for the Elderly (PACE) access Transition Services?

A:No. A member enrolled in the PACE program cannot receive Transition Coordination from a Transition Coordination Agency as it would duplicate services and supports already available through their PACE program. Members enrolled in PACE who are interested in transitioning back to the community from a facility should contact their PACE provider first to learn about transition services offered through the PACE Program.

If an individual residing in a nursing facility is not enrolled in PACE they can access Transition Coordination to help support their return to the community. If a member decides to enroll in PACE after they return to the community they will not continue to receive any Transition Services, as they are considered a duplication of services provided by the PACE program.

If a member would like more information on their options they can reach out to their local options counseling agency or a social worker in their nursing facility.

How long can a member access services?

For a member residing in a long-term care facility setting:

• The Transition Coordination Agency will work with a member to assess, plan and execute the transition from the long-term care facility to the community. After returning to the community the TCA will support a member based on their needs. If a member needs additional support beyond what is provided, there is a process to request additional support.
   
• Once a member has moved from the long-term care facility to the community, they can access the expanded HCBS services for up to 365 days based on need. Should they have a qualifying life event in the future while living in the community they can access these services again. Additionally, if a member returns to a long-term care facility for any reason they can access these services again when they are ready to return to their community.

For a member residing in the community:

• A member can access services for up to 365 days in the community based on need. Should they have another qualifying life event in the future they can access these services again. Additionally, if a member is admitted to a long-term care facility for any reason, they can access Transition Coordination to support their return to the community.

What happens at the end of 365 days?

A: After 365 days, a member will continue to receive Medicaid services including State Medicaid Benefit Plans and HCBS waiver, if they continue to meet eligibility criteria.

How does a member get started?

Facility to community transitions:

• If a member wants to move from a long-term care facility to the community, the first step is a referral to options counseling. Options counseling is a person-centered approach to helping individuals gain an understanding of the benefits and limitations of long-term services and support options, and the knowledge to access these resources, in order to empower them to make choices that reflect their unique needs, values and circumstances. Anyone can make a referral for options counseling, including a Medicaid member. Referrals to options counseling can be made by:
  • Individual
  • Long-term care facility staff
  • Family members
  • Friends
  • Community members
  • Or anyone else the member interacts with
     
• Long-term care facilities are required to make a referral for options counseling for a member who has indicated they are interested in moving into the community.
   
• Referrals can be directed to the local Options Counseling Agency in a member's area. This information is available in the nursing facility or on the Transition Services website. If a member is interested in learning more about Transition Services they can contact the local Options Counseling Agencies for options counseling in their area by completing this online Medicaid Member Options Counseling Referral Form.
   
• After a referral is made to the local Options Counseling Agency, an options counselor from that agency will contact the member within 10 business days of the referral. The member will work with the options counselor to discuss availability of appropriate services in the community and learn more about community living options.
   
• If the member decides to begin the transition process, they will choose a local Transition Coordination Agency. A list of all agencies is available on the Transition Services website. The agency will connect the member with a Transition Coordinator to help them begin the process.

Community to community transitions:

• A member residing in the community will need to contact their HCBS Case Manager or Case Management Agency when they are experiencing a life changing event in order to access Transition Services. The Case Manager will work with the member to identify, assess and document the need for one or more transition services.

Additional resources

• Targeted Case Management - Transition Services Rule - Colorado Code of Regulations 8.519 and 8.760
• Transition Services - Colorado Code of Regulations 8.553
• Long-Term Services and Supports Glossary
• Transition Coordination Agency List

Last Updated: February 12, 2021