Tracking# 2011-00779
FA/P 12/2/11, eff. 2/1/12 

I:/11072901.rtf
[I:/11072901.doc]

(2 CCR 503-1)

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Revision of Section 16.120 and addition of Sections 16.650-16.654 were adopted following publication at the 12/2/2011 State Board of Human Services rule-making session, with an effective date of 2/1/2012 (Rule-making# 11-7-29-1). Statement of Basis Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Colorado Department of Human Services, Office of Enterprise Partnerships, Division of Boards and Commissions, State Board Administration.

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16.120  DEFINITIONS [Rev. eff. 2/1/12]

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“Algorithm” means a formula that establishes a set of rules that precisely defines a sequence of operations.  An algorithm is used to assign clients into one of six support levels in the Home and Community Based Services for Persons with Developmental Disabilities (HCBS-DD) and Home and Community Based Services–Supported Living Services (HCBS-SLS) waivers. 

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“Case Management Agency” (CMA) means a Community Centered Board within a designated service area where an applicant or client can obtain case management services. 

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“Client” means an individual who has met Long Term Care (LTC) eligibility requirements and has been offered and agreed to receive Home and Community Based Services (HCBS) in the Children’s Extensive Supports (HCBS-CES) waiver, the HCBS waiver for Persons with Developmental Disabilities (HCBS-DD) or the Supported Living Services (HCBS-SLS) waiver.

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“Extreme Safety Risk to Self” means a factor in addition to specific Supports Intensity Scale (SIS) scores that is considered in the calculation of a client’s support level. This factor shall be identified when a client: 
A.  Displays self-destructiveness related to self-injury, suicide attempts or other similar behaviors that seriously threaten the client’s safety; and,  
B.  Has a rights suspension in accordance with Section 16.312 or has a court order that imposes line of sight supervision unless the client is in a controlled environment that limits the ability of the client to harm himself or herself. 

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“Public Safety Risk-Convicted” means a factor in addition to specific SIS scores that is considered in the calculation of a client’s support level. This factor shall be identified when a client has: 
A.  Been found guilty through the criminal justice system for a criminal action involving harm to another person or arson and who continues to pose a current risk of repeating a similar serious action; and, 
B.  A rights suspension in accordance with Section 16.312 or through parole or probation, or a court order that imposes line of sight supervision unless the client is in a controlled environment that limits his or her ability to engage in the behaviors that pose a risk or to leave the controlled environment unsupervised. 
“Public Safety Risk-Not Convicted” means a factor in addition to specific SIS scores that is considered in the calculation of a client’s support level. This factor shall be identified when a client has: 
A.  Not been found guilty through the criminal justice system, but who does pose a current and serious risk of committing actions involving harm to another person or arson; and, 
B.  A rights suspension in accordance with Section 16.312 or through parole or probation, or a court order that imposes line of sight supervision unless the client is in a controlled environment that limits his or her ability to engage in the behaviors that pose a risk or to leave the controlled environment unsupervised. 
“Rate” means the amount of money, determined by a standardized rate setting methodology, reimbursed for each unit of a defined waiver service provided to a client by a qualified provider. 

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“Respondent” means a person participating in the SIS assessment who has known the client for at least three months and has knowledge of the client’s skills and abilities. The respondent must have recently observed the person directly in one or more places such as home, work, or in the community.

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“Service Plan Authorization Limit” (SPAL) means an annual upper payment limit of total funds available to purchase services to meet the client’s ongoing needs. Purchase of services not subject to the SPAL are in accordance with the Department of Health Care Policy and Financing rules in Section 8.500.102, B (10 CCR 2505-10). A specific limit is assigned to each of the six support levels in the HCBS-SLS waiver. The SPAL is determined by the Department based on the annual appropriation for the HCBS-SLS waiver, the number of clients in each level, and projected utilization. 
“SIS Interviewer” means an individual formally trained in the administration and implementation of the Supports Intensity Scale by a Department approved trainer using the Department approved curriculum. SIS Interviewers must maintain a standard for conducting SIS assessments as measured through periodic interviewer reliability reviews. 

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“Supports Intensity Scale” (SIS) means the standardized assessment tool published in 2004 by the American Association on Intellectual and Developmental Disabilities. The assessment gathers information from a semi-structured interview of respondents who know the client well. It is designed to identify and measure the practical support requirements of adults with developmental disabilities. No later editions or amendments are included. Copies may be obtained or examined by contacting the Case Management Specialist, Colorado Department of Human Services, Division for Developmental Disabilities, 4055 South Lowell Blvd., Denver, Colorado 80236; or any State Publications Depository Library; and also available at: http://www2.ed.gov/policy/elsec/leg/esea02/index.html. 
“Support Level” means a numeric value determined using an algorithm that places clients into groups with other clients who have similar overall support needs. 

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“Waiver Services” means those optional Medicaid services defined in the current federally approved HCBS waiver document and do not include Medicaid State Plan services.
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16.650  SUPPORTS INTENSITY SCALE ASSESSMENT AND SUPPORT LEVELS 
16.651  Supports Intensity Scale (SIS) Assessment [Eff. 2/1/12]
A.  Completion of a Supports Intensity Scale (SIS) Assessment is a requirement for a client to participate in the Home and Community Based Services-Supported Living Services (HCBS-SLS) or the Home and Community Based Services for Persons with Developmental Disabilities (HCBS-DD) waiver. A client or his or her guardian refusing to have a SIS assessment shall not be enrolled in the HCBS-SLS or HCBS-DD waivers. 
B.  Specific scores from the client’s SIS assessment shall be used in addition to other factors to obtain the client’s Support Level in the HCBS-DD and HCBS-SLS waivers. 
C.  The Case Management Agency (CMA) shall conduct a SIS assessment for a client at the time of enrollment. Additional assessments will be conducted at a frequency determined by the Department. 
D.  The CMA shall: 
1.  Notify the client, his or her legal guardian, authorized representative, or family member, as appropriate, of the requirement for and the right to participate in the SIS assessment. 
2.  Support and encourage the client to participate in the SIS assessment. If the client chooses not to participate in the SIS assessment, the CMA shall document his or her choice in the client record on the Department required data system. 
3.  Schedule a SIS Interviewer to conduct the assessment. If the client, his or her legal guardian, authorized representative, or family member, as appropriate, objects to the assigned SIS Interviewer, he or she shall be offered a choice of a different SIS Interviewer. 
4.  Assist the client or other interdisciplinary team (IDT) members to identify at least two people who know the client well enough to act as respondents for the SIS assessment. If at least two respondents cannot be identified, the CMA shall document the efforts to find two respondents and the reasons this could not be done, and proceed with the assessment using the information available. 
E.  A qualified SIS Interviewer shall conduct the assessment. A SIS Interviewer shall not act as the respondent for a SIS assessment. 
F.  The CMA shall inform the client, his or her legal guardian, authorized representative, or family member, as appropriate, of the purpose of the SIS, the SIS Complaint Process, the Support Level Review Process, and that he or she may receive a copy of the completed SIS assessment upon request. The CMA shall document that this information was provided and received on the SIS and Support Level disclosure form. 
G.  After the initial SIS assessment has been completed, the CMA shall conduct another SIS assessment for the client only when approved by the Department through the following process: 
1.  Prior to a subsequent SIS assessment being conducted, the CMA shall submit a request to the Department for approval in the format prescribed by the Department. 
2.  The Department shall provide the CMA with a written decision regarding the request to conduct another SIS assessment within fifteen (15) business days after the date the request was received. 
3.  If the client, his or her legal guardian, authorized representative or family member, as appropriate, disagrees with the decision, then a request for review of the decision may be submitted within fifteen (15) business days after the date the decision was received by the Executive Director of the Department or his or her designee. 
4.  The Executive Director or his or her designee shall review the request for conducting another SIS assessment and provide a written decision within fifteen (15) business days. 
5.  The decision of the Executive Director or his or her designee shall constitute the final agency decision and will be subject to judicial review pursuant to Section 24-4-106, C.R.S. 
H.  A subsequent SIS assessment shall be conducted only when approved by the Department and when: 
1.  There has been a change in the client’s life circumstances or condition resulting in the significant change to the amount of services and supports needed to keep the client safe; 
2.  The client or his or her legal guardian, authorized representative, family member or case manager as appropriate, has reason to believe that the results of the most recent SIS assessment do not accurately reflect his or her current support needs; or,
3.  The Department deems it necessary to complete a new assessment in order to ensure its accuracy. 
I.  Administration of the SIS assessments shall be reviewed by the Department for the purpose of quality assurance. 
J.  When the Department identifies SIS Interviewer practices that result in inaccurate SIS assessments: 
1. Remediation efforts may occur to ensure that the SIS Interviewer performs assessments according to Department standards. The SIS Interviewer(s) who conducted the inaccurate SIS assessment(s) may be deemed no longer qualified to conduct SIS assessments. 
2.  Payments made for the administration of the inaccurate SIS assessments may be recovered through a repayment agreement; by offsetting the amount owed against current and future SIS determination payments; or, by any other appropriate action within its legal authority. 
3.  The client shall receive another SIS assessment conducted by a SIS Interviewer designated by the Department. 
4.  The client’s Support Level and Service Plan Authorization Limit will be adjusted as necessary and effective on the date determined by the Department. 
16.652  SIS Complaint Process [Eff. 2/1/12]
A.  The client, his or her legal guardian, authorized representative, or family member as appropriate, may file a complaint regarding the administration of the SIS assessment up to thirty (30) calendar days after the SIS assessment is conducted. 
B.  The complaint shall be filed verbally or in writing with the client’s CMA. Additional information to support the complaint may be submitted at that time. If the complaint has been filed verbally the CMA shall document in the client’s record on the Department required data system the time, date and details surrounding the complaint. 
C.  When the complaint requests that another SIS assessment be completed, the CMA shall submit a request for approval to conduct another SIS assessment, pursuant to the process identified in Section 16.651, G. 
D.  The CMA shall make efforts to resolve the complaint and provide the complainant with a written response within ten (10) business days after receipt of the complaint. 
E.  When a resolution cannot be reached, the CMA shall inform the complainant that he or she may submit the complaint to the Department within fifteen (15) business days after receipt of the CMA response. 
F.  The Department shall provide a written response to the complainant within fifteen (15) business days after receipt of the complaint. 
16.653  Support Levels [Eff. 2/1/12] 
A.  A client is assigned into one of six Support Levels according to his or her overall support needs and based upon the standardized algorithm for the HCBS-DD or HCBS-SLS waivers. 
B.  The factors included in the algorithm are: 
1.  Standard scores from Section 1: Parts A, B, and E from the SIS assessment; 
2. Exceptional Behavioral Support Needs score from the SIS assessment; 
3.  Exceptional Medical Support Needs score from the SIS assessment; and, 
4.  Whether the client presents as a safety risk, as follows: 
a.  In the HCBS-SLS waiver, Public Safety Risk-Convicted. 
b.  In the HCBS-DD waiver, Public Safety Risk-Convicted/Not Convicted or Extreme Safety Risk to Self.
C.  The CMA shall make a determination whether a client meets the definition of Public Safety Risk or Extreme Safety Risk to Self through the following process:
1.  The decision shall be made by a case management supervisor meeting the qualifications of a Developmental Disabilities Professional as defined in Section 16.120. He or she shall: 
a.  Document the rationale to support the decision which shall be kept in the client’s record; 
b.  Document that the client meets the definition in the Department required data system; and, 
c.  Review the client at least annually or when significant changes occur to assure that the client continues to meet the definition. 
2.  At the point when a client no longer meets the definition, his or her status must be changed in the Department required data system and his or her Support Level must be re-calculated. 
D.  The CMA shall inform each client, his or her legal guardian, authorized representative, or family member, as appropriate, of his or her Support Level at the time of the Service Plan development or when the Support Level changes for any reason.
E.  Notification of a Support Level change shall occur within ten (10) business days of the date after the Service Plan development or Support Level change.
F.  Each Support Level corresponds with the standardized reimbursement rates for individual waiver services and the Service Plan Authorization Limits (SPAL) in HCBS-SLS. 
G.  In HCBS-DD, the Department may assign a reimbursement rate for day habilitation services and residential habilitation services provided to a client with exceptional overall needs in accordance with the Support Level Review Process.
16.654  Support Level Review Process [Eff. 2/1/12] 
A.  The client, his or her legal guardian, authorized representative, family member, or CMA, as appropriate, may request a review regarding the Support Level assigned to meet the client’s needs.
B.  The CMA shall complete the information required by the Department to request that the client’s assigned Support Level be reviewed. Prior to submitting the request, the CMA shall provide an opportunity for the client, his or her legal guardian, authorized representative, or family member, as appropriate, to review and provide additional information that will be submitted the Department. 
C.  The Department shall convene a review panel to examine Support Level review requests monthly or as needed.
1.  The review panel shall be comprised of the following: 
a.  A minimum of three (3) members designated by the Department. 
b.  Members shall include staff from the Department, staff from a CMA that does not provide services to the client, or an additional party with extensive knowledge and experience with the SIS assessment, the Support Levels, case management, and HCBS waiver services. 
2.  The review panel: 
a.  Shall examine all of the information submitted by the CMA and seek to identify any significant factors not included in the Support Level calculation, which cause the client to have substantially higher support needs than those in the established Support Level. 
b.  In cases where the panel finds that the client does have substantially higher support needs than those in the initial Support Level, the panel may assign the client to a Support Level that is a closer representation of the client’s overall support needs. 
3.  A client who has been assigned to a higher Support Level shall have this assignment re-examined by the review panel annually or as determined by the Department, unless the panel determines that the client’s condition necessitating a higher Support Level is unlikely to improve. 
D.  The Department shall provide the CMA and the client, his or her legal guardian, authorized representative, or family member, as appropriate, with the written decision regarding the requested review of the client’s Support Level within fifteen (15) business days after the panel meeting.
1.  The results of the panel review for a client enrolled in the HCBS-DD waiver are conclusive. 
2.  If a client enrolled in the HCBS-SLS waiver, his or her legal guardian, authorized representative, or family member, as appropriate, disagrees with the decision provided by the panel, the client may request a review by the Executive Director or his or her designee, within fifteen (15) business days after the receipt of the decision. 
a.  The Executive Director or his or her designee shall review the request and provide a written decision within fifteen (15) business days. 
b.  The decision of the Executive Director or his or her designee shall constitute the final agency decision and will be subject to judicial review pursuant to Section 24-4-106, C.R.S. 
E.  The client shall be notified, pursuant to the Department of Health Care Policy and Financing rules in Section 8.057.2, A (10 CCR 2505-10) when a waiver service is terminated, reduced, or denied. At any time, the client may pursue a Medicaid Fair Hearing in accordance with Section 8.057.3, A (10 CCR 2505-10).