If you’ve heard the term ‘HCBS Waiver’, but you’re confused about what this means, this article is for you. We’ll break it down into plain language so you can understand HCBS Waivers in Colorado. Our state has 10 Medicaid HCBS waiver programs, one of the highest counts of waiver programs in the nation. This is good news for Colorado residents with disabilities who need home health care services! Let’s talk about the terms you’ll hear frequently so you’ll know what they mean.

What is Medicaid?

Medicaid is an entitlement program that was created in 1965 by the Federal government. An ‘entitlement program’ means that if you meet the income and eligibility requirements, the state is required to give you the services you qualify for. Even though it is optional (not mandated by the Federal government) to participate, all 50 states have a Medicaid program. Each state’s Medicaid program is jointly funded between the state and the Federal government. Basically, the Federal government matches dollar for dollar what each state puts toward their Medicaid program.

What is HCBS?

HCBS stands for Home and Community Based Services. Programs for Home and Community Based Services are called HCBS Waivers. A ‘waiver’ can be thought of as a ‘program.’ Anytime you see or hear the word ‘waiver,’ you can replace it in your mind with the word ‘program’ and it will make more sense.

HCBS Waivers (programs) are designed to help specific populations with the most intensive medical needs. Most often, these are people with disabilities. HCBS Waivers in Colorado are designed to give people with disabilities or certain diagnoses greater level of choice in how and where services are obtained. This often means the difference between having to be in a healthcare setting to receive medical services, or receiving services at home. For many people, receiving services at home leads to increased independence and quality of life.

What is Colorado Department of Health Care Policy and Financing (HCPF)?

If you see or hear about the Colorado Department of Health Care Policy and Financing (HCPF),  related to HCBS, this is because it is the state agency that oversees Colorado’s Medicaid program and HCBS Waivers. Most of the time, you’ll probably just hear Colorado’s Medicaid program being called Health First Colorado.

What is the difference between Medicaid and HCBS?

Home and Community Based Services (HCBS) are part of Medicaid. If you can imagine a

Triangle depicting 'Health First Colorado, Colorado State Medicaid plan (regular Medicaid)' at the base of the triangle [larger area] and 'HCBS Waivers, Benefits for participants with more intensive needs & specialized diagnoses' at the top of the triangle [smaller area].

As you can see by the graphic, a much smaller population fits into the HCBS Waivers population as compared to the greater regular Medicaid population.

triangle with the base of the triangle representing the general population who qualifies for regular Medicaid, and the top of the triangle representing a smaller group of participants, this is helpful when thinking about the relationship between HCBS and Medicaid. Many fewer participants in Medicaid will qualify for or need Home and Community Based Services than regular Medicaid.

How do I qualify for a HCBS Waiver?

Functional Eligibility

HCBS Waivers in Colorado have three eligibility criteria that need to be met. The first is functional eligibility. This means: do you meet the requirements for the level of care? Functional eligibility is determined by a caseworker for one of Colorado’s 47 contracted Case Management Agencies.

Case Management Agencies are contracted on a regional basis with the state to assess participant needs, provide referrals, develop service plans, track delivery of services and oversee participants’ experience with the program.

The assessment for services handled by Case Management Agencies is called the Uniform Long Term Care (ULTC) 100.2 assessment. We’ll talk more about this assessment in a future post.

Targeting Criteria

“Targeting criteria” is just a fancy way of saying: “Do you meet the certain age, specific injury, or diagnosis requirements?”

Participants may meet targeting criteria for more than one waiver. Therefore, it’s important for the Case Manager to be familiar with all the Waivers and their eligibility requirements so they can fully inform you of your options

Financial Eligibility

Financial eligibility has to do with income requirements. Eligibility for HCBS Waivers is determined by your county’s human or social service office. You’ll need to apply with them.

Conclusion

Waivers can vary greatly from state to state and have different names and services. Just because you have qualified for a waiver in another state does not mean you will qualify in Colorado. If you move to Colorado from another state where you qualified for a waiver, you will need to go through a new application process in Colorado.

Unlike regular Medicaid, which is based on entitlement, Waivers can have waiting lists. Participants can only be enrolled in one waiver at a time. Participants are allowed to be on one kind of waiver while waiting for a spot to open up on another waiver.

Once eligibility for a waiver has been met as described above, your case manager will work with you to develop an individualized service plan. In our next posts we’ll talk about how to apply for HCBS Waivers in Colorado, and what to expect at the ULTC 100.2 assessment in Colorado.