DENIALS, DISCONTINUATIONS, AND CASE TRANSFERS

A. The responsibility of the CMA is to determine the functional eligibility of the client. The CMA shall deny or discontinue the client from the HCA program if he or she is determined functionally ineligible and provide timely or adequate notice as required by Section 3.554. 1. The client shall be informed of his or her appeal rights as outlined in Section 3.587. 2. The client shall be provided appropriate referrals to other community resources within one (1) working day of discontinuation or denial. 3. If the discontinuation or denial is due to functional eligibility, the CMA shall notify the client that he or she must notify the providers on the care plan within one (1) working day of receiving notice from the county department. 4. If the discontinuation or denial is due to financial eligibility, the CMA shall notify the client that he or she must notify all providers on the care plan within one (1) working day of receiving notice from the county department. 5. The CMA shall notify the county department within five (5) working days of discontinuation. 6. The CMA shall prepare for and defend at the state level fair hearing any appeal related to functional denial or discontinuation. The CMA may request assistance and/or testimony from the county department. B. The responsibility of the county department is to determine the financial eligibility of the client. The county department shall deny or discontinue the client from the HCA program if he or she is determined financially ineligible and provide timely or adequate notice as required by Section 3.554. 1. The client shall be informed of his or her appeal rights as outlined in Section 3.587. 2. The client shall be provided appropriate referrals to other community resources within one (1) working day of discontinuation or denial. 3. The county department shall notify the CMA within five (5) working days of discontinuation. 4. The county department shall prepare for and defend at the state level fair hearing any appeal related to financial denial or discontinuation. The county department may request assistance and/or testimony from the CMA. C. Following the notice procedures outlined in Section 3.554, denial and/or discontinuation from the HCA program shall occur for the following reasons: 1. Financial and Functional Eligibility: The CMA or county department shall deny or discontinue a client if the client is not financially eligible and/or is not functionally eligible for HCA. 2. Level of Care: The CMA shall deny or discontinue when the client: a. Does not meet functional capacity score minimum requirements; or, b. Does not meet need for paid care score criteria. 3. Receipt of Services: The CMA or county department shall deny or discontinue when the client: a. Has not received services for one month; b. Has twice refused to schedule an appointment for an initial assessment, six (6)- month review, or reassessment within a thirty

(30) consecutive day period; c. Has failed to keep three (3) scheduled appointments within a thirty

(30) consecutive day period; d. Has refused to schedule an appointment for a required visit after the client's case has been transferred to a new CMA or county department; e. Refuses to use the HCA payment to pay for services or uses the payment for services not identified in the service agreement; f. Refuses to sign the intake form, care plan, or other documents and forms required to receive services. 4. Facility Status: The CMA or county department shall deny or discontinue when the client: a. Is a resident of a nursing facility, hospital, or any other long-term care facility; or, b. Enters a hospital or other long-term care facility for treatment, hospitalization, or rehabilitation that continues for thirty (30) calendar days or more. 5. Service Limitations Related to Safety: The CMA or county department shall deny or discontinue when the client cannot be safely served given the type and/or amount of services available. Evidence of safety concerns include, but are not limited to: a. The results of an Adult Protective Services assessment that substantiates ongoing risk. b. A statement from the client's physician attesting to diminished cognitive capacity, debilitating mental health concerns, or ongoing risk. c. Lack of available and/or appropriate service providers. d. A functional assessment score indicating a level of need for services in excess of those available under the HCA program. e. Other available information or evidence that will support the determination that the client's safety is at risk. 6. Service Limitations Related to Cost Effectiveness: The CMA or county department shall deny or discontinue when other more cost effective alternatives are available to meet the client's needs. 7. Living Arrangements: The CMA or county department shall deny or discontinue when the client is residing anywhere other than his OR her home. a. The CMA may continue to authorize services while a resident is on medical or non-medical leave. b. Combined leave shall not exceed a total of forty-two (42) days in a twelve (12) month period beginning with the date the client was approved for the HCA program. 8. Move Out of State: The CMA or county department shall deny or discontinue when the client has moved out of state. a. Discontinuation shall be effective the day after the date of the move. b. Clients who leave the State on a temporary basis with the intent to return to Colorado within thirty (30) calendar days shall not be discontinued. If the client fails to return to Colorado the client shall be discontinued on day thirty one (31). 9. Voluntary Withdrawal from the Program: The CMA or county shall deny or discontinue when the client requests withdrawal from the HCA program. 10. Death: The CMA or county shall discontinue the HCA program effective the day after the client's date of death. No notice of discontinuation shall be sent. D. The CMA shall complete the following procedures to transfer an HCA client to a new county department: 1. The CMA shall notify the county department of the client's plans to relocate to another county and the date of transfer. 2. If the client's current service providers do not provide services in the area where the client is relocating, the CMA shall make arrangements, in consultation with the client, for new service providers. E. The CMA shall complete the following procedures to transfer an HCA client to a new CMA SEP: 1. The transferring CMA shall contact the receiving CMA by telephone or email to give notification that the client is planning to transfer, to negotiate a transfer date, and to provide information. 2. The transferring CMA shall forward copies of the client's case records, including forms required for the HCA program, to the receiving CMA prior to the relocation, if possible, but in no case later than five (5) working days after the client's relocation. 3. The receiving CMA shall complete an in-person meeting with the client and an assessment and case summary update within ten (10) working days after notification of the client's relocation. 4. The receiving CMA shall review the care plan and the assessment tool, revise as necessary, and coordinate services and providers.