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C olorado L egislative C ouncil S taff

Room 029 State (303) Capitol, 866- Denver, 3521 FAX: CO 80203-1784 866-3855

TDD: 866-



Pursuant to section 24-72-202(6.5)(b),research Staff memorandaandotherfinalproducts research that are not related ofLegislativeCouncil to proposed or pending legislation are

subject considered to public public inspection. records and If are you think additional research is required and

product, this memorandum please call is the not Legislative a final Council Librarian at (303) 866-4011 by July 19, 2007.



Members of the Interim Committee to StudyLong-

for term Persons Care Services with Developmental and Supports Disabilities

Elizabeth Burger, Research Associate II, 303-866-

Jessika 6272 Shipley, Senior Research Assistant, 303-866-

Kelly 3528 Stapleton, Senior Research Assistant, 303-866-

Amy 4789 Larsen, Senior Fiscal Analyst, 303-866-3488




SUBJECT: Overview of the System of Long-term Care for Persons

with Developmental Disabilities in Colorado

This memorandum provides an overview of Colorado's with developmental system of long-term disabilities. carefor Specifically, persons this memorandum

services discusses and the describes administration the services of that are provided. In addition, the

current memorandum funding describes for services in the state and discusses the waiting lists

memorandum for services. Finally, provides the estimates of the funding required to eliminate

and the waiting describes lists issues for services, related to the restructuring of Medicaid waivers

persons used to provide with developmental services to disabilities.

Definition of Developmental Disability

State statute defines a developmental disability as a disability

person reaches that is manifested 22 years of before age which the constitutes a substantial

In disability addition, to the the disability affected individual. must be attributable to mental retardation or

includecerebralpalsy, related conditions which epilepsy, autism,orother neurological conditions

in when impairment such conditions of general result intellectual functioningoradaptivebehavior

similar mental retardation. to that ofapersonwith

similar mental retardation. to that ofapersonwith Page 2 Administration of Services The Division of

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Administration of Services

The Division of Developmental Disabilities within the oversees Department theadministration of Human of services Services forpersons withdevelopmental

majority disabilities. of state Becausethevast services for persons with developmental disabilities

Medicaid are funded program, through the the state state Department of Health Care Policy and

administers Financing also services oversees for persons and with developmental disabilities.

Community Centered Boards (CCBs). In Colorado, persons access services withadevelopmentaldisability through a Community Centered Board (CCB). There

Community are 20 CCBs Centered in Colorado. Boards are private entities which, as designated by statute:

• are authorized to determine the eligibility for services of

disabilities persons with who developmental live in a specific geographic region;

• provide case management services to persons with

• serve developmental as the single disabilities; point of entry for persons to receive

state- services and and federally-funded supports; and

• provide authorized services and supports to persons with

either developmental directly or disabilities by purchasing services and supports from service agencies.

Eligibility for Services

Anyperson mayrequest an evaluation to determine whether disability that and person is eligible has adevelopmental for services. CommunityCentered Boards are

whether responsible the for person determining is eligible for services. If the CCB determines the

within person 30 is eligible days of for the services, eligibilitydetermination, the CCB must develop

individual. an individualized The individualized plan for the plan must identify:

• the needs of the person or family receiving services;

• the specific services and supports appropriate to meet

• the those projected needs; date for initiation of services and supports;

• the and anticipated results to be achieved by receiving the services and supports.

The individualized plan must be reviewed at least annually

appropriate. and modified as necessary or

Services Provided

Services for those individuals who qualify are provided through four main programs:

• Adult Comprehensive Services (Comp);

• Supported Living Services (SLS);

• Children's Extensive Support (CES); and

• Family Support Services (Family Support).

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Below is a description of each program, who is eligible, and what services are provided.

Adult Comprehensive Services (Comp). Comprehensive individuals services with a are developmental provided to adult disability who are living outside

24-hour their family supervision home and and require residential services. To be eligible, one must

a be developmental at least 18 years disability, old, have and require extensive support services to

Some live safely services outside included the home. in this program are:

• residential habilitation with 24 hour supervision;

• day habilitation services including supported

community employment life services, activities, access and to generalized typical skill

• training development; and habilitation services in the areas of

personal, development; physical, mental, and social

• transportation;

• specialized medical equipment and supplies, such as

adaptation, wheelchairs, van wheelchair adaptation, or toys or computers that aid

• in skilled communication; nursing;

• behavioral services and mental health services; and

• dental and vision services.

Some services take placewithin the communitysetting, while sheltered others workshops takeplacein or training segregated centers where the majority of people may have a disability.

Supported Living Services (SLS). Supported Living Services

assist persons are services with developmental and supports to disabilities to live in the their own

or home, rental apartment, unit that familyhome, qualifies as an SLS setting. Supported Living

alternative Services are to provided institutional as an placement for individuals with

intended developmental to provide disabilities, 24-hour but supervision are not like Comp services. To be

independentlywith eligible, one must either limited live supports or alreadyreceive services from

other members. resources Services such include: as family

• specialized medical equipment and supplies;

• counseling and therapeutic services;

• dental, hearing, and vision services;

• day habilitation services including physical,

• occupational, home modification; or speech therapy;

• personalassistanceservicesincluding dressing, assistancewithbathing,personalhygiene,eating, grooming, reliefto familymembers who

normallyprovide medications; personal care, and

• communication services such as speech/language

• counseling therapy; services including individual, group,

evaluations, behavioral interventions, occupational, diagnostic and physical therapy;

• transportation; and

• assistance with employment (pre-vocational and supported employment).

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Children's Extensive Support Services (CES). Children's provided Extensive to children Support who have Services a developmental are disability, or to

are children at risk under of a the developmental age of five who disability or developmental delay. To

intensive be eligible, behavioral one must or have medical needs. Children's Extensive Support

alternative Services are to provided institutional as an placement for children with developmental disabilities. Services include:

• personal assistanceservicesincluding assistancewithbathing,personalhygiene,eating, dressing, grooming, and medications;

• child care assistance;

• professional services such as counseling and therapeutic

• household services; services such as housekeeping tasks;

• home modification services such as adaptation of

home showers accessible or toilets with and ramps making or the railings;

• community connection services such as providing for

• specialized recreational medical equipment; equipment and and supplies including

adaptation, wheelchairs, van wheelchair adaptation, or toys or computers that aid in communication.

FamilySupport Services. FamilySupport Services are children intended and adults to with provide developmental services to allow disabilities to remain in their

support family home to families and to as provide the primary care givers. Referrals to the Family

through Support CCBs. program Thoseeligiblearerequired are made tohaveafamilymember

living withadevelopmental in the household. disability Eligibility for the Family Support Services

guarantee program does services not necessarily or support. The Family Support program is not

waiver, funded through but is funded a Medicaid with state dollars.

A family support plan is developed in conjunction with an order to avoid individual's duplicative Individual services. Plan Services in may include:

• family support grants;

• support service coordination and educational materials;

• emergency and outreach services;

• reimbursement for medical and dental expenses not programs; covered by health insurance

• child care;

• mobility aids and adaptive equipment;

• therapy and family counseling;

• recreation and leisure needs;

• transportation; and

• special dieting foods, clothing, and homemaker services.

Current Funding and Waiting Lists

The vastmajorityof services for personswithdevelopmental

federal Medicaid disabilitiesare waiversfor fundedthrough home- andcommunity-based services.

the TheseMedicaid state to support waiversenable services for persons with developmental disabilities using Medicaid funds that

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originate as 50 percent General Fund and 50 percent federal funds. from However, other waiver parts of services the state differ Medicaid program in that the state may

program limit the participants. total number As of a result, there are waiting lists for services.

Table I reflects FY 2007-08 funding and waiting list Services, information. Adult Supported Adult Living Comprehensive Services, and the Children's

funded Extensive primarily Support or programs entirely by are Medicaid with a 50 percent state

purposes, contribution. program For budgetary resources are the number of individuals who are

a expected full year to and receive may services vary from for the actual number of clients served.

waiting Some of lists the are persons anticipated on the to be removed during FY 2007-08 due to

and the funding changing of client new resources needs. Family Support Services are primarily

moneys, funded with and state current General funding Fund serves about 4,000 families.

Community Program

Adult Comprehensive Services (Comp)

Adult Supported Living Services (SLS)

Children's Extensive Support (CES)

Family Support Services

Table I FY 2007-08 Funding and Waiting Lists
















Cost Full


Resource Year



April of











a) Reflects funding in the Developmental Disability Services, Community Services, Program Costs

line item 2007-08 of the Long FY Bill. It does not include 403 adult residential resources at the regional centers or

services local dollars. funded with

b) Of the resources shown, 78 adult comprehensive resources and 24 adult supported living services

are funded an average for of six months in FY 2007-08. These resources are counted as 0.5.

Eliminating the Waiting Lists

The waiting lists for developmental disability services are a manypeople fundamental anticipated problem. a judicial While resolution from a lawsuit alleging

developmental that the state's waiting disability lists services for were illegal, the courts ruled in the

waiting state's favor lists allowing to continue. the The ruling leaves the state with broad

services flexibility to to the set developmentally funding levels for disabled.



Mandy R. v. Owens. In February 2005, Judge Richard P. Matsch, the trial court judge for the

state's federal favor. district On court, September ruled 21, in the 2006, the 10th Circuit Court of Appeals upheld the ruling.

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Services foradults. The projected cost to the state of

lists for adult entirelyeliminating services is estimated the current at $46.6 waiting million annually. Costs

comprehensive are shared between services and supported living services as shown in Table II.

Table II Cost of Eliminating the Current Medicaid Waiting Lists for Services for Adults with Developmental Disabilities


Net State Cost



per Client*





Adult Comprehensive Services (Comp)



Cost $32,478,672

Adult Supported Living Services (SLS)







*Costs are based on FY 2007-08 average net state costs including case management. **Resources required are based on the waiting list as of April 2007, reduced by 20 percent to

removed account for from individuals the wait list not in a timely fashion and assuming 344 SLS slots would be opened up by

to individuals comprehensive moving services from SLS.

Eliminatingthecurrent waitinglist would the demand onlytakecareoftheproblem for services continues to foroneyear grow much because faster than

Committee population growth. staff estimates Joint Budget that growth in demand for comprehensive

4.1 residential percent services per year, is while about growth in the state's population is between

rapid 1 and growth 2 percent is tied, per year. in part, The to the baby boom generation cohort of

disabilities. persons with This developmental group increasingly requires state-funded services as

longer their parents able to age care and for are them. no

Joint Budget Committee staff estimates that 180 new year in the resources near future would to need avoid to ongoing beadded waiting each list growth. After

annual eliminating increase the waiting of about list, $6 an million in state funds is required to avoid recreating it. Services for children. At this time, staff is unable to

requirements accurately to eliminate estimate the funding waiting list for the Children's Extensive

delays Support and program. problems Placement with the program's abilityto spend funds while

resulted children in areawaiting large under-expenditures placement going back to FY 2005-06. In FY

Children's 2006-07, thirty Extensive new Support resourceswere added, but under-

Budget expenditures Committee topped staff 30 percent. anticipates Joint that an FY 2007-08 budget

numbers adjustment, of children either to who increase maybe served or to reducethe budget, is

may likely. be While as high state as $1.6 funding million needs (157 children x $10,000), at this time,


children would remain on a waiting list after current funding is


is unknown how many

Services for families. State funding for Family Support

a block grant Services in that is administered CCBs receive much a set like amount of money and that

services funding is to used as manyfamilies to provide as possible. Thus, anyadditional

expand fundingwould services. be State used funding to enhanceand as high as $24.6 million may be

all required families to provide on the waitinglist full services ($5,900 to x 4,178 families). However, it is

of important the families to note on that the waiting many list are receiving some services. Local

available funds may for also this be program. made

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available funds may for also this be program. made – 6 – Page 7 Restructuring of

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Restructuring of Payments for Services Funded through Medicaid Waivers

As noted earlier, the vast majority of state services for

disabilities persons are funded with developmental through the Medicaid program through various waivers. through FY From 2005-06, thelate the 1990s developmentaldisabilitysystemwa

agreement smanagedpursuanttoa between the systemschange Joint Budget Committee and the Department

systems of Human change Services. agreement, Underthe CCBs received payments based on an

individual average service regions rate and for persons their served, and the CCBs negotiated

providers agreements based with upon individual the specific needs of the persons served. This

eliminated quasi-managed in FY care 2006-07 system after was the federal Centers for Medicare and

notified Medicaid the Services state that (CMS) the payment methodology would no longer be permitted.

In Februaryof 2006, the state began a process to revamp its

and SLS billing waiver system services. for As comprehensive directed byCMS, Colorado must

rates, establish develop clearguidelines a process for for determining provider client levels of need, and

allows implement specific a payment costs to system be tied that to an individual for all waiver programs.

The billing system change has driven a substantial workload

Services, for CCBs, the Department and providers. of Human In addition, the transition initially

delays resulted to in providers. significant Finally, payment a system developed to "hold harmless"

losses anyprovider as a result who of faced the financial billing system change had technical

were difficulties not distributed and hold to harmless providers payments until the spring of 2007.

The state is currentlyin the process of developing uniform

and day tiered habilitation rates for services residential and evaluating services all clients to determine their appropriate level of reimbursement need and the tier for their services. An interim rate

SLS structure waiver for services comprehensive was put and into place in August of 2006. The final

comprehensive rate structure for services was expected to be implemented July1, 2007,

have but delays pushed in back implementation the start date for the new rate structure to sometime in structure 2008. The for SLS final waiver rate services is anticipated to be implemented in FY 2008-09.

The change from a quasi-managed care to a fee-for-service

services payment will have system short- and for waiver long-term fiscal implications forthe

the state. state For budgeted instance, over in FY $1.8 2006-07, million for one-time costs associated

implementation. with the billing system In addition, in FY 2006-07, a General Fund

$7.6 expenditure million of was approximately incurred to replace local funds that could no longer

billing be accessed system. under Finally, the new in FY 2006-07, the new billing system

expenditure resulted in a of one-time funds for under- services for individuals with developmental

$29.8 disabilities million. of approximately This under-expenditure was due to decreased

funds, flexibility as well of CCBs as the to switch administer to a cash the system of accounting for

Accordingto Medicaid-funded the Joint waiver Budget services. Committee staff, although thefiscal

uncertain, implicationsfor under thestatearestill the new system, the state's control on overall waiver costs than under will be the far former more limited quasi-managed care system.

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of the Developmental Disabilities System in