LCA DQ 2026-0469 Final.docx

HCPF Solicitation #:

DQ UHAA 2026000469

Local Contact Agency - In-Reach Counseling

TABLE OF CONTENTS

APPENDIX A – HIPAA BAA

APPENDIX B – PII CERTIFICATION

APPENDIX C – W-9

APPENDIX D – PRICING WORKSHEET

APENDIX E – PO REGIONS

Section 1.0 INTRODUCTION AND BACKGROUND

1.1. GENERAL INFORMATION

1.1.1. The Colorado Department of Health Care Policy and Financing (Department) is soliciting competitive, responsive proposals from experienced and financially sound organizations to perform Individual and Group In-Reach.

1.1.2. The Offeror may submit a proposal to provide Individual and Group In-Reach services in one or more Defined Service Areas. The Department reserves the right to award multiple Contracts pursuant to this Request for Proposal (RFP), as deemed appropriate. The geographic boundaries of the Defined Service Areas for which proposals are being solicited are set forth in Appendix E: PO Regions.

1.1.3. General solicitation information, timelines and quotation response submission requirements are available in Section 6.0, Administrative Information, and Section 8.0, Submittal Requirements.

1.2. ANTICIPATED PO TERM

1.2.1. The initial operational period of the Purchase Order (PO) is anticipated to begin at the end of the start-up period and will last until June 30, 2027.

1.2.2. The Period of the awarded PO may be for more than one Fiscal year, depending on the overall price quoted by the Offeror.

1.2.3. The Department is not responsible for any goods delivered or services performed by the awarded Respondent without a Department-issued Purchase Order.

1.3. SUBRECIPIENT STATUS

1.3.1. The Respondent will be considered a subrecipient subject to the requirements of the Office of Management and Budget Uniform Guidance, 2 CFR Part 200. As a subrecipient, the Respondent shall comply with all reporting, auditing, and other requirements of 2 CFR Part 200.

1.4. BACKGROUND

1.4.1. Department of Health Care Policy and Financing Background

1.4.1.1. The Department serves as the Medicaid Single State Agency as defined by 45 C.F.R. §205.100. The Department develops and implements policy and financing for Medicaid and the Children’s Health Insurance Program, called Child Health Plan Plus (CHP+) in Colorado, as well as a variety of other publicly funded health care programs for Coloradans who qualify. For more information about the Department, visit www.Colorado.gov/HCPF.

1.4.1.2. The Department is a Covered Entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (42 U.S.C. §§1320d – 1320d-8) and its implementing regulations.

1.4.1.3. The Department operates the Colorado Medicaid Program, known as Health First Colorado, in accordance with the Colorado Medical Assistance Act (§§25.5-4-104, et seq., C.R.S.) and Title XIX of the Social Security Act. Colorado Medicaid is annually funded from appropriations authorized by the Colorado General Assembly and matched by federal funds.

1.4.2. Project Background

1.4.2.1. This Program exists to ensure that every Health First Colorado Member residing in Skilled Nursing Facilities can make an educated choice regarding where they live and receive services regardless of their location within the state, their medical diagnosis, or access to natural support. To support this goal, the Department is contracting to offer Group and Individual In-Reach Counseling at each identified Medicaid nursing facility in the State, which aims to provide information about community living options to individuals. The metrics for this work is being guided by the Settlement Agreement for U.S. v Colorado, No 1:23-cv-2538.

1.4.2.2. Offerors are encouraged to apply to some, one, or all of the regions listed in Appendix E, PO Regions Section 2.0 TERMINOLOGY

2.1. ACRONYMS, ABBREVIATIONS AND OTHER TERMINOLOGY

2.1.1. Acronyms, abbreviations and other terminology are defined at their first occurrence in this Documented Quote (DQ). The following list is provided to assist the reader in understanding acronyms, abbreviations and terminology used throughout this document.

2.1.2. Aging and Disability Resources for Colorado (ADRC) – The Colorado Adult Resources for Care and Help Program which provides a coordinated and streamlined access point to long term services and support for adults aged 60 and over, or age 18 and over living with a disability, and their caregivers.

2.1.3. Authorization for Release of Information Form – A form signed by an individual authorizing the ADRC to release and/or obtain verbal, electronic or written information regarding the individual with the service providers and agencies for the purpose of making Referrals for services and coordination in support of a transition to the community.

2.1.3.1. Business Day - Any day in which the State is open and conducting business, but shall not include Saturday, Sunday, or any day which the State observes one of the holidays listed in C.R.S. §24-11-101(1).

2.1.3.2. Business Interruption – Any event that disrupts Contractor’s ability to complete the Work for a period, and may include, but is not limited to a Disaster, power outage, strike, loss of necessary personnel or computer virus.

2.1.3.3. Case Management Agency (CMAs) – A public or private not-for-profit or for-profit agency that meets all applicable state and federal requirements and is certified by the Department to provide case management services for Home and Community-Based Services waivers and pursuant to a provider participation agreement with the state department.

2.1.3.4. Case Managers (CMs) – An individual employed by a CMA who is qualified to perform case management activities.

2.1.3.5. Child Health Plan Plus (CHP+) – Colorado’s public low–cost health insurance for certain children and pregnant women. It is for people who earn too much to qualify for Health First Colorado, but not enough to pay for private health insurance.

2.1.3.6. Closeout Period – The period beginning on the earlier of 90 days prior to the end of the last Extension Term or notice by the Department of its decision to not exercise its option for an Extension Term, and ending on the day that the Department has accepted the final Deliverable for the Closeout Period, as determined in the Department-approved and updated Closeout Plan, and has determined that the closeout is complete.

2.1.3.7. Community- any long-term care setting that is not classified as institutional in which people live, work, recreate, and receive services. A target population Member’s community residence is often, but is not always, the most appropriate, integrated setting that the Member does not oppose. This may include a residence owned or rented by the Member or the Member’s natural support(s). Other appropriate, integrated settings in the community may include Provider owned and operated residential programs.

2.1.3.8. Community-Based Long-Term Services and Supports (or “Community-Based LTSS”) - Individualized, Person-Centered, flexible, and culturally and linguistically competent services, delivered in integrated settings; to help target population Members live in the community. These services may include Home and community-Based Services, long term home health, private duty nursing, and the program of all-inclusive care for the elderly.

2.1.3.9. Community-Based Services – Services that include: Community-Based LTSS, Housing Services.

2.1.3.10. Case management- described in this Agreement, including transition coordination services.

2.1.3.11. Community Transition - When an institutionalized population Member transitions from a Nursing Facility and into a less restrictive living environment.

2.1.3.12. Contractor - The individual or entity selected as a result of this solicitation to complete the Work contained in the PO.

2.1.3.13. Data – State Confidential Information and other State information resources transferred to Contractor for the purpose of completing a task or project assigned in the Statement of Work.

2.1.3.14. Deliverable - Any tangible or intangible object produced by Respondent as a result of the work that is intended to be delivered to the Department, regardless of whether the object is specifically described or called out as a “Deliverable” or not.

2.1.3.15. Department - The Colorado Department of Health Care Policy and Financing, a department of the government of the State of Colorado.

2.1.3.16. Educated Choice – Member’s choice of service setting, based on full and accurate information about community-based alternatives to nursing facility care, including non-disability-specific concerns or objectives to community living raised by members or by any natural support.

2.1.3.17. Effective Date - The date on which the Purchase Order resulting from this solicitation is approved and signed by the Colorado State Controller or designee, as shown on the Purchase Order.

2.1.3.18. Group In-Reach - Actively seeking to engage an institutionalized population Member, and providing the institutionalized population Member with: (1) full and accurate information about Housing Services and other Community-Based Services, as an alternative to Nursing Facility-based services; (2) responses to any questions or concerns raised by the Member or the Member’s natural support; and (3) referrals to appropriate agencies as identified by the State, that help Members meet their needs in the community.

2.1.3.19. Health First Colorado - Colorado’s Medicaid program.

2.1.3.20. Health Insurance Portability and Accountability Act (HIPAA) - The Health Insurance Portability and Accountability Act of 1996, as amended.

2.1.3.21. Home and Community-Based Services (“HCBS”) Waiver Services - Services and supports provided through a waiver authorized in Section 1915(c) or 1915(k) of the Social Security Act, 42 U.S.C. § 1396n(c), and provided to a Member who requires an institutional level of care that would otherwise be provided in a hospital, Nursing Facility, or intermediate care facility for Members with intellectual disabilities.

2.1.3.22. Independent Living Center (ILC) – A consumer-controlled, Community-Based, cross-disability, non-residential private nonprofit agency that is designed and operated within a local Community by individuals with disabilities to provide an array of independent living services to disabled individuals.

2.1.3.23. Individual In-Reach – Direct meeting with institutional population Members and their natural support and/or guardian at their place of residence. The LCA will provide: (1) full and person-centered information about Medicaid and non-Medicaid services as an alternative to nursing facility living; (2) provide printed materials regarding community living options; (3) responses to any questions or concerns raised by the Member or the Member’s natural support; and (4) referrals to appropriate agencies that help Members meet their needs in the community.

2.1.3.24. In-Reach Counselor - A person not affiliated with, employed, or enriched by any Nursing Facility, who conducts Group and/or Individual In-Reach.

2.1.3.25. Key Personnel – The position or positions that are specifically designated as such in this Contract.

2.1.3.26. Local Contact Agencies (LCAs) – An organization that the Department has a contract with to engage in In-Reach will be designated as a Local Contact Agency (LCA) by the Colorado Department of Health Care Policy and Financing (HCPF) under the Minimum Data Set (MDS) 3.0, Section Q protocol.

2.1.3.27. Member – Any individual enrolled in Health First Colorado or Colorado’s Child Health Plan Plus (CHP+) as determined by the Department.

2.1.3.28. Minimum Data Set (MDS) 3.0 - A federally mandated clinical assessment of all Members in Medicaid certified Nursing Facilities.

2.1.3.29. Natural Support- Non-paid informal relationships that provide assistance and occur in the participant's everyday life including, but not limited to, community supports and relationships with family members, friends, co-workers, neighbors and acquaintances.

2.1.3.30. Nursing Facility – An intermediate or skilled care facility, the owners, administrators, and staff thereof. Also known as a nursing home.

2.1.3.31. Nursing Facility Staff – The staff members of a Nursing Facility in which a Member resides.

2.1.3.32. Operational Start Date – When the Department authorizes Contractor to begin fulfilling its obligations under the Contract.

2.1.3.33. Other Personnel – Individuals and Subcontractors, in addition to Key Personnel, assigned to positions to complete tasks associated with the Work.

2.1.3.34. Person-Centered – Focus on the individual with the principles that are set forth in the planning process described in 42 C.F.R. § 441.301(c)(1).

2.1.3.35. PII means personally identifiable information including, without limitation, any information maintained by the State about an individual that can be used to distinguish or trace an individual’s identity, such as name, social security number, date and place of birth, mother’s maiden name, or biometric records; and any other information that is linked or linkable to an individual, such as medical, educational, financial, and employment information. PII includes, but is not limited to, all information defined as personally identifiable information in §§24-72-501 and 24-73-101, C.R.S. “PII” shall also mean “personal identifying information” as set forth at § 24-74-102, et. seq., C.R.S.

2.1.3.36. Pre-Admission Screening and Resident Review (PASRR) Level II – The purpose of the PASRR Level II evaluation is to evaluate and determine whether Nursing Facility services are needed, whether an individual has mental illness or intellectual or developmental disability and whether specialized mental health or intellectual or developmental disability services are needed. After admission to a Nursing Facility, Level II Evaluation is also required promptly following any significant change in the resident's condition.

2.1.3.37. Provider – Any health care professional or entity that has been accepted as a provider in the Colorado Medicaid program, Colorado’s CHP+ program or the Colorado Indigent Care Program, as determined by the Department.

2.1.3.38. Purchase Order (PO) – The agreement, including all attached Exhibits, all documents incorporated by reference, all referenced statutes, rules, and cited authorities, and any future modifications thereto, that is entered into as a result of this solicitation.

2.1.3.39. Purchase Order (PO) Funds – The funds that have been appropriated, designated, encumbered, or otherwise made available for payment by the State under the PO resulting from this solicitation.

2.1.3.40. Regional Accountable Entity - A single regional entity responsible for duties previously performed by Regional Care Collaborative Organizations and Behavioral Health Organizations (BHO).

2.1.3.41. Respondent - Any individual or entity that submits a quotation response (also called a Quote), or intends to submit a quotation response, in response to this solicitation.

2.1.3.42. Rural – Defined Service Areas that are eligible for rural travel add-on reimbursement for required in-person activities reimbursed through this Contract.

2.1.3.43. Section Q – The Section which addresses Community Referrals on the Minimum Data Set (MDS) 3.0, a federally mandated clinical assessment of all Members in Medicaid certified Nursing Facilities.

2.1.3.44. State – The State of Colorado, acting by and through any State agency.

2.1.3.45. State Fiscal Quarter – The quarterly period of a State Fiscal Year in which Contractor’s performance is measured.

2.1.3.46. State Unit on Aging – The unit in the State, designated to administer the Colorado State Plan on Aging, including Older Americans Act and Older Coloradans Act programs. In Colorado, this agency is within the Colorado Department of Human Services, Division of Aging and Adult Services.

2.1.3.47. Subcontractor – Any third party engaged by Respondent to aid in performance of the Work.

2.1.3.48. Transition Coordination Agency (TCAs) – A public or private not-for-profit or for-profit agency that is enrolled as a provider and is certified by the Department to provide transition coordination pursuant to a provider participation agreement with the state department.

2.1.3.49. Transition Coordinators (TC) – A person who provides transition coordination services and meets all regulatory requirements for a transition coordinator.

2.1.3.50. Work – The Goods delivered and Services performed pursuant to any PO that may result from this solicitation.

2.1.3.51. Work Product – The tangible and intangible results of the Work, whether finished or unfinished, including drafts. Work Product includes, but is not limited to, documents, text, software (including source code), research, reports, proposals, specifications, plans, notes, studies, data, images, photographs, negatives, pictures, drawings, designs, models, surveys, maps, materials, ideas, concepts, know-how, and any other results of the Work. “Work Product” does not include any material that was developed prior to the Effective Date of any PO that may result from this solicitation that is used, without modification, in the performance of the Work.

Section 3.0 ACRONYMS AND ABBREVIATIONS

3.1. THE FOLLOWING LIST IS PROVIDED TO ASSIST THE READER IN UNDERSTANDING CERTAIN ACRONYMS AND ABBREVIATIONS USED IN THIS CONTRACT:

3.1.1. ADRC - Aging and Disability Resources for Colorado

3.1.2. CFR – Code of Federal Regulations

3.1.3. CHP+ –Child Health Plan Plus

3.1.4. CM – Case Manager

3.1.5. CMA – Case Management Agency

3.1.6. CORA –Colorado Open Records Act, C.R.S. §24–72–200.1, et. seq.

3.1.7. C.R.S. – Colorado Revised Statutes

3.1.8. CPI – Consumer Price Index

3.1.9. CPI-U – CPI for all urban consumers

3.1.10. GIR – Group In-Reach

3.1.11. HCBS - Home and Community-Based Services

3.1.12. HIPAA – Health Insurance Portability and Accountability Act of 1996, as amended.

3.1.13. IIR – Individual In-Reach

3.1.14. ILC - Independent Living Center

3.1.15. LCA – Local Contact Agency

3.1.16. LTSS – Long-term Support Services

3.1.17. MDS - Minimum Data Set

3.1.18. PCI – Payment Card Information

3.1.19. PASRR - Pre-Admission Screening and Resident Review

3.1.20. PHI – Protected Health Information

3.1.21. PII – Personally Identifiable Information

3.1.22. RAE – Regional Accountable Entity

3.1.23. RFP – Request for Proposals

3.1.24. SFY – State Fiscal Year

3.1.25. TC – Transition Coordinator

3.1.26. TCA – Transition Coordination Agency

3.1.27. U.S.C. – United States Code

3.1.28. VARA – Visual Rights Act of 1990

Section 4.0 RESPONDENT’S EXPERIENCE

4.1. ORGANIZATIONAL EXPERIENCE

4.1.1. The Department has determined that it desires specific experience and skills for a Respondent to possess in order for the Respondent to be able to complete the Work efficiently while meeting the demands and deadlines of the Department.

4.1.2. The Department will evaluate the Respondent’s quotation response pertaining to the following:

4.1.2.1. Experience within the last ten years in educating adults with disabilities on their benefit options through Health First Colorado in a person-centered manner. This could include Home and Community-Based Services, Long-Term Services and Supports, Transition Coordination, or other Health First Colorado benefits.

4.1.2.2. Experience working with Medicaid Members and community organizations that are a part of the disability and elderly community.

4.1.2.3. Knowledge of local and non-profit resources that could support adults with disabilities in the community.

QUOTATION RESPONSE 1. Please list the Designated Service Area(s) your organization is submitting a proposal for and how your organization will plan on engaging all Skilled Nursing Facility Medicaid members at least twice a year for Group In-Reach or twice per year for Individual In-Reach.

QUOTATION RESPONSE 2. Provide a detailed description of the Offeror’s organizational experience related to the Statement of Work. Specifically, address how your organization has experience relating to: engaging with the elderly and those with disabilities along with their natural supports in a person-centered format, approach for ongoing education for your staff on updates to Medicaid & Medicare, and describe Offeror’s organization experience working with disability and other community organizations.

QUOTATION RESPONSE 3. Describe in detail the Offeror’s strategy to create and/or improve your working relationship with Skilled Nursing Facilities and other community partners such as Regional Accountable Entitles (RAE), Transition Coordination Agencies (TCA), Area Agency on Aging (AAA), Case Management Agencies (CMA), Aging and Disability Resource Centers (ADRC) or other community agencies in order to support a person in connecting to Medicaid and community resources to address any Social Determinants of Health. How Offeror intends to expand those strategies to cover the Colorado Regions listed in Appendix E that Offeror is offering for. Offeror may select one or multiple Colorado Regions for coverage in Offeror’s response. Include descriptions of any additional contacts and connections that the Offeror has, or would be, used to support your clients.

QUOTATION RESPONSE 4. Provide a detailed description of the strategies and workflow process that the Offeror will use to ensure that all member facing materials are accessible per the Accessibility Standards for Individuals with a Disability, as established by the Office Of Information Technology pursuant to Section §24-85-103 (2.5), C.R.S. and 3) all State of Colorado technology standards related to technology accessibility and with Level AA of the most current version of the Web Content Accessibility Guidelines (WCAG), incorporated in the State of Colorado technology standards.

4.2. PERSONNEL REQUIREMENTS

4.2.1. Respondent shall provide qualified personnel as necessary to perform the Work throughout the term of the PO. If the Department determines that Respondent has not provided sufficient personnel to perform the Work in accordance with the requirements of the PO, Respondent shall provide all additional personnel necessary to perform the Work in accordance with the requirements of the PO at no additional cost to the Department.

4.2.1.1. Upon request by the Department, Respondent shall provide the Department with a list of individuals assigned to the PO and appropriate contact information for those individuals.

4.2.1.1.1. DELIVERABLE: Final list of names of the individuals assigned to the PO

4.2.1.1.2. DUE: Within five Business Days after the Department’s request

4.2.2. Respondent shall ensure personnel assigned to the PO are available for meetings with the Department during the Department’s normal business hours, as determined by the Department. Respondent shall also make these personnel available outside of the Department’s normal business hours and on weekends with prior notice from the Department.

4.2.3. Respondent may subcontract to complete a portion of the Work required by the PO. The conditions for using a Subcontractor or Subcontractors are as follows:

4.2.3.1. Respondent shall provide the organizational name of each Subcontractor and all items to be worked on by each Subcontractor to the Department.

4.2.3.1.1. DELIVERABLE: Name of each Subcontractor and items on which each Subcontractor will work

4.2.3.1.2. DUE: Not later than five days prior to the Subcontractor beginning work

4.2.3.2. Respondent shall obtain prior consent and written approval from the Department for any use of a Subcontractor.

4.2.4. The Key Personnel are as follows:

4.2.4.1. Project Lead

4.2.4.1.1. The Project Lead shall have the following qualifications:

4.2.4.1.1.1. Working knowledge of Medicaid benefits including but not limited to:

4.2.4.1.1.1.1. Knowledge of Long-Term Care Health First Colorado including Home. and Community-Based Services (HCBS).

4.2.4.1.1.1.2. Long-Term Services and Supports (LTSS).

4.2.4.1.1.1.3. Targeted Case Management-Transition Coordination (TCM-TC).

4.2.4.1.1.1.4. Transition Services.

4.2.4.1.1.1.5. In-Home Support Services (IHSS).

4.2.4.1.1.1.6. Consumer-Directed Attendant Support Services (CDASS).

4.2.4.1.1.1.7. Medicare Savings Programs (MSP).

4.2.4.1.1.1.8. Navigate Medicare Advantage Plans.

4.2.4.1.1.1.9. Coordinate with Dual Special Needs Plans (D-SNP)s.

4.2.4.1.1.1.10. Navigate Medicare benefits.

4.2.4.1.1.2. Working knowledge of the role of each community partner including but not limited to:

4.2.4.1.1.2.1. Regional Accountable Entitles (RAEs).

4.2.4.1.1.2.2. Transition Coordination Agencies (TCA).

4.2.4.1.1.2.3. Area Agency on Aging (AAA).

4.2.4.1.1.2.4. Case Management Agencies (CMA).

4.2.4.1.1.2.5. Aging and Disability Resource Centers (ADRC) or other community agencies in order to locate and support a person.

4.2.4.1.2. The Project Lead shall be responsible for all of the following:

4.2.4.1.2.1. Serving as Contractor’s primary point of contact for the Department.

4.2.4.1.2.2. Ensuring the completion of all Work in accordance with the Contract’s requirements. This includes, but is not limited to; ensuring the accuracy, timeliness, and completeness of all work.

4.2.4.1.2.3. Overseeing all other Key Personnel and Other Personnel and ensuring proper staffing levels throughout the term of the Contract.

4.2.5. Additional Key Personnel

4.2.5.1. The Contractor shall use its discretion to determine the number of Other Personnel necessary to perform the Work in accordance with the requirements of this DQ. If the Department determines that Contractor has not provided sufficient Other Personnel to perform the Work in accordance with the requirements of this Contract, Contractor shall provide all additional Other Personnel necessary to perform the Work in accordance with the requirements of this Contract at no additional cost to the Department.

4.2.5.2. The Contractor shall ensure that all Other Personnel have sufficient training and experience to complete all portions of the Work assigned to them. Contractor shall provide all necessary training to its Other Personnel, except for State-provided training specifically described in this DQ QUOTATION RESPONSE 5. Provide a detailed explanation of how the Offeror will provide sufficient personnel to perform the Work, including all of the following:

1. How the Offeror will provide Key Personnel that meets or exceeds the requirements contained in this Statement of Work.

2. How the Offeror will provide and train all Other Personnel so that the Work is completed accurately and in a timely manner. Additionally, include a listing of the position titles for each position related to the Contract, the general responsibilities of that position, the number of individuals filling that position and the numbers of hours each week the position will be dedicated to the Work.

3. Clarify how the Offeror will distribute staff amongst regions if applying for more than one.

4. A plan for how the Offeror will replace all Key Personnel and Other Personnel so that the transition between personnel does not impact on the ability of the Contractor to complete the Work.

Section 5.0 STATEMENT OF WORK/SPECIFICATIONS AND REQUIREMENTS

5.1. ACCESSIBILITY REQUIREMENTS

5.1.1. All work performed as a result of this solicitation and under any PO must comply with all applicable provisions of §§24-85-101, C.R.S., et seq., and the Accessibility Standards for Individuals with a Disability, as established by the Office Of Information Technology pursuant to §24-85-103 (2.5), C.R.S., and all State of Colorado technology standards related to technology accessibility and with Level AA of the most current version of the Web Content Accessibility Guidelines (WCAG), incorporated in the State of Colorado technology standards.

PROJECT SPECIFIC STATEMENT OF WORK

5.1.2. Regional Transition Coordination Meeting

5.1.3. Contractor shall organize and conduct quarterly Regional Transition Coordination Meetings.

5.1.3.1. Contractors may utilize already established meetings with Case Management Agency (CMAs), Regional Accountable Agency (RAEs), or Transition Coordination Agency (TCAs) to convene and facilitate conversations around transition coordination with partners or create a separate transition coordination council/committee.

5.1.3.2. Target Membership of the Regional Transition Coordination meeting may include, but is not limited to, representatives from the following perspectives:

5.1.3.2.1. ADRC/AAA Site.

5.1.3.2.2. Community Providers.

5.1.3.2.3. Case Management Agencies.

5.1.3.2.4. Independent Living Centers.

5.1.3.2.5. Local Government.

5.1.3.2.6. Local Housing Authorities.

5.1.3.2.7. Nursing Facilities.

5.1.3.2.8. Ombudsmen.

5.1.3.2.9. Regional Accountable Entities.

5.1.3.2.10. TCAs.

5.1.3.2.11. Veterans Community Living Centers.

5.1.4. Contractor shall organize and conduct quarterly Regional Transition Coordination Meetings.

5.1.4.1. Some meeting topics that can be covered, but are not limited to, include:

5.1.4.1.1. Regional Resource Document Updates.

5.1.4.1.2. Outreach Opportunities.

5.1.4.1.3. What is working well and what could be improved within the transition process within each region.

5.1.4.1.4. Education series from different community partners to update the group on roles and responsibilities.

5.1.4.1.5. Individual member transition challenges and coordination efforts.

5.1.5. Contractor shall submit quarterly meeting minutes to the Department which shall include, but not be limited to:

5.1.5.1. Meeting invitees.

5.1.5.2. Meeting attendees.

5.1.5.3. General details of what was covered in the meeting.

5.1.5.3.1. DELIVERABLE: Regional Transition Coordination Meeting Minutes

5.1.5.3.2. DUE: Quarterly August 15th, November 15th, and February 15th, and May 15th

5.1.6. Local Contact Agency (LCA) Outreach

5.1.7. Contractor shall develop a Regional Resource Document.

5.1.7.1. Contractor shall distribute the Regional Resource Document as directed by the Department.

5.1.7.2. The Regional Resource Document shall also address CMAs, RAEs, TCAs and other agencies that directly support populations in the Target Audience.

5.1.7.3. The Regional Resource document shall include, at a minimum, the following information from the Contractor’s Region:

5.1.7.4. Housing, food, and caregiver support, including respite options.

5.1.7.5. Diagnosis-specific resources, as relevant.

5.1.7.6. Transportation, Legal Services, and Financial Resources.

5.1.7.7. Contractor shall deliver the Regional Resource Document to the Department for review and approval.

5.1.7.7.1. DELIVERABLE: Regional Resource Document

5.1.7.7.2. DUE: By September 15, 2025

5.1.7.8. Contractor shall update the Regional Resource Document Quarterly to reflect and ensure quality of resource availability.

5.1.7.9. Contractor shall provide the Updated Regional Resource Document as needed and as approved by the Department.

5.1.7.9.1. The update may not be needed and may not be provided by Contractor without approval from the Department.

5.1.7.10. Contractor shall update the Regional Resource Document quarterly and deliver it to the Department for review and approval.

5.1.7.10.1. DELIVERABLE: Updated Regional Resource Document

5.1.7.10.2. DUE: December 15th, March 15th, June 15th.

5.1.8. Group In-Reach

5.1.9. The goal of Group In-Reach is to actively support institutionalized population residents in making an Educated Choice about transitioning to the Community.

5.1.10. The Contractor shall increase Educated Choice about transitioning to the Community while adhering to all Nursing Facility rules and regulations when meeting with a Member.

5.1.11. The Contractor shall conduct at least one Group In-Reach session at each Medicaid-certified nursing facility in the region per each 6-month period of the Contract (or document attempted scheduling if not feasible) and ensure compliance with all of the following:

5.1.11.1. Use Department-approved materials and document attendance.

5.1.11.2. Ensure attendees include, as appropriate: Medicaid Members, Medicare Members, PACE participants, privately praying residents, legal guardians, POAs, and natural supports. Provide Group In-Reach only to individuals age 18 and over.

5.1.12. Group In-Reach Plan

5.1.13. The Contractor shall develop and submit a Group In-Reach Plan to the Department for review and approval.

5.1.13.1. The Group In-Reach Plan shall include the following:

5.1.13.2. Scheduling strategy to visit each Medicaid-certified facility twice per fiscal year.

5.1.13.3. How contractor plans to verify guardianship and conservatorships prior to In-Reach.

5.1.13.4. Topics to be covered during group sessions.

5.1.13.5. Facility engagement plan including how to verify that residents and natural supports were notified.

5.1.13.6. Escalation process, including how to notify the Department of interference.

5.1.13.7. Detail your process of assigning In-Reach Counselors to each Medicaid nursing facility in your regions.

5.1.13.8. Detail how your agency will mitigate possible conflicts of interest if applicable.

5.1.13.8.1. Documented consent that the contractor has read the Group In-Reach portion of the contract and understands the requirements.

5.1.13.9. The Contractor shall deliver the Group In-Reach Plan to the Department for review and approval.

5.1.13.9.1. DELIVERABLE: Group In-Reach Plan

5.1.13.9.2. DUE: Annually, by August 15th

5.1.14. Group In-Reach Presentation

5.1.15. The Contractor shall engage in the Nursing Facility institutionalized population Member and any natural support in a group setting of one or more individuals, and provide the Members with:

5.1.15.1. Information about housing navigation, transition services, Targeted Case Management – Transition Coordination (TCM-TC), Home & Community-Based Services (HCBS), or State Plan benefits, as an alternative to Nursing Facility-based services.

5.1.15.2. Responses to any questions or concerns raised by the Member or the Member’s Natural Support.

5.1.15.3. Referral process to Transition Coordination Agencies, or other agencies, as identified by the State to help members meet their needs in the Community.

5.1.15.4. Current approximate transition coordination timelines.

5.1.15.5. General role and contact information of CMA, RAE, TCA, SNF staff, and LCA regarding community transitions.

5.1.16. The Contractor shall create a Group In-Reach Presentation using training materials provided by the Department to include all required topics. The presentation must be branded with the contractor’s agency.

5.1.17. The Contractor shall deliver the Group In-Reach Presentation to the Department for review and approval prior to use.

5.1.17.1. DELIVERABLE: Group In-Reach Presentation

5.1.17.2. DUE: Annually, by September 1st

5.1.18. The Contractor shall schedule and facilitate Group In-Reach to residents of a skilled Nursing Facility and their natural supports as directed by the Department.

5.1.19. The Contractor shall provide Group In-Reach to Nursing Facility residents who are willing to participate and have expressed interest in moving to or gaining more knowledge about moving home and Community-Based settings.

5.1.20. Children under the age of 18 are excluded from Group In-Reach.

5.1.21. The Contractor shall provide Group In-Reach in all Medicaid-certified nursing facilities within the Contractor’s designated region.

5.1.22. Medicaid Members may or may not be residing at the Nursing Facility at the time Group In-Reach is provided.

5.1.23. The Contractor shall work with the Nursing Facility to disseminate an invitation to the Nursing Facility residents and their natural supports.

5.1.24. The Contractor shall coordinate the Group In-Reach meeting with the Nursing Facility via email, phone, in-person meeting, or other means of communication.

5.1.25. If the Nursing Facility interferes with scheduling, after the Contractor shall submit an escalation report to the Department within 30 days. The report shall include the following information:

5.1.25.1. List attempts to schedule Group In-Reach meetings, including the date of the call and the name and title of the person you attempted to contact.

5.1.25.2. Calls to Nursing Facility Social Worker or Social Service Director.

5.1.25.2.1. After the Contractor has made a minimum of two calls.

5.1.25.3. Calls to Nursing Facility Administration.

5.1.25.3.1. After the Contractor has made a minimum of two calls.

5.1.25.4. Emails to Nursing Facility Social Worker/Administrator or Social Service Director.

5.1.25.4.1. After the Contractor has made a minimum of two emails.

5.1.26. The Contractor shall explain and describe the programs available to the Members and/or their natural supports.

5.1.26.1. PERFORMANCE STANDARD: All referrals that are the result of In-Reach should be completed within the system of designation within 4 business days.

5.1.26.2. PERFORMANCE STANDARD: Contractor must complete a Group In-Reach assessment within the system of designation for every Medicaid Skilled Nursing Facility that received Group In-Reach within 4 business days.

5.1.26.3.

5.1.26.4. Contractor shall make a referral only if the member is requesting one, to Individual In-Reach.

5.1.27. The Contractor shall make a referral to the Transition Coordination Agency if Member states they are interested in a Community transition.

5.1.27.1. The Contractor shall obtain a signed Authorization for Release of Information Form from the Member before sending any information to the Member’s chosen TCA or any other agency.

5.1.28. The Contractor shall not assess any Member for the feasibility of transition or cognitive ability.

5.1.29. The Contractor shall explain all transition supports and services provided in the State, regardless of availability in the current region. The Contractor should explain that no transition is guaranteed and that the member is not required to use Medicaid services.

5.1.30. The Contractor shall provide an overview of the transition coordination process with approximate timelines.

5.1.31. The Contractor shall inform that they may relocate to a region within Colorado where the services are available if interested.

5.1.32. The Contractor should inform residents that TCAs can also support residents who wish to transfer out-of-state with the aid of the incoming state’s Medicaid Care Coordinators.

5.1.33. The Contractor shall assign a Group In-Reach Counselor for each Nursing Facility in their contracted region. All Group In-Reach Counselors shall be assigned within four weeks of the Effective Date of the current contract.

5.1.33.1. The Group In-Reach Counselor can facilitate Group In-Reach in one or more Nursing Facilities.

5.1.33.2. The Contractors should work to avoid any staffing conflicts of interest.

5.1.33.2.1. If Contractor foresees any conflict of interest for any staff during the contracting period, Contractor shall create a plan to mitigate these conflicts and submit it to the Department Representative for review and approval prior to the staff member starting work.

5.1.34. The Contractor shall document any Nursing Facility interference via email to the Contract Manager within 30 days of the attempted scheduling of a Group In-Reach meeting.

5.1.34.1. The Contractor shall deliver the Group In-Reach Report to the Department in the format requested by the Department. The report will also include verification from the SNF staff on how both residents and natural supports were invited to the meeting.

5.1.34.1.1.1. DELIVERABLE: Group In-Reach Report

5.1.34.1.1.2. DUE: Monthly, by the 15th of each month following the month for which the report covers

5.2. Individual In-Reach

The Goal of Individual In-Reach is to actively connect with institutionalized population Members in a person-centered manner to answer any individualized questions, in a private setting, that they may have about transitioning into the Community so that they can make an Educated Choice on where they would like to live and receive services.

Individual and Group In-Reach can be conducted on the same day, but must occur separately.

Members who receive Group In-Reach are not required to complete an Individual In-Reach session and should be referred to any service or support deemed necessary for their transition, including but not limited to Transition Coordination.

The Contractor shall conduct Individual In-Reach with Members residing in a Skilled Nursing Facility.

The Contractor must obtain permission from the member's Guardian or Conservator prior to engaging in Individual In-Reach with members, if applicable.

The member can request any of the following parties to attend their Individual In-Reach, and it is not limited to:

Member’s Power of Attorney Member’s Guardian or Conservator Natural Supports of Member Each member who receives Individual In-Reach must be given the option to opt back in to receive it again in 6 months, and must not be automatically opted back in. Members will receive Individual In-Reach every subsequent six months unless the member opts out.

If a member opts out once, the Contractor should inform the Member that they can decide to attend Group In-Reach in the future, request Individual In-Reach in the future, complete a JotForm referral, or talk to SNF staff at any time about transitions.

Members who opt out must be asked to sign the Opt-Out form to verify that they have chosen not to receive the education. Only if the member cannot physically sign can two adults who witnessed the opt-out, sign the form on the member’s behalf. Members themselves can decline to sign, but must be informed that they will be contacted separately to verify opt-out.

Members who have confirmation of incapacitation or significant cognitive decline by a doctorate-level medical provider are not required to receive In-Reach.

Residents who are actively on hospice or palliative care can also be opted out. The contractor must receive written verification from SNF staff.

If a Member states that they would like to opt out, the Contractor shall notate that decision in the system of the Department’s designation within 4 business days and upload verification into system of designation.

All referrals for Individual In-Reach education- verbal, written, or electronic- must be entered into the Department’s designated system (e.g., JotForm).

PERFORMANCE STANDARD: Contractor has 2 business days to accept or deny referrals, and must complete Individual In-Reach for any referrals for Medicaid members that are received, regardless of Medicaid status. Referrals for non-Medicaid members must be declined.

PERFORMANCE STANDARD: In-Reach should occur within 10 business days of the referral being accepted.

Individual In-Reach should be completed in person unless:

The member prefers virtual, Severe weather conditions are present, illness outbreak in the facility or with Contractor, Guardian/Conservator requests for it to be virtual, if the Member has already received Individual In-Reach within the past six months.

The Contractor shall develop and submit an Individual In-Reach Plan to the Department to review and approve.

The Individual In-Reach Plan shall include all the following:

Assignment of In-Reach Counselors for purposes of complete Individual In-Reach at every Medicaid skilled nursing facility within your region.

Outline efforts of future coordination with SNF staff to schedule Individual-In-Reach with members.

Procedures to obtain Guardian/Conservator permission prior to In-Reach and obtain medical capacity provider statements if applicable.

Training schedule for In-Reach Counselors, including specific processes on how the contractor will ensure that everyone providing In-Reach has completed the required training outlined in the LCA Training Document.

Procedures for deliverable tracking, invoice submission, and staff conflict-of-interest mitigation plans.

Documentation of performance standards, timelines, and milestones.

Documented consent that the contractor has read the Individual In-Reach portion of the contract and understands the requirements.

DELIVERABLE: Individual In-Reach Plan DUE: Annually by August 15th The Contractor shall engage the Nursing Facility institutionalized population Medicaid Members in a private setting of the member’s choosing within the SNF to provide the following services:

Home and Community-Based Services (HCBS) Housing Navigation process and CAT referrals if applicable, Program of All-Inclusive Care if available in your region, Long-Term Services and Support benefits that could support the member in their specific needs, Resident’s Rights, including that residents have the option to choose where they live.

Role of Ombudsman, where to find their contact information, and when to contact them.

Transition Services and Targeted Case Management – Transition Coordination (TCM-TC), and reiteration that no transition is ever guaranteed.

Notification that no transition is guaranteed and that residents are not required to use Medicaid services.

Timeline of transition process and referrals to support agencies.

PERFORMANCE STANDARD: All referrals that are a result of Individual In-Reach must be sent within four business days within the system of designation.

The Contractor shall offer Individual In-Reach to all Nursing Facilities Medicaid Members and PACE participants during the inaugural implementation of Individual In-Reach until every NF or PACE resident has been outreached.

Ongoing Individual In-Reach must be offered for Medicaid residents who decide to opt back in, new Medicaid residents within 6 months of admission, or incoming referrals for Medicaid residents.

The Contractor, at a minimum, will document in the system of the Department designation the member’s name, date of meeting, and the Community Living Options that were discussed, and the member’s level of interest in community transition.

PERFORMANCE STANDARD: Contractor must complete an Individual In-Reach assessment for every resident who was offered Individual In-Reach within 4 business days in the system of designation.

If the Nursing Facility declares that a member has a Legal Guardian or Conservator, the Contractor must request a copy of the document. A Legal Guardian or Conservator can only opt a resident out of In-Reach once verification is received by the contractor.

The Contractor can coordinate with Nursing Facility staff via email, phone, in-person meeting, or other professional means of communication.

If the Nursing Facility interferes with scheduling or follow-up, the Contractor shall follow the escalation process in the Group In-Reach section of the contract.

The Contractor shall deliver the Individual In-Reach Report to the Department in the format requested by the Department. The report will include verification of members who opted in and those who opted out of receiving Individual In-Reach.

DELIVERABLE: Individual In-Reach Report DUE: Monthly, by the 15th of each month following the month for which the report covers

5.3. In-Reach SNF Education

5.3.1. The Contractor shall meet with every Skilled Nursing Facility to provide annual training on In-Reach and related topics. Suggested attendees would include the Social Services Director, Nursing Home Administrator, Social Worker, or any other staff member who helps coordinate community transitions.

5.3.2. SNF Education must include:

5.3.2.1. Overview of the community transition process, including referral process to LCAs and Individual In-Reach Overview

5.3.2.2. Group In-Reach Overview to include that the SNF will be required to submit verification on how they invited residents and natural supports,

5.3.2.3. Process for verifying legal guardians or conservators,

5.3.2.4. Process of receiving confirmation of Incapacitation or significant cognitive decline verification from a doctorate-level medical provider,

5.3.2.5. Process of notifying LCAs of members who may have triggers around community transition topics,

5.3.2.6. Escalation process to submit questions, concerns, or request a change in TCA.

5.3.2.7. Answer questions regarding community transitions or In-Reach by SNF staff.

5.3.3. The Contractor must submit a signed copy of the meeting agenda that includes the date of the education along with the signatures of all present parties.

5.3.3.1. DELIVERABLE: Skilled Nursing Facility Education

5.3.3.2. DUE: the 15th of the month following the month that each one was completed. Reporting requirements Section 6.0 COMPENSATION

6.1.1.…