RFI 2027-0010 Posted to CORE.pdf

RFI UHAA 2027-0010

TITLE: Medical Frailty Determination Services:

Medicaid Community Engagement Exemption

Released: [8/6/2026]

THIS IS A REQUEST FOR INFORMATION (RFI) ONLY

THIS IS NOT A FORMAL BID SOLICITATION.

NO AWARD WILL RESULT FROM THIS RFI

Table of Contents

SECTION 1.0 OVERVIEW

1.1. DEPARTMENT BACKGROUND

1.2. PURPOSE

1.3. PROJECT BACKGROUND

SECTION 2.0 DESIRED SCOPES OF SERVICES

2.2. MEDICAL FRAILTY DETERMINATION APPROACH

2.3. OPERATIONAL CONSIDERATIONS

2.4. ANTICIPATED TIMEFRAMES

2.5. STANDARDIZED AND PROGRAM RELATED REPORTING

2.6. ELIGIBILITY PROCESSING INFORMATION

2.7. APPEAL AND QUALITY ASSURANCE

2.8. INFORMATION SECURITY AND PRIVACY

SECTION 3.0 RESPONSE INFORMATION

3.1. CONFIDENTIALITY

3.2. INFORMATION REQUESTED

3.3. GENERAL QUESTIONS

SECTION 4.0 ADMINISTRATIVE INFORMATION

4.1. POINT OF CONTACT

4.2. NOTICES AND COMMUNICATIONS

4.3. TIMELINE AND SCHEDULE OF ACTIVITIES

4.4. RESPONSE MATERIAL OWNERSHIP

4.5. VENDOR ASSISTANCE

SECTION 5.0 RESPONSES

5.1. INQUIRIES

5.2. RESPONSE FORMAT

5.3. RFI TERMS AND CONDITIONS

SECTION 6.0 EXAMPLE FORMS (ATTACHED)

- WORK REQUIREMENTS WORKSHEET (Worksheet J)

- WORK REQUIEMENTS FORM

RFI UHAA 2027-0010 Page 1 of 15

SECTION 1.0 OVERVIEW

1.1. DEPARTMENT BACKGROUND

1.1.1. The Department of Health Care Policy and Financing (HCPF) 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 health care programs for Coloradans who qualify. For more information about the Department, visit www.Colorado.gov/HCPF.

1.1.2. 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.

1.1.3. 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.

1.2. PURPOSE

1.2.1. The Department is conducting market research to better understand the capabilities of organizations that may be able to provide independent medical frailty determination services for Medicaid members requesting a specified exclusion based on medical frailty from the Medicaid Community Engagement requirements that are necessary to comply with the newly enacted federal requirements introduced under H.R.1. Vendors responding to this RFI should be familiar with applicable provisions of Public Law 119-21, CMS-2454-IFC, and 42 CFR

Part 435 governing community engagement requirements, specified exclusions, verification requirements, program integrity expectations, and medical frailty determinations.

https://cohcpf.sharepoint.com/sites/PurchasingContracting/PSA/Shared%20Documents/Section%20Processes/Drafting%20Templates/Solicitation%20Templates/RFI/www.Colorado.gov/HCPF

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1.2.2. The purpose of this Request for Information (RFI) is to better understand the qualifications, clinical capabilities, operational approaches, technology solutions, and staffing models of organizations that may be able to support the State in evaluating whether an individual's physical, mental, intellectual, developmental, substance use-related, or other behavioral health condition significantly impairs the individual's ability to comply with Medicaid community engagement requirements, consistent with federal law and implementing regulations. The

Potential Service Components is intended solely to facilitate responses to this RFI).

It reflects the Department’s current understanding of the services that may be needed but does not represent final procurement requirements, evaluation criteria, or contractual obligations. The Department has also included two exhibits in order to better understand the work requirements and exemption processes, located in Section 6.0 Forms Exhibits. Information received may be used to refine future procurement documents.

1.2.3. The Department welcomes recommendations from respondents regarding industry best practices, operational models, staffing approaches, reporting capabilities, technology solutions, and any other considerations that would improve the effectiveness or efficiency of these services.

1.3. PROJECT BACKGROUND

1.3.1. The Medicaid Community Engagement program includes a specified exclusion for individuals who are determined to be medically frail and meet the applicable medical frailty criteria. The medical frailty provision is intended to identify individuals who meet one or more of the statutory medical frailty categories or whose physical, mental, or other behavioral health condition significantly impair their ability to comply with the community engagement requirement. Medical frailty functions as a specified exclusion rather than a hardship or temporary exemption. The Department has included

RFI UHAA 2027-0010 Page 3 of 15

1.3.2. The Department is exploring approaches for obtaining independent medical frailty assessments for Medicaid applicants and beneficiaries seeking a specified exclusion from the community engagement requirement. The Department is interested in understanding the capabilities of organizations that can conduct timely, consistent, and clinically sound reviews of medical, behavioral health, and functional information; apply state-defined medical frailty criteria in a uniform manner; produce well-supported and well-documented determinations; and support state oversight, quality assurance, appeals, reporting, and related administrative processes. The Department is also interested in understanding vendors’ approaches to assessing functional limitations and their ability to support consistent application of medical frailty criteria across a large and diverse Medicaid population.

SECTION 2.0 DESIRED SCOPES OF SERVICES

2.1.1. The Department is interested in learning how vendors would provide independent medical frailty determination services. The Department is interested in vendor feedback based on an estimated annual referral volume of approximately 100,000 determinations. Referral volume is expected to fluctuate, and respondents are encouraged to describe how they would accommodate varying workload. Potential responsibilities may include:

2.1.1.1. Receiving referrals from counties or other designated eligibility entities.

2.1.1.2. Reviewing available medical, behavioral health, and functional documentation.

2.1.1.3. Requesting additional supporting documentation when necessary.

2.1.1.4. Conducting clinical reviews and, when appropriate, interviews or other information gathering activities.

2.1.1.5. Evaluating whether an individual's condition substantially limits the individual's ability to comply with Community Engagement requirements.

2.1.1.6. Documenting the clinical rationale supporting each determination.

2.1.1.7. Supporting HCPF during appeals, audits, and quality assurance activities.

RFI UHAA 2027-0010 Page 4 of 15

2.1.1.8. Respondents are encouraged to describe any additional services or capabilities they believe would improve the determination process.

2.2. MEDICAL FRAILTY DETERMINATION APPROACH

2.2.1. The Department is interested in understanding how vendors would evaluate medical frailty in a manner that promotes consistency, fairness, clinical accuracy, and compliance with applicable Medicaid Community Engagement requirements.

2.2.2. Medical frailty determinations conditions such as:

2.2.2.1. Blindness

2.2.2.2. Substance Use Disorder

2.2.2.3. Disabling mental illness

2.2.2.4. Physical, intellectual, or developmental disabilities that significantly impair one or more Activities of Daily Living

2.2.2.5. Serious or complex medical conditions

2.2.3. The Department anticipates that determinations would consider multiple sources of information, which may include:

2.2.3.1. Medical records

2.2.3.2. Behavioral health records

2.2.3.3. Functional assessments

2.2.3.4. Provider documentation

2.2.3.5. Disability determinations

2.2.3.6. Activities of Daily Living (ADL) assessments

2.2.3.7. Other relevant clinical evidence

The Department is interested in understanding how vendors ensure that determinations are based on an overall assessment of functional impairment rather than diagnosis alone.

2.3. OPERATIONAL CONSIDERATIONS

RFI UHAA 2027-0010 Page 5 of 15

2.3.1. HCPF is interested in vendor feedback regarding operational models, including:

2.3.1.1. Referral intake processes

2.3.1.2. Staffing models

2.3.1.3. Clinical qualifications of reviewers

2.3.1.4. Escalation procedures

2.3.1.5. Quality assurance programs

2.3.1.6. Documentation management

2.3.1.7. Communication with referring entities

2.3.1.8. Member facing communications

2.3.1.9. Appeal support

2.3.2. Technology Integrations, including:

2.3.2.1. Experience integrating with eligibility systems

2.3.2.2. Secure document exchange

2.3.2.3. Case management platforms

2.3.2.4. Application Programming Interface (APIs) or electronic referral capabilities

2.3.2.5. Reporting dashboards

Respondents should describe how they ensure consistency among reviewers and maintain quality across determinations.

2.4. ANTICIPATED TIMEFRAMES

The Department is interested in understanding vendors' ability to support timely determinations. Respondents are encouraged to describe:

2.4.1.1. Typical turnaround time for standard determinations

2.4.1.2. Ability to accommodate expedited requests

2.4.1.3. Processes for handling incomplete referrals

2.4.1.4. Factors that may affect processing timelines

RFI UHAA 2027-0010 Page 6 of 15

2.4.1.5. Recommended service-level expectations

2.4.2. As a point of reference, the Department is interested in researching service models that could support:

2.4.2.1. Standard determinations within approximately 10 business days following receipt of all necessary documentation.

2.4.2.2. Expedited determinations within approximately three business days when appropriate.

2.4.2.3. Notification regarding incomplete referrals within approximately two business days.

2.5. STANDARDIZED AND PROGRAM RELATED REPORTING

2.5.1. The Department anticipates that future services may include standardized reporting.

Respondents are encouraged to describe their ability to provide information such as:

a. Individual Determination Information, including:

i. Member identifier

ii. Referral receipt date

iii. Determination date

iv. Determination outcome

v. Clinical rationale summary

vi. Medical frailty category

vii. Temporary or permanent designation

viii. Effective date

ix. Review date (if applicable)

b. Program Reporting, including:

i. Potential programmatic reporting capabilities that may include:

RFI UHAA 2027-0010 Page 7 of 15

(1) Referral volumes

(2) Approval and denial rates

(3) Processing timelines

(4) Geographic trends

(5) Referral sources

(6) Quality metrics

(7) Appeals activity

(8) Operational dashboards

Respondents are encouraged to provide examples of standard reports available through their organization.

2.6. ELIGIBILITY PROCESSING INFORMATION

2.6.1.1.1. The Department is interested in approaches that provide eligibility staff with the minimum information necessary to support eligibility processing while appropriately protecting sensitive health information.

How would the respondents describe the process for separating clinical information from administrative outputs.

2.7. APPEAL AND QUALITY ASSURANCE

2.7.1. The Department is interested in understanding how vendors support:

2.7.1.1. Internal quality assurance

2.7.1.2. Clinical peer review

2.7.1.3. Appeals preparation

2.7.1.4. Audit support

2.7.1.5. Continuous quality improvement

Please describe your organization’s quality assurance methodology, review frequency, and corrective action processes.

2.8. INFORMATION SECURITY AND PRIVACY

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2.8.1. Because medical frailty determinations involve sensitive health information, The

Department is interested in understanding vendors' experience with protecting confidential information and complying with applicable federal and state privacy requirements.

Respondents are asked to describe:

2.8.1.1.1. Information security controls

2.8.1.1.2. Secure transmission methods

2.8.1.1.3. Access controls

2.8.1.1.4. Record retention practices

2.8.1.1.5. Incident response procedures

2.8.1.1.6. Experience supporting government healthcare programs

SECTION 3.0 RESPONSE INFORMATION

3.1. CONFIDENTIALITY

3.1.1. All responses to this RFI shall be considered confidential until after an award based on a subsequent solicitation has been made or until the Procurement Official from the issuing agency determines that the Department will not pursue a solicitation based on this RFI. After such time, the responses to this RFI shall be open to public inspection in accordance with the provisions of the Colorado Open Records Act.

Reference §24-103-201.5(4), C.R.S.

3.1.2. The Department reserves the right to have information submitted in response to this RFI be reviewed by other entities within the State for purposes of compiling and analyzing possible options.

3.2. INFORMATION REQUESTED

3.2.1. Vendor Feedback

3.2.1.1. The Department is requesting vendors to send any comments or answers, no matter how minor, to the Department. Vendors are encouraged to address the questions listed below.

RFI UHAA 2027-0010 Page 9 of 15

3.2.1.2. The Department encourages vendors to submit feedback regarding the RFI as soon as possible. Vendors do not need to wait until August 20, 2026 (see Section

4.3) to submit comments. In addition, vendors may have multiple submissions, as not all comments and answers need to be under a single submission. The

Department appreciates receiving any and all comments from vendors.

3.3. GENERAL QUESTIONS

Provide a brief overview of the following areas, including all subsections mentioned:

a. Respondents Organization, including:

i. Company overview

ii. Number of years in business

iii. Number of employees

iv. The Nature of the services this business provides

v. Years of providing similar services

vi. Relevant Medicaid experience

vii. Relevant state government experience

viii. Description of current clients

b. Clinical Operations, including:

i. Clinical staffing model

ii. Reviewer qualifications

iii. Medical specialties represented

iv. Quality assurance process

c. Operational Capacity, including:

i. Anticipated referral capacity

ii. Average turnaround times

iii. Technology platforms used

RFI UHAA 2027-0010 Page 10 of 15

iv. Data required to perform the Scope of Work

v. Reporting capabilities

d. Implementation, including:

i. Estimated implementation timeline

ii. Training approach

iii. Transition support

iv. Recommendations for implementation

The Department welcomes any recommendations regarding the following:

a. Alternative workflows

b. Innovative service delivery models

c. Performance metrics

d. Reporting approaches

e. Technology solutions

f. Risks or implementation considerations

g. Best practices observed in other states

How would the Respondents organization approach independent medical frailty determinations for a Medicaid population?

How would the Respondent approach the development of an auditable framework around their approach?

What staffing model would you recommend?

What information, including data needed, is essential to make consistent clinical determinations?

What reporting capabilities would you recommend?

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What performance measures best demonstrate quality?

What implementation challenges or risks should HCPF anticipate, and what strategies would you recommend to mitigate them?

What recommendations would you make to improve this proposed outline?

What, if any, difficulties may Offerors anticipate experiencing based on the proposed outline?

Are there any sections that require additional information or an alternative approach?

SECTION 4.0 ADMINISTRATIVE INFORMATION

4.1. POINT OF CONTACT

4.1.1. The Department’s sole point of contact for this RFI is:

4.1.1.1. Kim Taylor

4.1.1.2. Kim.Taylor@state.co.us with a cc to hcpf_rfpquestions@state.co.us

4.2. NOTICES AND COMMUNICATIONS

4.2.1. All official communication with vendor organizations will be via notices on the

Colorado Vendor Self Service (VSS) website at https://colorado.gov/vss. It is the vendor’s responsibility to periodically check the Colorado VSS website for notices, changes, additional documents, or amendments that pertain to this RFI.

4.2.2. Vendors can self-register for this system free of charge, or may click on “Public

Access” on the website to view RFI documents and modifications without registering. Vendors are encouraged but not required to register prior to or at the time they submit their response. The Department also recommends that interested vendors check Colorado VSS on a regular basis throughout this RFI process. The

Colorado VSS Help Desk is available Monday through Friday 8:00 a.m. to 5:00 p.m.

MT and can be reached by emailing VSSHelp@state.co.us.

4.3. TIMELINE AND SCHEDULE OF ACTIVITIES

https://colorado.gov/vss mailto:VSSHelp@state.co.us

RFI UHAA 2027-0010 Page 12 of 15

4.3.1. This Timeline and Schedule of Activities is for information and planning purposes only. Schedules of Activities listed as “Estimated” may be subject to change depending on the needs of the Department. All times are stated in Mountain Time

(MT) , as appropriately adjusted for daylight saving time.

4.3.2. The Timeline and Schedule of Activities for this RFI is as follows:

4.3.2.1. INQUIRY DEADLINE August 13, 2026 2:00 PM Mountain Time

4.3.2.2. RESPONSE SUBMISSION DEADLINE August 20, 2026 2:00 PM Mountain Time

4.3.3. Responses must be submitted in the method described below.

4.4. RESPONSE MATERIAL OWNERSHIP

4.4.1. All material submitted in response to this RFI becomes the property of the State.

4.5. VENDOR ASSISTANCE

4.5.1. Any vendors needing support responding to this RFI or other solicitations may contact the Colorado Supplier Diversity Navigator at the Statewide Equity Office of Supplier Diversity. Services provided include assistance with responding to solicitations, interpretation of solicitation documents, technical assistance referrals, availability of resources, construction bond assistance through the

Construction Statewide Bond Assistance Program, and free business directory listings and verifications through the Colorado Supplier Diversity Directory. The office can be reached during normal business hours by calling 303-866-5765 or emailing DPA_SupplierDiversityHelp@state.co.us.

SECTION 5.0 RESPONSES

5.1. INQUIRIES

5.1.1. Submit all inquiries by electronic mail (email) to Kim.Taylor@state.co.us with a cc to hcpf_rfpquestions@state.co.us. The email should include the following:

5.1.1.1. The RFI number and title listed in the email subject line.

5.1.1.2. The section or line numbering in the RFI that precedes the text on which the inquiry is based. Follow the numbering with the vendor organization’s question(s) pertaining to that text in the RFI.

https://urldefense.proofpoint.com/v2/url?u=https-3A__dhr.colorado.gov_statewide-2Dequity-2Doffice_supplier-2Ddiversity&d=DwMFaQ&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=2K9kkYDPzg9W7wrnb9URPPzWuzXzmzc6oQUqmP_d9mA&m=UsSCoCc_Nnj_It7iTj2w9Xh-U0kW8zKwh7sIdTrgvW_OXQDDQG8CMBmOZsCmKo6l&s=AHk9LQL8xQKwtYW6AlMhIpKhc64M4gHnBm1wvGiKqhU&e= https://urldefense.proofpoint.com/v2/url?u=https-3A__dhr.colorado.gov_statewide-2Dequity-2Doffice_supplier-2Ddiversity&d=DwMFaQ&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=2K9kkYDPzg9W7wrnb9URPPzWuzXzmzc6oQUqmP_d9mA&m=UsSCoCc_Nnj_It7iTj2w9Xh-U0kW8zKwh7sIdTrgvW_OXQDDQG8CMBmOZsCmKo6l&s=AHk9LQL8xQKwtYW6AlMhIpKhc64M4gHnBm1wvGiKqhU&e= https://urldefense.proofpoint.com/v2/url?u=https-3A__dhr.colorado.gov_supplier-2Ddiversity_construction-2Dand-2Dbond-2Dassistance&d=DwMFaQ&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=2K9kkYDPzg9W7wrnb9URPPzWuzXzmzc6oQUqmP_d9mA&m=UsSCoCc_Nnj_It7iTj2w9Xh-U0kW8zKwh7sIdTrgvW_OXQDDQG8CMBmOZsCmKo6l&s=zAjgTZu5BkDViYCi42ZSaaEFbnZ4EzaMtQulSrBPsw8&e= https://urldefense.proofpoint.com/v2/url?u=https-3A__dhr.colorado.gov_supplier-2Ddiversity_colorado-2Dsupplier-2Ddiversity-2Ddirectory&d=DwMFaQ&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=2K9kkYDPzg9W7wrnb9URPPzWuzXzmzc6oQUqmP_d9mA&m=lJCgtcQ4bpjUYTb-DL2vTiTtjs5tP9GdjxCxohJukG4cRYarpnnyVjmEkozBFRPl&s=nq-3ZxXvzK0CyjE_Sukw4DfkzHfxneqrfzbnzxsO-hw&e= mailto:DPA_SupplierDiversityHelp@state.co.us

RFI UHAA 2027-0010 Page 13 of 15

5.1.2. Inquiries received by the Department by the Inquiry Deadline will be responded to by the Department via a posting on the Colorado VSS website. Inquiries received after the Inquiry Deadline may not be included in the Department’s response.

5.1.3. The Department will not accept inquiries submitted through the Colorado VSS website.

5.2. RESPONSE FORMAT

5.2.1. Submit all responses to the RFI by electronic mail (email) to the Point of Contact identified in Section 4.1 above with a cc to hcpf_rfpquestions@state.co.us and show as the subject line: “Response submission from (insert respondent name) for

UHAA 2027-0010.” The Department will not accept responses submitted through the Colorado VSS website.

5.2.2. The responses should:

5.2.2.1. Be presented in a writing format that is self-explanatory on pages that are consecutively numbered in a consistent numbering format.

5.2.2.2. Repeat the numbered “RFI Response” items from the RFI in bold font with the vendor organization’s response in unbolded font following the “RFI Response” item.

5.2.2.3. Answer all RFI Responses in a concise manner.

5.2.2.4. Present attachments, if any, with labels according to the numbered RFI

Response item or topic covered within the attachment in a commonly accessible file type.

5.2.3. Any response that fails to respond to the RFI Responses or is purely promotional material may be disregarded.

5.3. RFI TERMS AND CONDITIONS

5.3.1. This RFI is issued solely for information and planning purposes and does not constitute a solicitation. Information about costs and pricing is submitted voluntarily and is non-binding on the respondent. Responses to this RFI will not be considered legal offers nor will they result in an award of any type of contract.

mailto:hcpf_rfpquestions@state.co.us

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5.3.2. The Department is not responsible for any costs incurred by a vendor organization for the development and provision of a response to this RFI.

5.3.3. The Department is subject to strict accountability and reporting requirements as a recipient of funds from public sources. Responses to this RFI are subject to disclosure by the Department as required by the Colorado Open Records Act

(CORA). See also Section 4.4.8 below. All material submitted in response to this

RFI becomes the property of the State.

5.3.4. The Department reserves the right to copy any information provided by responding vendor organizations for the purposes of facilitating the Department’s review of use of the information.

5.3.5. The Department reserves the right to use information or ideas that are provided by responding vendor organizations in the vendor’s response. By submitting information in response to this RFI, the vendor represents that such copying or use of information will not violate any copyrights, licenses, or other agreements with respect to information submitted.

5.3.6. The responses received from this RFI may be used for the development of a future solicitation. Should a solicitation be issued, further details on the solicitation process will be provided.

5.3.7. Respondents shall not issue any news releases, communications, or announcements of any kind pertaining to this RFI without prior written approval by the Department.

5.3.8. Submission of Confidential or Proprietary Information

5.3.8.1. As per §24-103-201.5, C.R.S, all responses to requests for information are confidential until after an award based on a subsequent solicitation has been made or until the procurement official determines that the state will not pursue a solicitation based on the RFI. After such time, the responses to a RFI shall be open to public inspection in accordance with the provisions of the “Colorado

Open Records Act”, part 2 of the article 72 of this title 24.

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5.3.8.2. A Respondent may submit, as a part of its Response, a written request for classification of certain portions of the response as a trade secret or other confidential or proprietary information. Material for which the Respondent is requesting confidentiality shall be readily identifiable and separated from other portions of the response to facilitate public inspection of the non-confidential portion of the response. Commingling of confidential and non-confidential information is not acceptable. Neither price information nor any information that will be included in a resulting Contract or purchase order will be considered confidential.

5.3.8.3. The Respondent must include the rationale for any request to classify portions as a trade secret or confidential or proprietary, including references to the authority that allows for such treatment.

5.3.8.4. A complete redacted response should also be included along with an unredacted

Response and confidentiality justification.

5.3.8.5. Except as provided in Section 1.3 above, in no event shall an entire response be classified as confidential. The Procurement Official or his or her designee shall determine if the information identified in the Respondent’s request is exempt from disclosure in accordance with §24-72-204, C.R.S., and shall inform the Respondent in writing of his or her determination.

SECTION 6.0 EXAMPLE FORMS (ATTACHED)

- WORK REQUIREMENTS WORKSHEET (Worksheet J)

- WORK REQUIREMENTS FORM

Work Requirements

Answer yes or no to each question below.

1. Are you a parent, guardian, caretaker relative or family caregiver responsible for a child aged 13 or younger? Yes No

2. Are you a parent, guardian, caretaker relative or family caregiver responsible for caring for a person of any age, who has a disability? Yes No

3. Are you currently pregnant or were you pregnant within the last 12 months? Yes No

4. Are you a veteran with a service-connected disability that the U.S. Department of Veterans Affairs (VA) has determined to have either: A 100% disability rating (temporary or permanent) OR a Total Disability based on Individual Unemployability (TDIU), even if your combined disability rating is below 100%? Yes No

5. Are you in a treatment program for a drug or alcohol use disorder? Yes No

6. Are you living in a jail, prison or other correctional facility now or in the past three months? Yes No

7. Are you living with a drug or alcohol use disorder that prevents you from completing 80 hours per month of work, school, and/or volunteer activities? Yes No

8. Have you been in recovery from a drug or alcohol use disorder for 5 years or less that prevents you from completing 80 hours per month of work, school, and/or volunteer activities? Yes No

9. Are you living with a physical, intellectual, or developmental disability that makes it hard to do daily activities and that prevents you from completing 80 hours per month of work, school, and/or volunteer activities? Yes No

10. Are you living with a disabling mental health disorder that prevents you from completing 80 hours per month of work, school, and/or volunteer activities? Yes No

11. Are you living with a serious health condition that requires regular treatment that prevents you from completing 80 hours per month of work, school, and/or volunteer activities? Yes No

12. Are you blind, and does your condition prevent you from completing 80 hours per month of work, school, and/or volunteer activities? Yes No

13. Are you living in a hospital, nursing home or other long-term care facility now or in the past three months? Yes No

14. Are you receiving long-term care services (for example, in a nursing home or through home-based care)? Yes No

15. Are you receiving Supplemental Security Income (SSI) and/or Social Security Disability Insurance (SSDI)? Yes No

Worksheet J

Person 1 Name: Date of Birth:

You are applying for Health First Colorado (Colorado’s Medicaid program). Some Health First Colorado members must comply with specific work requirements, also known as community engagement requirements, to receive or keep their coverage. This worksheet shows us if you need to comply with work requirements. All household

Worksheet J continues on next page members between the ages of 19 and 64 must answer all questions in this worksheet, even if they believe they don’t need to comply with work requirements.

This is not a disability application. If you have a disability and would like to apply for disability benefits, contact your eligibility site.

If you have more than one person in your household who is between ages 19 and 64, make a copy of this worksheet before you complete it.

If you answer ‘yes’ to any of the questions in this worksheet, you may receive a letter asking for proof of the information you provided. Please respond to all letters we send you by the deadline in the letter.

M ake copies of these pages if necessary.

Worksheet J continues on next page

Person 1 Name: Date of Birth:

Work Requirements (ctd.)Worksheet J

16. Are you 18 or younger? Yes No

17. Are you 65 or older? Yes No

18. Do you qualify for, or are you enrolled in Medicare? Yes No

19. Were you in foster care when you turned 18 and are you now between ages 19 and 26? Yes No

20. Are you an American Indian or Alaska Native (AI/AN)? Yes No

21. If you are an American Indian or Alaska Native (AI/AN), are you eligible for Indian Health Services (IHS), a Tribal Health program, or an Urban Indian Health program? Yes No

22. If you are an American Indian or Alaska Native (AI/AN), have you ever received services from Indian Health Services (IHS), a Tribal Health program, or an Urban Indian Health program, now or in the past? Yes No

23. Have you applied for, or are you already receiving, Supplemental Nutrition Assistance Program (SNAP) or Colorado’s Temporary Assistance for Needy Families (TANF) benefits? Yes No

24. If you are applying for the first time, go to question a. If you are renewing your health coverage, skip question a and go to question b.

24a. First time applicants a1. Did you earn at least $580 in the calendar month before you submitted your application?

Yes. Go to the Signature section.

No. Proceed to question a2.

�a2. In the calendar month before you submitted your application, did you go to school or spend at least 80 hours working, participating in a work program, volunteering, or a combination of these activities?

Yes, in the calendar month before I submitted my application, I went to school or spent at least 80 hours working, participating in a work program, volunteering or a combination of these activities. Complete the table on the following page for each activity.

No. Go to the Signature section.

24b. Renewing applicants b1. Did you earn at least $580 in at least one calendar month since your last renewal?

Yes. Go to the Signature section.

No. Proceed to question b2

� b2. In at least one month since your last renewal date, did you go to school or spend at least 80 hours working, participating in a work program, volunteering, or a combination of these activities?

� Yes, since the last renewal date, I went to school or spent at least 80 hours working, participating in a work program, volunteering or a combination of these activities. Complete the table on the following page for each activity.

No. Go to the Signature section.

M ake copies of these pages if necessary.

Work Requirements (ctd.)

End of Worksheet J

Worksheet J

Person 1 Name: Date of Birth:

I certify, under penalty of perjury, that the information I have provided on this form is true and complete to the best of my knowledge. I understand that I may be required to provide documentation or verification of the hours or information I provided. I understand that if I don’t complete the required number of hours, or prove I do not need to complete them, it may affect my Health First Colorado benefits.

Applicant’s Signature

Applicant’s Printed Name

Date (mm/dd/yyyy)

School, organization, or program name, or employer/ job name

Activity type Month and year:

mm/yyyy

Hours for this activity in that month

School Volunteering Work program Work (paid and unpaid)

School Volunteering Work program Work (paid and unpaid)

School Volunteering Work program Work (paid and unpaid)

School Volunteering Work program Work (paid and unpaid)

School Volunteering Work program Work (paid and unpaid)

School Volunteering Work program Work (paid and unpaid)

Signature

Name: Date of birth:

Work Requirements Form You are applying for Health First Colorado (Colorado’s Medicaid program). Some Health First Colorado members must comply with specific work requirements, also known as community engagement requirements, to receive or keep their coverage.

This worksheet shows us if you need to comply with work requirements. All household members between the ages of 19 and 64 must answer all questions in this worksheet, even if they believe they don't need to comply with work requirements.

This is not a disability application.If you havea disability and would like to apply for disability benefits, contact your eligibility site.

If you have more than one person in your household who is between ages 19 and 64, make a copy of this worksheet before you complete it.

If you answer ‘yes’ to any of the questions in this worksheet, you may receive a letter asking for proof of the information you provided.Please respondto all letters we send you by the deadline in the letter.

Answer yes or no to each question below.

Question Yes No

1. Are you a parent, guardian, caretaker relative or family caregiver responsible for a child aged 13 or younger?

2. Are you a parent, guardian, caretaker relative or family caregiver responsible for caring for a person of any age, who has a disability?

3. Are you currently pregnant or were you pregnant within the last 12 months?

Question Yes No

4. Are you a veteran with a service-connected disability that the U.S. Department of Veterans Affairs (VA) has determined to have either:

-A 100% disability rating (temporary or permanent); or

-A Total Disability based on Individual Unemployability (TDIU), even if your combined disability rating is below 100%?

5. Are you in a treatment program for a drug or alcohol use disorder?

6. Are you living in a jail, prison or other correctional facility now or in the past three months?

7. Are you living with a drug or alcohol use disorder that prevents you from completing 80 hours per month of work, school, and/or volunteer activities?

8. Have you been in recovery from a drug or alcohol use disorder for 5 years or less that prevents you from completing 80 hours per month of work, school, and/or volunteer activities?

9. Are you living with a physical, intellectual, or developmental disability that makes it hard to do daily activities and that prevents you from completing 80 hours per month of work, school, and/or volunteer activities?

10. Are you living with a disabling mental health disorder that prevents you from completing 80 hours per month of work, school, and/or volunteer activities?

11. Are you living with a serious health condition that requires regular treatment that prevents you from completing 80 hours per month of work, school, and/or volunteer activities?

12. Are you blind, and does your condition prevent you from completing 80 hours per month of work, school, and/or volunteer activities?

13. Are you living in a hospital, nursing home or other long-term care facility now or in the past three months?

14. Are you receiving long-term care services (for example, in a nursing home or through home-based care)?

15. Are you receiving Supplemental Security Income (SSI) and/or Social Security Disability Insurance (SSDI)?

16. Are you 18 oryounger? ☐ ☐

17. Are you 65 orolder? ☐ ☐

18. Do you qualify for, or are you enrolled in Medicare? ☐ ☐

19. Were you in foster care when you turned 18andareyou now between ages 19 and 26?

20. Are you an American Indian or Alaska Native (AI/AN)? ☐ ☐

21. If you are an American Indian or Alaska Native (AI/AN), are you eligible for Indian Health Services (IHS), a Tribal Health program, or an Urban Indian Health program?

22. If you are an American Indian or Alaska Native (AI/AN), have you ever received services from Indian Health Services (IHS), a Tribal Health program, or an Urban Indian Health program, now or in the past?

23. Have you applied for, or are you already receiving, Supplemental Nutrition Assistance Program (SNAP) or Colorado’s Temporary Assistance for Needy Families (TANF) benefits?

24. If you are applying for the first time, go to question a. If you are renewing your health coverage, skip question a and go to question b.

24a. First time applicants a1.Did you earn at least $580in the calendar monthbefore you submitted your application?

Yes. Go to the Signature section.

No. Proceed to question a2.

a2. In the calendar month before you submitted your application,did you go to school or spendat least 80 hoursworking, participatingin a work program, volunteering, or a combination of these activities?

Yes,in the calendar month before I submitted my application,I went to school or spentat least 80 hoursworking,participating in a work program, volunteering or a combination of these activities.

Complete the table on the following page for each activity.

No. Go to the Signature section.

24b. Renewing applicants b1.Did you earn at least $580in at least one calendarmonth since your last renewal?

Yes. Go to the Signature section.

No. Proceed to question b2.

b2. In at least one month since your last renewal date,did you go to school or spendat least 80 hoursworking, participatingin a work program, volunteering, or a combination of these activities?

Yes,since the last renewal date,I went to schoolor spentat least 80 hoursworking, participating in a work program, volunteering or a combination of these activities.Complete the tableon the following page for each activity.

No. Go to the Signature section.

School, organization, or program name, or employer/ job name

Activity type Month and year:

mm/yyyy

Hours for this activity in that month

School Volunteering Work program Work (paid and unpaid)

School Volunteering Work program Work (paid and unpaid)

School Volunteering Work program Work (paid and unpaid)

Signature

I certify, under penalty of perjury, that the information I have provided on this form is true and complete to the best of my knowledge. I understand that I may be required to provide documentation or verification of the hours or information I provided. I understand that if I don’t complete the required number of hours, or prove I do not need to complete them, it may affect my Health First Colorado benefits.

Applicant’s Printed Name: ______________________________