Health First Colorado (Colorado Medicaid) Long Term Care Programs, Benefits & Eligibility
Summary
Medicaid is a joint federal and state program, so its rules, coverage plans and even its name all vary by state. This article focuses on Colorado Medicaid Long Term Care for seniors. This is different from regular Medicaid, which is for low-income people of all ages. In Colorado, Medicaid is called Health First Colorado and is administered by the Colorado Department of Health Care Policy & Financing. Colorado residents can receive long term care benefits through Medicaid in a nursing home, in their home, the home of a loved one or an alternative care facility through one of three programs – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid.
Colorado Medicaid Long Term Care Programs
Nursing Home / Institutional Medicaid
Colorado Medicaid, which is called Health First Colorado, will cover the cost of long term care in a nursing home for eligible Colorado residents who require a Nursing Facility Level of Care. Nursing home coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physician’s visits, prescription medication, medication management, mental health counseling, social activities and assistance with the Activities of Daily Living (eating, bathing, moving, dressing, toileting).
Some of the things that Health First Colorado won’t cover in a nursing home are a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example), personal reading items, plants, flowers, and any care services not considered medically necessary.
Nursing Home Medicaid is an entitlement. This means that eligible Colorado residents who apply are guaranteed by law, aka “entitled,” to receive Nursing Home Medicaid benefits once their application has been approved.
Any Health First Colorado beneficiary who receives nursing home coverage must give most of their income to the state to help pay for the cost of the nursing home. They are only allowed to keep a “personal needs allowance” of $95.97 / month, as of 2023. This can be spent on personal items such as clothes, haircuts, cell phones, etc.
Home and Community Based Service (HCBS) Waivers
Home and Community Based Service (HCBS) Waivers will pay for long term care services and supports that help Health First Colorado (Colorado Medicaid) recipients who require a Nursing Facility Level of Care remain living “in the community” instead of moving to a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long term care services and supports for Colorado residents who live in their home, the home of a loved one or an alternative care facility (similar to an assisted living residence).
Unlike Nursing Home Medicaid, HCBS Waivers are not an entitlement. Remember, entitlement means guaranteed by law. So, even if an applicant is eligible for an HCBS Waiver program in Colorado, they are not guaranteed by law to receive the benefits.
Colorado currently offers one waiver relevant to the elderly population, the Elderly, Blind and Disabled (EBD) Waiver.
Elderly, Blind and Disabled (EBD) Waiver
Colorado’s Elderly, Blind and Disabled (EBD) Waiver should not be confused with Aged Blind and Disabled Medicaid in Colorado, which is detailed in the next section. The EBD Waiver is intended to delay nursing home placement for elderly (age 65+), blind or disabled Colorado Medicaid beneficiaries who require a Nursing Facility Level of Care but live in their own home, the home of a loved one or an alternative care facility. While the EBD Waiver will cover some long term care services and supports in those settings, it will not cover the cost of room and board.
EBD Waiver program participants receive benefits depending on their needs and circumstances. These benefits can include adult day care, meal delivery, home modifications, housekeeping services, Personal Emergency Response Systems and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).
EBD Waiver benefits can be provided by licensed caregivers, but program participants also have the option to self-direct some of their care by hiring relatives (including spouses) or friends as providers for certain services like personal care assistance and housekeeping. EBD Waiver beneficiaries can do this through Consumer-Directed Attendant Support Services (CDASS) or In-Home Support Services (IHSS). If the beneficiary uses CDASS, they are considered the self-directed caregiver’s employer. They also manage their own budget and set their caregiver’s rate of pay. They do, however, have the help of a financial services agency to deal with responsibilities like tax withholding, payments and background checks. With IHSS, the EBD Waiver program beneficiary is not considered the employer. Program participants who do not have the cognitive ability to direct their own care can have a representative make choices for them using either CDASS or IHSS.
The EBD Waiver had 29,040 enrollment spots as of 2022.
Aged Blind and Disabled / Regular Medicaid
Colorado’s Aged Blind and Disabled (ABD) Medicaid provides healthcare and long term care services and supports to low-income Colorado residents who are aged (age 65+) or disabled and live “in the community.” Living “in the community” in terms of Colorado’s ABD Medicaid means living in means living in one’s own home, the home of a loved one or an alternative care facility (similar to an assisted living residence). While Health First Colorado (Colorado Medicaid) will cover some services in all of those settings, it will not cover room and board costs. ABD Medicaid can sometimes be referred to as Regular Medicaid for Seniors, but it should not be confused with the Regular Medicaid that is available for low-income people of all ages.
ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait.
1) Standard ABD Benefits
In addition to medical care, ABD Medicaid benefits can include non-medical services and supports such as in-home personal care, adult day care, home modifications and Personal Emergency Response Systems (PERS). ABD Medicaid beneficiaries qualify for these benefits and services one at a time, which is different from Nursing Home Medicaid, which makes all of its services immediately available for anyone who qualifies. Instead, ABD Medicaid recipients will be evaluated by the state to determine what kind of long term care benefits they need and will receive.
2) Program of All-Inclusive Care for the Elderly (PACE)
Colorado residents who are age 55 or older and have Aged Blind and Disabled Medicaid can coordinate their medical, social service and non-medical personal needs into one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. Colorado’s PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. Colorado’s PACE programs are located in Grand Junction (HopeWest PACE), Denver (InnovAge Colorado PACE), Colorado Springs (Rocky Mountain PACE), Montrose (Senior CommUnity Care of CO) and Lafayette (TRU PACE). More.
Eligibility Criteria For Colorado Medicaid’s Long Term Care Programs
To be eligible for Health First Colorado (Colorado Medicaid), a person has to meet certain financial and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid.
Colorado Nursing Home Medicaid Eligibility Criteria
Financial Requirements
Colorado residents have to meet an asset limit and an income limit in order to be financially eligible for nursing home coverage through Health First Colorado (Colorado Medicaid). For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $2,742 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Health First Colorado beneficiaries who reside in nursing homes are only allowed to keep $95.97 / month of their income as a “personal needs allowance” and must give the state the rest to help offset nursing home costs.
For married applicants with both spouses applying, the 2023 asset limit for nursing home coverage through Health First Colorado is $3,000 combined if the couple will live in separate rooms, and $4,000 combined if they will live in a shared room. And the income limit for married applicants with both spouses applying for nursing home coverage is $5,484 / month combined. For a married applicant with just one spouse applying, the 2023 asset limit is $2,000 for the applicant spouse and $148,620 for the non-applicant spouse, and the income limit is $2,742 / month for the applicant. The income of the non-applicant spouse is not counted.
Colorado Nursing Home Medicaid applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Colorado has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for nursing home coverage through Health First Colorado (Colorado Medicaid) is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. To determine if the Nursing Facility Level of Care requirement is for Medicaid purposes, Colorado uses the Level of Care (LOC) Determination Screening Instrument. This takes into consideration the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, cooking, cleaning and taking medications), as well as cognitive ability.
Colorado Medicaid Home and Community Based Service (HCBS) Waivers Eligibility Criteria
Financial Requirements
Colorado residents have to meet an asset limit and an income limit in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. For a single applicant in 2023, the asset limit for HCBS Waivers in Colorado is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $2,742 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.
For married applicants with both spouses applying, the 2023 asset limit for HCBS Waivers in Colorado is $3,000 combined, and the income limit is $5,484 / month combined. For a married applicant with just one spouse applying, the 2023 asset limit is $2,000 for the applicant spouse and $148,620 for the non-applicant spouse, and the income limit is $2,742 / month for the applicant. The income of the non-applicant spouse is not counted.
HCBS Waiver applicants in Colorado are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Colorado has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for Home and Community Based Service (HCBS) Waivers through Health First Colorado (Colorado Medicaid) is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. To determine if the Nursing Facility Level of Care requirement is for Medicaid purposes, Colorado uses the Level of Care (LOC) Determination Screening Instrument. This takes into consideration the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, cooking, cleaning and taking medications), as well as cognitive ability.
Colorado Aged Blind and Disabled Medicaid Eligibility Criteria
Financial Requirements
Colorado residents have to meet an asset limit and an income limit in order to be financially eligible for Aged Blind and Disabled (ABD) Medicaid through Health First Colorado (Colorado Medicaid). For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $914 / month. Almost all income is counted (IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.) other than COVID-19 stimulus checks and Holocaust restitution payments.
For married applicants, the 2023 asset limit for Health First Colorado’s ABD Medicaid is $3,000 combined between the two applicants/spouses, and the income limit is $1,371 / month combined. These limits apply to married couples with both spouses applying and married couples with just one spouse applying.
While Colorado has a “look-back” period of five years for Nursing Home Medicaid and Home and Community Based Service Waivers applicants to make sure they don’t give away their assets to get under the limit, there is no “look-back” period for ABD Medicaid applicants. However, ABD applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid, or an HCBS Waiver, and those programs will deny or penalize the applicant for giving away assets.
Functional Requirements
The functional requirements for Health First Colorado’s Aged Blind and Disabled (ABD) Medicaid through Health First Colorado (Colorado Medicaid) are being disabled, blind or aged (65 or over). For ABD Medicaid applicants who require in-home services and supports, Health First Colorado will conduct an assessment of their ability to perform the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, cooking, cleaning and taking medications) to determine what kind of services the applicant needs and the state will cover.
One’s home is often their most valuable asset, and if counted toward the asset limit, it would likely cause them to be over the limit for eligibility. However, in some situations the home is not counted against the asset limit. If the applicant lives in their home and the home equity interest (the portion of the home’s equity value that the applicant owns minus any outstanding mortgage / debt) is less than $1,033,00 (as of 2023) then the home is exempt. If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives. If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $1,033,000. These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. More on Medicaid & Homeownership.
Applying For Colorado Medicaid Long Term Care Programs
The first step in applying for Health First Colorado (Colorado Medicaid) Long Term Care coverage is deciding which of the three Medicaid programs discussed above you or your loved one wants to apply for – Nursing Home Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid.
The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for Health First Colorado when not financially eligible will result in the application, and benefits, being denied.
During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Health First Colorado applicant. These documents will be needed for the official Medicaid application. Necessary documents include five years of quarterly bank statements from all accounts; the most recent monthly or quarterly statements from all investments, IRAs, 401Ks, annuities and any other financial accounts; a letter from the Social Security Administration showing the applicant’s gross Social security income and deductions; tax forms to verify income streams including wages, pensions, royalties and interest; lists of items of any trusts; proof life insurance (if the applicant has any) and a list of beneficiaries; Power of Attorney documentation.
After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Colorado residents can apply for Health First Colorado online here. They can also call the Colorado Department of Human Services at 1-800-221-3943, or they can download, complete and submit an Application for Health Insurance & Help Paying Costs.
Choosing a Colorado Medicaid Nursing Home
After an applicant has been approved for nursing home coverage through Health First Colorado (Colorado Medicaid), they need to choose which Medicaid-approved nursing home they will live in. Even though Medicaid nursing home coverage is an entitlement, Health First Colorado will only cover stays and care in approved nursing homes. This Colorado Department of Public Health & Environment webpage can help you find and compare Medicaid-approved nursing homes across the state. Colorado residents can also use Nursing Home Compare, which is a federal government website that has information about more than 15,000 nursing homes across the country. All of the nursing homes on this site are either Medicaid- or Medicare-approved.