Board adopts amended LTSS sustainability rule after heated debate over caregiver limits

The Medical Services Board on Friday adopted an amended rule package that aims to curb rapid spending growth in long‑term services and supports while preserving access for people with the greatest needs.

Bonnie Silva, director of the Office of Community Living at the Department of Health Care Policy & Financing, told the board the rules are a targeted response to a sharp increase in utilization that the department says threatens Medicaid sustainability. "If we don't take targeted action, costs will continue to outpace the money that we have available," Silva said, explaining the department sought federal approvals and coordinated state action with an April 1 effective date for some elements.

The adopted package includes a reduction of the annual community connector allotment from 520 to 260 hours per member and language establishing soft caps for personal care, homemaker services and health maintenance activities (HMA). The rules also define an exceptions process enabling members and case managers to request more hours when medically necessary. Silva emphasized the department’s intention that the caps be flexible: the rules include an exceptions review that proceeds from case manager to supervisor to the department.

Board members and public commenters pressed department staff over several provisions, most notably the limits on hours that a legally responsible person (for example a parent or spouse) may be paid for providing homemaker services. Under the language debated at the meeting, payment to a legally responsible caregiver would be limited to five hours per week. Department staff repeatedly stressed that the cap limits reimbursed hours per caregiver, not the total number of hours a child may be authorized; "the limit here is per legally responsible person," Silva said during questioning. The board also heard from dozens of families and advocates who said the five-hour-per‑person ceiling would create inequities for single parents and pose real risks for medically complex children.

After more than three hours of public testimony and board discussion, members agreed to amend the rule package by removing specific homemaker subsections to allow for further work on how caregiver limits are structured. The board then adopted the remainder of the rule package as amended; the motion carried on a recorded voice roll call. Department staff told the board the Joint Budget Committee had included cost savings premised on these changes in the enacted statewide budget, and staff said they lacked the fiscal authority to raise the per‑person homemaker cap at this time.

Why it matters: The changes are intended to slow growth in the long‑term care portion of the Medicaid budget so that Colorado can preserve community services over the long term. Supporters say the changes are targeted to the services driving the fastest growth and include an exceptions process to protect people with higher needs. Opponents including parents and disability advocates say even soft caps will act as de‑facto hard limits if the exceptions path is hard to use, and they warned of disproportionate harm to single parents and families caring for medically fragile children.

What’s next: The department will implement the adopted sections of the rule and work further with stakeholders on the removed homemaker subsections. Advocates said they expect to continue pressing the department and legislators for additional mitigations; the board said it will monitor implementation and exceptions outcomes.

Sources: Department presentations and board discussion; public testimony from advocates and families. Quotes in this story come from the meeting record and were attributed to speakers who identified themselves on the record.