By Cory Gaines | Commentary, Colorado Accountability Project
Untangling a (rather hefty) reader statement about Medicaid.
Be forewarned, the government programs and acronyms pile up fast here. I’ll try my best to get around that, but read carefully and slowly.
It’s been a while because it’s taken a while to learn it, but this post is in response to a reader comment about combining some of Colorado’s Medicaid services under one banner. Before we can touch on that, however, we have to do some prerequisite work first.
A Medicaid waiver seems at first to have no connection to what it actually is, but if you stop and reason it out, the word makes sense. Remember that Medicaid is a program that is run by states, and the states partly fund it. The feds also fund Medicaid via matching dollars. As you might expect, the feds put rules on what they’ll fund. Any state can fund and do nearly anything it likes; for example, Colorado funds medical care for illegal immigrants. This isn’t allowed under federal rules, but as long as Colorado doesn’t use federal money for it, it’s legal.
If a state would like to use federal money for some program, they can apply for (or sometimes the feds offer) a waiver of the normal federal Medicaid reimbursement rules. So, when you read about Medicaid and waivers, what you’re reading about is a federal permission slip to use federal money for any particular program.
Colorado has plenty of waivers and the one I want to discuss in this post today is called the Home and Community Based Services Waivers (HCBS Waiver from here forward). The HCBS Waiver has been around a while and, as its name suggests, allows the state to use federal money to help pay for someone to get care in their homes or perhaps in a community setting instead of needing to be institutionalized. The first link below is for this program.
Quoting that page, an HCBS Waiver is “…an extra set of Health First Colorado (Colorado’s Medicaid program) benefits that you could qualify for in certain cases. These benefits can help you remain in your home and community. HCBS Waivers have extra program rules and some programs may have waitlists.”
There are several different types of HCBS Waivers you can get, but I picked on and included a summary table from the site for you to see. Screenshot 1a is the summary table for a particular type of HCBS Waiver service you can get. Screenshot 1b explains the acronyms at the top right of the table.
As I mention above, HCBS Waivers have been around for a while. From what I can find online, Colorado was one of the first states to offer such extra services, dating back to 1983 and growing ever since. For some background on the Federal law that allowed such programs, check out the second link below. The rationale is in line with the posts from yesterday about early childhood policy recommendations: it’s cheaper and better for the people involved.
I have less doubt about the cheapness of this kind of waiver than I do about the early childhood recommendations from yesterday, though. Institutionalized care is incredibly expensive. You’d have to have a huge bill for home care to come close. In addition, knowing what I myself would want, I imagine that being around family would lead to better health outcomes. Medicine always focuses on the human organism as machine, too often ignoring the interplay of mind and body that has health consequences.
The HCBS Waivers might not be new, but something is and this is what the reader had commented on. The Colorado Department of Healthcare Policy and Financing (HCPF–hereafter I will label it “the Department”) moved some other programs into the HCBS Waiver umbrella.
The third link below is to the Department’s Community First Choice (CFC–hereafter First Choice) Option page. In one sense, First Choice is a new name and new organization for existing programs. In another sense, it’s an expansion of who can get different kinds of care and a way to draw down more federal matching money. Quoting from that page:
“Community First Choice (CFC), also known as 1915(k), is an optional Medicaid program that allows states to offer select home and community based attendant services and supports to eligible members on the State Plan, expanding these long-term care services to more Health First Colorado (Colorado’s Medicaid Program) members.”
Let me reiterate since it’s easy to get lost in the all the programs. That last sentence above has it. Rephrased, it’s saying that they’re expanding coverage options.
Before expanding on that, I need to now mention a couple other things. I told you there was going to be a lot here. Earlier, when I said a reader commented about Medicaid programs, the two things they mentioned were Consumer-Directed Attendant Support Services (CDASS — hereafter called Consumer Directed Services) and In-Home Support Services (IHSS — hereafter called In Home Services). Links for these programs are listed fourth and fifth below respectively.
In addition to reading on my own, I reached out to The Department’s spokesperson with some questions, in particular the way that long-term care programs were combined and why. Quoting from the statement I got back (with links intact):
“Colorado implemented Community First Choice, or CFC, on July 1, 2025. CFC did not combine Colorado’s Home and Community-Based Services waivers, Consumer-Directed Attendant Support Services (CDASS) and In-Home Support Services (IHSS) into a single program. Instead, CFC is a Medicaid State Plan benefit (existing under a 1915(k) waiver authority) that makes certain long-term services and supports available to eligible Health First Colorado members outside of a traditional HCBS 1915(c) waiver. CDASS and IHSS are service-delivery options available through CFC for certain services, including personal care, homemaker and health maintenance activities.”
“An eligible member does not need to be enrolled in an HCBS waiver to receive CFC services. Members must meet Health First Colorado eligibility requirements, meet the applicable institutional level-of-care criteria (i.e. Nursing Facility or Hospital), and have an assessed need for the service.”
“Members who also qualify for an HCBS waiver may receive CFC services alongside other waiver-specific services, as long as the services are not duplicative. CFC does not replace existing Colorado’s HCBS waivers, which continue to provide services that are not available through CFC.”
“Colorado pursued CFC to expand access to home and community-based services, increase member choice and opportunities for self-direction, and make more effective use of federal Medicaid funding. CFC also provides Colorado with an additional six percentage points in federal matching funds for qualifying CFC services.”
And lastly, “For many members who were already receiving personal care or similar services through an HCBS waiver, the change primarily affects the Medicaid authority under which those services are provided. Members may continue to receive waiver-specific services through their waiver while receiving qualifying services through CFC.”
Again, hitting the high notes, this is a reorganization that allows more people to access Medicaid services and it helps draw down more federal money for them. The HCBS Waiver has been around since forever, and, according to The Department’s spokesperson, the two other programs folded into First Choice have been around since 2022 or for two decades (for Consumer Directed and Home Services respectively). Nothing new here, just moving them around.
There is a lot to digest. You have an existing program/program category. The overarching idea here is to allow people to be cared for in homes or community centers as opposed to care in an institution.
On top of that, you have programs which allow people more choice in who delivers the care, and how they deliver it. This by the way is care that now moves beyond things like a nurse coming to your home to help you maintain a functioning airway, things medical. We are also talking about (if you look in the links) care that includes, for example, homemaking services–help in doing your dishes and preparing meals.
Another big theme here is one we’re all becoming more familiar with, and that’s extension of services to more people and trying to squeeze more money out of the federal government.
To me, looking in on things like this from the outside, I have to say it’s a mixed pickle. There are parts of this system that make sense (paying for home vs. institutional care), and parts that don’t (expanding care more and more vs focusing on how to make the current system sustainable).
The problem is certainly on the scale of the departments themselves.
In the second post today, a quick look at an asked-for and granted ruling from the federal government about payments for care and taxes.
https://hcpf.colorado.gov/hcbs-waivers
https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915c
https://hcpf.colorado.gov/community-first-choice-option
https://hcpf.colorado.gov/consumer-directed-attendant-support-services
https://www.google.com/url?q=https://hcpf.colorado.gov/in-home-su
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