Exemption Process for Clients Exceeding the Annual Service Cap Limits:

Background: 
Effective April 1, 2026 soft caps on home care services were introduced in Colorado, limiting the amount of Personal Care, Homemaker, and Health Maintenance Activities (HMA) services that a Medicaid client can receive annually. These caps were designed to help manage Medicaid spending. The specific limits are: 
Health Maintenance Activities (HMA): Up to 19,000 units per year (about 13 hours per day), Personal Care: Up to 10,000 units per year (about 6.8 hours per day) and Homemaker: Up to 4,500 units per year (about 3 hours per day)

Exception Process: High-acuity Medicaid members whose documented medical needs surpass the annual soft caps for Personal Care, Homemaker, or Health Maintenance Activities (HMA) can have their assigned case manager request an exception from the Department of Health Care Policy & Financing (HCPF). 

Specifically, individuals enrolled in Health First Colorado (Colorado's Medicaid program) who demonstrate a clinical need exceeding standard annual limits (such as 10,000 units for Personal Care or 19,000 units for HMA) or clients with a documented need, i.e. members requiring extra support due to complex medical conditions, specialized care requirements, or intense daily functional dependencies. 

How the Exception Process Works: Initiated by Case Management! The member or their representative cannot apply directly; instead, they must work through their designated case manager (from their local Case Management Agency, e.g. RMHS or Developmental Pathways). Review and Submission: The case manager reviews the client's medical necessity, assesses the Prior Authorization Request (PAR), and submits the formal request for additional service units up the chain to state authorities. Timeline: The process is expected to take 30-60 days from submission to determination.