CCR Dept. 2505,1305 | Code of Colorado Regulations — Department of Health Care Policy and Financing

1305 Health Data Commission - [Rules repealed eff. 03/04/2007]

8 CCR 1305-1 COLLECTION, VERIFICATION, EXEMPTION OF DATA - Repealed eff. 03/04/2007 {#sec-8-ccr-1305-1 omnilex-key=us-co-regs-official--department-7--8 CCR 1305-1}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

Health Data Commission COLLECTION, VERIFICATION, EXEMPTION OF DATA - Repealed eff. 03/04/07 8 CCR 1305-1 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ This rule was repealed effective March 1, 2007. _________________________________________________________________________ Editor’s Notes

History

2505 Cooperative Health Care Agreements Board [Rules repealed eff. 04/30/2013]

10 CCR 2505-1 REGULATIONS - [Repealed eff. 04/30/2013] {#sec-10-ccr-2505-1 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-1}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

Cooperative Health Care Agreements Board REGULATIONS 10 CCR 2505-1 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ This rule was repealed, effective April 30, 2013 _________________________________________________________________________ Editor’s Notes

History Entire rule repealed eff. 04/30/2013.

2505 Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)

10 CCR 2505-3 Financial Management of the Children's Basic Health Plan {#sec-10-ccr-2505-3 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-3}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

FINANCIAL MANAGEMENT OF THE CHILDREN’S BASIC HEALTH PLAN

10 CCR 2505-3 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

50 DEFINITIONS 50.1 “Applicant” shall mean a person applying or re-applying for benefits on behalf of a child and/or themselves. 50.2 “CBMS” shall mean Colorado Benefits Management System is the computer system that determines an applicant’s eligibility for public assistance in the state of Colorado. 50.3 “Child” means a person who is less than nineteen years of age. 50.4 “Cost sharing” shall mean payments, such as copayments that are due on behalf of the enrollee. 50.5 “Department” shall mean the Colorado Department of Health Care Policy and Financing which is responsible for administering the Colorado Medical Assistance Program and Children’s Basic Health Plan as well as other Statefunded health care programs. 50.6 “Dependent child” shall mean a child who lives with a parent, legal guardian, caretaker relative or foster parent and is under the age of 18, or, is age 18 and a full-time student, and expected to graduate by age 19 50.7 “Effective Date” shall mean the first day of eligibility which is the date the application is received and date-stamped by the Eligibility site or the date the application was received and date-stamped by an Application Assistance site or Presumptive Eligibility site. In the absence of a date-stamp, the application date is the date that the application was signed by the client. 50.8 “Eligibility Site” shall mean a location outside of the Department that has been deemed by the Department as eligible to accept applications and determine eligibility for applicants. 50.9 “Enrollee” shall mean an eligible person who is enrolled in the Children’s Basic Health Plan. 50.10 “ Essential Community Provider” means a healthcare provider that:

A. Has historically served medically needy or medically indigent patients and demonstrates a commitment to serve low-income and medically indigent populations who make up a significant portion of its patient population, or in the case of a sole community provider, serves medically indigent patients within its medical capability; and B. Waives charges or charges for services on a sliding scale based on income and does not restrict access or services because of a client's financial limitations. 50.11 “ Evidence of Coverage” or “EOC” shall mean any certificate, agreement, or contract issued to an enrollee from time-to-time by a Managed Care Organization (MCO) setting out the coverage to which the enrollee is or was entitled under the Children’s Basic Health Plan. 50.12 “ Grievance Committee” shall mean a conference with the Department or its Designee in which a contested decision regarding an applicant or enrollee is reexamined. 50.13 “ Household” shall be determined by relationships to the tax filer as declared on the Single Streamlined Application and as required in 10 CCR 2505-10- 8.100.4.E. 50.14 “ Income” shall be any compensation from participation in a business, including wages, salary, tips, commissions and bonuses. The Modified Adjusted Gross Income is a methodology used to determine eligibility as required in 10 CCR 2505-10-8.100.4.C. 50.15 “ Managed Care Organization” or “MCO” shall mean:

A. A carrier which meets the definition in §10-16-102 (8), C.R.S. with which the Department contracts to provide health care or dental services covered by the Children’s Basic Health Plan; or, B. Essential community providers and other health care and dental service providers with whom the Department contracted to provide health care services under the Children’s Basic Health Plan using a managed care model. 50.16 “ Presumptive Eligibility” shall mean children and pregnant women who have applied and appear to be eligible for the Children’s Basic Health Plan shall be presumed eligible and may receive immediate temporary medical coverage. 50.17 “Qualified Hospital Presumptive Eligibility Site” is a hospital that has voluntarily elected to serve as a Presumptive Eligibility site. Qualified Hospital Presumptive Eligibility Sites agree to make determinations in accordance with State policies and assist individuals with completing Medical Assistance applications and understanding documentation requirements. 50.18 “Unearned Income” shall be the gross amount received in cash or kind that is not earned from employment or self-employment. 50.19 “Woman” shall mean a female who is 19 years in age or older.

100 ELIGIBILITY

110 INDIVIDUALS ASSISTED UNDER THE PROGRAM 110.1 To be eligible for the Children’s Basic Health Plan, an eligible person shall:

Be less than 19 years of age; or 2. Be a pregnant woman B. Fall into one of the following categories:
Be a citizen or national of the United States, the District of Columbia, Puerto Rico, Guam, the United States Virgin Islands, the Northern Mariana Islands, American Samoa, or Swain's Island; or 2. Be a lawfully admitted non-citizen who entered the United States prior to August 22, 1996, or 3. Be a non-citizen who entered the United States on or after August 22, 1996 and is applying for Medical Assistance who falls into one of the following categories:

a. Lawfully admitted for permanent residence under the U.S.

Immigration and Nationality Act (hereafter referred to as the “INA”); or b. Paroled into the United States for at least one year under 8 U.S.C § 1182(d)(5); or c. Granted conditional entry under Section 203(a)(7) of the INA, as in effect prior to April 1, 1980; or d. determined by the Eligibility site, in accordance with guidelines issued by the U.S. Attorney General, to be a spouse, child, parent of a child, or child of a parent who, in circumstances specifically described in 8 U.S.C. §1641(c), has been battered or subjected to extreme cruelty which necessitates the provision of Medical Assistance (Children’s Basic Health Plan); or 4. Be a non-citizen who arrived in the United States on any date, who falls into one of the following categories:

a. Lawfully residing in Colorado and is an honorably discharged military veteran; or 1. A spouse of such military veteran; or 2. An unremarried surviving spouse of such military veteran; or 3. An unmarried dependent child of such military veteran.7 b. Lawfully residing in Colorado and is on active duty in the United States Armed Forces, excluding military training; or 1. A spouse of such individual; or 2. An unremarried surviving spouse of such individual; or 3. An unmarried dependent child of such individual.

c. Granted asylum under Section 208 of the INA; or d. Refugee under Section 207 of the INA; or e. An individual with deportation withheld:

Under Section 243(h) of the INA, as in effect prior to September 30, 1996; or 2. Under Section 241(b)(3), as amended by P.L. 104- 208 of the INA.

f. A Cuban or Haitian entrant, as defined under Section 501(e) of the U.S. Refugee Education Assistance Act of 1980; or g. An individual who:

Was born in Canada and possesses at least 50 percent American Indian blood; or 2. Is a member of an Indian tribe, as defined in 25 U.S.C. Section 450(b)e.

h. Admitted into the United States as an Amerasian immigrant under Section 584 of the U.S. Foreign Operations, Export Financing, and Related Programs Appropriation Act of 1988, as amended by P.L. 100-461; or i. A lawfully admitted, permanent resident, who is a Hmong or Highland Lao veteran of the Vietnam conflict; or j. An alien who was admitted in the United States on or after December 26, 2007 who is an Iraqi Special Immigrant under

section 101(a)(27) of the INA; or k. An alien who was admitted in the United States on or after December 26,2007 who is an Afghan Special Immigrant under section 101(a)(27) of the INA; and 5. Be a lawfully admitted non-citizen in the United States who falls into one of the categories:

a. granted temporary resident status in accordance with section 8 U.S.C. 1160 or 1255a; or b. granted Temporary Protected Status (TPS) in accordance with section 8 U.S.C 1254a and pending applicants for TPS granted employment authorization;

c. granted employment authorization under section 8 CFR 274a.12(c);or d. Family Unity beneficiary in accordance with section 301 of Pub. L. 101-649, as amended.

e. Deferred Enforced Departure (DED), pursuant to a decision made by the President f. Granted Deferred Action status (excluding Deferred Action for Childhood Arrivals (DACA)) as described in the Secretary of Homeland Security’s June 15,2012 memorandum;

g. Granted an administrative stay of removal under section 8 CFR 241; or h. Beneficiary of approved visa petition who has a pending application for adjustment of status.

i. Pending an application for asylum under section 8 U.S.C. 1158, or for withholding of removal under section 8 U.S.C. 1231, or under the Convention Against Torture who- 1. as been granted employment authorization; or 2. Is under the age of 14 and has had an application pending for at least 180 days.

j. Granted withholding of removal under the Convention Against Torture;

k. Citizens of Micronesia, the Marshall Islands, and Palau; or l. Is lawfully present American Samoa under the immigration of laws of American Samoa.

m. A non-citizen in a valid nonimmigrant status, as defined in

section 8 U.S.C. 1101(a)(15) or under section 8 U.S.C. 1101(a)(17); or n. A non-citizen who has been paroled into the United States for less than one year under section U.S.C. 1182(d)(5), except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; or o. A child who has a pending application for Special Immigrant Juvenile status under 8 U.S.C 1101(a)(27)(J).

p. Exception: Persons who are under the age of 19, whose 19th birthday occurred in the current month, who are pregnant, or who are within 12 months of the beginning of their postpartum period, and who meet the criteria for one of the specific Child Basic Health Plan Programs, but who are not citizens or qualified non-citizens according to the criteria set forth in 110.1.B, shall receive Medical Assistance benefits for programs included under the CRS 25.5-8-109.

The rules on confidentiality indicated under CRS § 24- 74-103 prevent the Department or eligibility site from reporting to the USCIS persons who have applied for or are receiving assistance.

C. For determinations of eligibility for the Children’s Basic Health Plan, legal immigration status must be verified. This requirement applies to a noncitizen individual who meets the criteria of any category defined at 110.1.B and has declared that he or she has a legal immigration status.

The Verify Lawful Presence (VLP) interface will be used to verify immigration status as required in 10 CCR 2505-10-8.100.3.G.2 2. If the state cannot verify immigration status the individual will receive a Reasonable Opportunity Period as required in 10 CCR 2505-10-8.100.3.H.9 3. This requirement does not apply to the following groups:

a. Individuals applying for Child Healthcare Plan covered by Cover All Coloradans detailed in Sections 8.100.3.g.viii and 110.1.B.5.p D. Be a resident of Colorado; and residence shall be retained until abandoned. A person temporarily absent from the state, inside or outside the United States, retains Colorado residence. Temporarily absent means that at the time he/she leaves, the person intends to return.

E. Have a household income greater than 142% but not exceeding 260% of the Federal Poverty Level, adjusted for household size for children under the age of 19; or F. Have a household income greater than 195% but not exceeding 260% of the Federal Poverty Level, adjusted for household size for pregnant women.

G. Failure to complete an application or to provide required documentation in

Section 130 will result in the denial of the incomplete application or individual applicant (s).

120 INSUFFICIENT ACCESS TO OTHER HEALTH COVERAGE 120.1 To be eligible for the Children’s Basic Health Plan, an eligible person shall not:

A. Be covered under a group health plan or under health insurance coverage excluding Consolidated Omnibus Budget Reconciliation Act (COBRA) at the time of application or at redetermination; or B. Be eligible to receive assistance under Title XIX of the Social Security Act; or C. Be an inmate of a public institution or a patient in an institution for mental diseases, except that Reentry Demonstration Initiative Services authorized by the 1115 Demonstration Waiver titled Colorado Expanding the Substance Use Disorder (SUD) Continuum of Care and described in Attachment G to the Center for Medicare & Medicaid Services’ (“CMS”)

Demonstration Approval dated October 14, 2025 are available to inmates of public institutions 90 days prior to their release. Reentry Demonstration Initiative Services are only available while approved by CMS. CMS’s Demonstration Approval dated October 14, 2025 is hereby incorporated by reference. This incorporation excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17 Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.medicaid.gov. 120.2 The Department shall not require that applicants be uninsured for any period of time prior to becoming eligible for the Children’s Basic Health Plan.

130 VERIFICATION REQUIREMENTS 130.1 To be eligible for the Children’s Basic Health Plan, an applicant shall provide minimal verification as required in 10 CCR 2505-10-8.100.4.B.

140 REDETERMINATION 140.1 “ Redetermination of eligibility” is a case review and/or the request for necessary verification to determine whether a member enrolled in a Medical Assistance Program continues to be eligible. Eligibility shall be redetermined at least every twelve months since the last eligibility determination. Eligibility may be redetermined through telephone, mail, or online electronic means. Prior to making a determination of ineligibility, the eligibility site must review on all bases of Medical Assistance eligibility for a member.

A. “Ex Parte Review” is a redetermination of eligibility for a member without requesting verification by utilizing available information from the member’s account, electronic sources and other assistance programs.

If verified information is available for any of the six months prior to the redetermination month, and the member meets all other eligibility requirements, then an approval notice will be sent to eligible members of the household who are requesting assistance.

This approval notice shall include directions on how to view the information used to determine eligibility.

If all required information is not available and/or the information on file does not support a finding of eligibility, a redetermination form,as described in Section 140.1.A.3, and/or a verification form will be issued to the household at least 30 days before the end of the eligibility period. The household will be sent a prepopulated redetermination form with the current information on file and a notice of required verifications to determine eligibility at least 30 days prior to the end of the eligibility period.
The redetermination form shall direct members to verify that the information provided is accurate or to report any changes to the information. Members must complete and return the redetermination form with the necessary verifications and the signature form. If a member fails to sign the signature form or comply with any of these requirements, the member will be terminated from the program for failure to complete the redetermination process.
If the member submits the redetermination form and/or verification information before the end of the eligibility period, the member must maintain coverage until the eligibility site can make a final determination.

i. The eligibility site has 30 calendar days from the date the documents are received to make a final determination.

If the member submits the redetermination form and/or verification information after the end of the eligibility period, the member will not maintain coverage.
If incomplete information is submitted or a member reports new changes, the eligibility site must contact the member by telephone or in writing to provide required documents or requested verifications.

i. If requested verifications are needed, the eligibility site must send a form with a letter specifying the items that require completion. The member shall return the completed request form to the eligibility site no later than ten working days;

ii. The eligibility site will have fifteen working days from the date the documents are received to make a final determination.

B. “Reconsideration period” is the 90-day time period allowed after a member's eligibility is terminated due to failure to return the redetermination with the necessary verifications and the signature. The member’s eligibility must be reconsidered if the member submits the requested information within 90 days following termination of eligibility.

Members who return properly completed redetermination forms and requested information during the reconsideration period will not be required to submit a new application for eligibility. If redetermination forms and requested information are not returned within 90 days after the termination, the member must submit a new application for enrollment in the program.
For members who are determined to be eligible for Medical Assistance within the reconsideration period, the effective date of coverage will be the first day of the month in which the redetermination form was returned. If the member has a gap in coverage due to submitting the redetermination within the reconsideration period, the member can request up to three months in retro coverage.

150 CALCULATION OF HOUSEHOLD INCOME 150.1 Calculation of income for the Children’s Basic Health Plan shall be determined as required in 10 CCR 2505-10-8.100.4.C 150.2 Income disregards for the Children’s Basic Health Plan shall be determined as required in 10 CCR 2505-10-8.100.4.D 160 [Repealed eff. 12/30/2012]

170 PRESUMPTIVE ELIGIBILITY 170.1 A pregnant woman or a child under the age of 19 may apply for presumptive eligibility for immediate temporary medical services through designated presumptive eligibility sites or a qualified hospital presumptive eligibility site that provides presumptive eligibility determinations.

A. To qualify for presumptive eligibility, a child under the age of 19 shall have a declared household income that shall be greater than 142% but not exceed 260% of Federal Poverty Level; or B. To qualify for presumptive eligibility, a pregnant woman shall have an attested pregnancy, declare that her household's income shall be greater than 195% but not exceed 260% of the Federal Poverty Level; and C. The applicant must be a United States citizen or a lawfully residing immigrant as defined in Section 110 or meet the exceptions outlined in 110.1.C.3.a. 170.2 Presumptive eligibility sites and qualified hospital presumptive eligibility sites must be certified by the Department of Health Care Policy and Financing to make presumptive eligibility determinations. Presumptive eligibility sites and qualified hospital presumptive eligibility sites must be re-certified by the Department of Health Care Policy and Financing every year to remain approved as presumptive eligibility sites.

A. The presumptive eligibility site or qualified hospital presumptive eligibility site shall forward the medical assistance application to the County Department of Human Services within five business days of the received date. 170.3 The presumptive eligibility period begins on the date the applicant(s) is determined eligible and ends with the day an eligibility determination for Medical Assistance is made for the applicant(s). 170.4 The County Department of Human Services or Medical Assistance site must make an eligibility determination within 45 days from the date of the medical assistance application.

A. Medical Assistance applicants may appeal if a County Department of Human Services is unable to act within 45 days of the medical assistance application date or the denial of a medical assistance application. Appeal procedures are outlined in Section 600.

B. A presumptively eligible member may not appeal the end of a presumptive eligibility period. 170.5 Applicants who already receive another medical assistance program cannot receive presumptive eligibility. 170.6. An applicant may only receive presumptive eligibility once every 12 months with the exception of pregnant women who may receive presumptive eligibility once every pregnancy. 180 Express Lane Eligibility Express Lane Eligibility shall allow for automatic initiation of Medical Assistance enrollment by using available data and findings from other programs as listed below. 180.1 Free/Reduced Lunch Program A. Recipients of the Free/Reduced Lunch Program who have submitted a Free/Reduced Lunch application at a participating school district 1. Families will be given the option to opt into Medical Assistance coverage for their potentially eligible child.

Children who meet all necessary eligibility requirements as outlined in this volume will be automatically enrolled.
Children who meet all necessary eligibility requirements except verification of U.S. citizenship and identity will receive 90 days of eligibility while awaiting this verification.
Any additionally required verification will be requested from the client through CBMS prior to being automatically enrolled.
Eligibility is based on income declared on the Free/Reduced Lunch application as well as eligibility requirements outlined in section 150.
If it would be found that a child does not satisfy an eligibility requirement for Medical Assistance, the child’s eligibility will be evaluated using the application for Medical Assistance.

B. Recipients of the Free/Reduced Lunch Program who were not required to submit a Free/Reduced Lunch application at a participating school district 1. Families who are automatically enrolled Free/Reduced Lunch recipient children will not be forwarded to the Department for Express Lane Eligibility in compliance USDA confidentiality guidelines.

These families must apply for Medical Assistance in order to give consent for request of benefits. 180.2 Direct Certification A. When an application for Supplemental Nutrition Assistance Program (SNAP) or Colorado Works (Temporary Assistance for Needy Families Program (TANF)) has been submitted, families will be given the option to opt into Medical Assistance coverage for their potentially eligible children.
Children who meet all necessary eligibility requirements as outlined throughout sections 100 through 180 will be automatically enrolled, 2. Children who are only missing verification of U.S. citizenship and identity will receive 90 days of coverage while waiting for this verification.
Any additionally required verification will be requested from the client through CBMS prior to being automatically enrolled.
Eligibility is determined based on income declared on the Food Stamp or Colorado Works application as well as eligibility requirements outlined throughout this volume.
If it would be found that a child does not satisfy an eligibility requirement for Medical Assistance, the child’s eligibility will be evaluated using the Single Streamlined application for Medical Assistance.
Individuals whose eligibility is not determined through Express Lane Eligibility may also submit a separate Single Streamlined Application for Medical Assistance to determine eligibility.

200 BENEFITS PACKAGE 210 The following are covered benefits including any applicable limitations:

A. Emergency Care and Urgent/After Hours Care;

B. Emergency Transport/Ambulance Services;

C. Hospital/Other Facility Services Including:

Inpatient;
Physician;
Outpatient/Ambulatory;

D. Medical Office Visits Including:

Physician;
Mid-Level Practitioner;
Specialist;

E. Diagnostic Services;

F. Preventative, Routine and Family Planning Services Including:

Immunizations;
Well-child visits;
Health maintenance visits;
Abortion (Effective January 1, 2026)

G. Maternity Care Including:

Prenatal;
Delivery and inpatient well-baby care;
Postpartum care 4. Lactation Services & Support H. Mental Illness Treatments such as:
Neurobiologically-based mental illness 2. Mental disorders 3. All other mental illness;

I. Physical Therapy, Speech Therapy and Occupational Therapy shall be limited to 30 visits per diagnosis per year. Effective November 1, 2007, Physical, Speech and Occupational Therapy services shall be unlimited for children from birth up to the child’s third birthday.

J. Durable Medical Equipment shall be limited to the lesser of the purchase price or rental price for medically necessary durable medical equipment that shall not exceed two thousand dollars per year.

K. Transplants must be medically necessary and are limited to:

Liver;
Heart;
Heart/lung;
Cornea;
Kidney;
Bone marrow which shall be limited to the following conditions:

a. Aplastic anemia;

b. Leukemia;

c. Immunodeficiency disease;

d. Neuroblastoma;

e. Lymphoma;

f. High risk stage II and III breast cancer;

g. Wiskott aldrich syndrome;

Peripheral stem cell support which shall be limited to the following conditions:

a. Aplastic anemia;

b. Leukemia;

c. Immunodeficiency disease;

d. Neuroblastoma;

e. Lymphoma;

f. High risk stage II and III breast cancer;

g. Wiskott aldrich syndrome;

L. Home health care;

M. Hospice care;

N. Prescription medication;

O. Kidney dialysis shall be excluded only if the member is also eligible for Medicare;

P. Skilled nursing facility care must be provided only when there is a reasonable expectation of measurable improvement in the members' health status.

Q. Vision services shall be limited to:

Vision screenings for age appropriate preventative care;
Referral required for refraction services;
Minimum fifty dollar benefit for eyeglasses;

R. Audiology services shall be limited to:

Hearing screenings for age appropriate preventative care;
Hearing aids without financial limitation for enrollees age 18 and under no more than once every five years unless medically necessary including:

a. A new hearing aid when alterations to the existing hearing aid cannot adequately meet the needs of the child b. Services and supplies including, but not limited to, the initial assessment, fitting, adjustments, and auditory training that is provided according to accepted professional standards.

S. Intractable pain;

T. Gender-affirming care (see 10 CCR 2505-10, 8.735)

U. Case management is covered only when medically necessary; except that Targeted Case Management authorized by the 1115 Demonstration Waiver titled Colorado Expanding the Substance Use Disorder (SUD)

Continuum of Care and described in Attachment G to the Center for Medicare & Medicaid Services’ (“CMS”) Demonstration Approval dated October 14, 2025 is available to inmates of public institutions 90 days prior to their release. Targeted Case Management is only available while approved by CMS. CMS’s Demonstration Approval dated October 14, 2025 is hereby incorporated by reference. This incorporation excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17 Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request.

Incorporated materials may also be obtained from the original issuer at www.medicaid.gov.

V. Dietary counseling/nutritional services shall be limited to:

Formula for metabolic disorders;
Total parenteral nutrition;
Enterals and nutrition products;
Formulas for gastrostomy tubes;

W. Dental services are limited to:

Those dental services described in the Children’s Basic Health Plan dental Evidence of Coverage booklet provided to enrollees, who are less than nineteen years of age. Beginning October 1, 2019, the dental services listed below are covered benefits for enrolled pregnant women of any age, excepting Limited Orthodontic services under Section 210.W.1.h for pregnant women age nineteen and above. Children’s Basic Health Plan dental services are provided by the dental MCO (or its designee) with which the Department has contracted for the applicable plan year to provide the following dental services;

a. Diagnostic b. Preventive c. Restorative d. Endodontic e. Periodontic f. Prosthodontic g. Oral and Maxillofacial Surgery h. Limited Orthodontic, excepting pregnant women age nineteen and above.

i. Adjunctive General Services 2. Orthodontic and prosthodontic treatment for cleft lip or cleft palate in newborns (covered as a medical service in accordance with

section 10-16-104, C.R.S.); and 3. Treatment of teeth or periodontium required due to accidental injury to naturally sound teeth (covered as a medical service in accordance with section 10-16-104, C.R.S.). A physician or legally licensed dentist must perform treatment within 72 hours of the accident.

X. Therapies covered shall include:

Chemotherapy;
Radiation;

Y. The following are not covered benefits:

Acupuncture;
Artificial conception;
Biofeedback;
Storage Costs for umbilical blood;
Chiropractic care;
Convalescent care or rest cures;
Cosmetic surgery;
Custodial care;
Domiciliary care;
Duplicate coverage;
Government institution or facility services;
Hair loss treatments;
Hypnosis;
Infertility services;
Maintenance therapy;
Nutritional therapy unless specified otherwise;
Personal comfort items;
Physical exams for employment or insurance;
Private duty nursing services;
Routine foot care;
Taxes;
Temporomandibular joint (TMJ) treatment, unless it has a medical

basis;

Other therapies and treatments which are not medically necessary;
Vision services unless specified otherwise;
Vision therapy;
War-related conditions;
Weight-loss programs;
Work-related conditions;

300 ENROLLMENT FEES AND COPAYMENTS 310 [Repealed eff. 10/30/2022]

320 COPAYMENTS 320.1 The following copayments shall be due for enrollees at the time of service:

A. For families with income, at the time of eligibility determination, less than 101% of the Federal Poverty Level (MAGI-equivalent), all copayments shall be waived, except for emergency and care, which shall be $3.00 per use and urgent/after hours care, which shall be $1.00 per use.

B. For families with income, at the time of eligibility determination, between 101% and 150% of the Federal Poverty Level (MAGI-equivalent), the 1. Effective July 1, 2012:

a. $2.00 per office visit;

b. $2.00 per outpatient mental health or substance abuse visit;

c. $1.00 per generic or brand name prescription;

d. $2.00 per physical therapy, occupational therapy or speech e. $2.00 per vision visit;

f. $3.00 per use of emergency care (co-payment is waived if client is admitted to the hospital);

g. $1.00 per use of urgent/after hours care;

h. $2.00 per trip for emergency transport/ambulance services;

i. $2.00 per inpatient hospital visit;

j. $2.00 per inpatient hospital visit for physician services in the hospital;

k. $2.00 per outpatient hospital or ambulatory surgery center C. For families with income, at the time of eligibility determination, between 151% and 200% of Federal Poverty Level (MAGI-equivalent), the 1. Effective July 1, 2012:

a. $5.00 per office visit;

b. $5.00 per outpatient mental health or substance abuse visit;

c. $3.00 per generic prescription;

d. $10.00 per brand name prescription;

e. $5.00 per physical therapy, occupational therapy or speech f. $5.00 per vision visit;

g. $30.00 per use of emergency care ((co-payment is waived if client is admitted to the hospital)

h. $20.00 per use of urgent/after hours care;

i. $5.00 per date of service for laboratory and radiology/imaging services j. $15.00 per trip for emergency transport/ambulance services;

k. $20.00 per inpatient hospital visit;

l. $5.00 per inpatient hospital visit for physician services;

m. $5.00 per outpatient hospital or ambulatory surgery center 3. Due to the Coronavirus COVID-19 Public Health Emergency, members who are eligible for Children’s Basic Health Plan will have waived laboratory copayments, specifically as it relates to laboratory copayments associated with COVID-19 testing.

Copayments will continue to be waived after May 11,2023 the ending of Coronavirus COVID-19 Public Health Emergency.

D. For families with income, at the time of eligibility determination, between 201% and 260% of Federal Poverty Level (MAGI-equivalent), the 1. Effective July 1, 2012:

a. $10.00 per office visit;

b. $10.00 per outpatient mental health or substance abuse visit;

c. $5.00 per generic prescription;

d. $15.00 per brand name prescription;

e. $10.00 per physical therapy, occupational therapy or speech f. $10.00 per vision visit;

g. $50.00 per use of emergency care (co-payment is waived if client is admitted to the hospital);

h. $30.00 per use of urgent/after hours care;

i. $10.00 per date of service for laboratory and radiology/imaging services j. $25.00 per trip for emergency transport/ambulance services;

k. $50.00 per inpatient hospital visit;

l. $10.00 per inpatient hospital visit for physician services;

m. $10.00 per outpatient hospital or ambulatory surgery center 3. Due to the Coronavirus COVID-19 Public Health Emergency, members who are eligible for Children’s Basic Health Plan will have waived laboratory copayments, specifically as it relates to laboratory copayments associated with COVID-19 testing.

Copayments will continue to be waived after May 11,2023 the ending of Coronavirus COVID-19 Public Health Emergency.

330 COST SHARING LIMITATIONS 330.1 American Indians and Alaskan Natives shall be exempt from cost sharing requirements. American Indian shall mean a member of a federally recognized Indian tribe, band, or group, or a descendant in the first or second degree of any such member. Alaskan Native shall mean an Eskimo or Aleut or other Alaska Native enrolled by the Secretary of the Interior. 330.2 The maximum yearly cost sharing requirements for families of enrollees shall be 5% of income. 330.3 No copayments shall apply to preventive services. For the purpose of this

section, preventive services shall mean:

A. All healthy newborn and newborn inpatient visits, including routine screening whether provided on an inpatient or outpatient basis;

B. Routine examinations;

C. Immunizations and related office visits; and D. Routine preventive and diagnostic dental services. 330.4 Prenatal Care Program clients shall be exempt from cost sharing requirements.

400 ENROLLMENT 400.1 An applicant found eligible for Children’s Basic Health Plan can elect to be enrolled the Children’s Basic Health Plan.

410 SELECTION OF A MANAGED CARE ORGANIZATION 410.1

A. Once eligibility has been determined, an eligible person shall have the opportunity to select a participating MCO in the county of the eligible person’s residence. If there is only one participating MCO available in the county of the eligible person’s residence, the eligible person shall be enrolled in that MCO.

B. In the event the Department contracts with an MCO to provide dental services to Children’s Basic Health Plan enrollees, an enrollee automatically will be enrolled with such MCO. No separate MCO election will be required.

410.2 MCO SELECTION

A. Upon determination of eligibility for the Children’s Basic Health Plan program, if the eligible person has notified the Department or its designee of his/her chosen MCO prior to the last business day of the month in which eligibility was determined, the Department or its designee shall enroll the eligible person in that MCO.

B. Upon determination of eligibility for the Children’s Basic Health Plan program, if the eligible person has not chosen an MCO, the Department or its designee shall enroll the eligible person in an MCO selected by the Department or its designee. In areas of the state where there is only one participating MCO available, the Department or its designee shall select that MCO and enroll the eligible person.

C. The Department or its designee shall notify the enrollee of the MCO selected. If the enrollee wants to change MCOs, the enrollee shall contact the Department or its designee within 90 days from the effective date of the MCO enrollment. An enrollee may also change a pending MCO enrollment before the effective date.

D. For renewal applications, the Department or its designee shall reassign the eligible person to the participating MCO the applicant approved for the previous enrollment period. If the eligible person wishes to change MCO enrollment, he/she shall notify the Department or its designee within his/her re-enrollment period. 410.3 In counties in which a participating MCO as defined in section 50.14.A is not available, the eligible person shall be enrolled in an MCO as defined in section 50.14.B. 410.4 Once an enrollee has selected an MCO or upon expiration of the timeframe to change, the enrollee shall remain enrolled in that MCO for the remainder of his/her eligibility period, unless the eligible person meets any of the disenrollment criteria set forth in section 440. 410.5 An eligible person shall have an opportunity to change to a different MCO serving the eligible person’s geographic region, if one is available, during the applicant’s annual redetermination period.

420 ENROLLMENT OF ALL ELIGIBLE PERSONS IN A FAMILY 420.1 If one eligible child from a family is enrolled in the Children’s Basic Health Plan, all eligible children in that family must be enrolled in the Children’s Basic Health Plan. 420.2 All eligible children in a family must be enrolled in the same MCO.

430 ENROLLMENT DATE 430.1 Eligibility for the Children’s Basic Health Plan shall be effective on the latter of:

A. The first day of the month of application for Medical Assistance; or B. The first day of the month the person becomes eligible for the Children’s Basic Health Plan program. 430.2 Upon being enrolled in the Children’s Basic Health Plan, continuous eligibility applies to children under the age of 19, who through an eligibility determination, reassessment or redetermination are found eligible for the Children’s Basic Health Plan program. The continuous eligibility period may last for up to 12 months and will begin on the month of application or from the authorization date.

A. The continuous eligibility period applies without regard to changes in income or other factors that would otherwise cause the child to be ineligible.

i) If the reported income decreases, a member may transition to the MAGI Medical Assistance program specified in section 10 CCR 2505-10-8.100.4.G.2, and a new 12-month continuous eligibility period will begin on the first day of the month of the transition.

B. A child’s continuous eligibility period will end effective the earliest possible month, if any of the following occur:

i) Child is deceased;

ii) Becomes an inmate of a public institution;Incarcerated children receiving CHP+ benefits will move to a limited Incarceration benefit. If the child is released within the initial 12 months of the CE period, coverage will be reinstated for the remaining 12-month CE period, unless any of the other exceptions apply;

iii) The child states that she/he has moved out of the household permanently;

iv) Is no longer a Colorado resident;

v) Is unable to be located based on evidence or reasonable assumption;

vi) Requests to be withdrawn from continuous eligibility;

vii) Fails to provide documentation during a reasonable opportunity period as specified in section 10 CCR 2505-10-8.100.3.H.9; or viii) Eligibility was erroneously granted at the most recent determination, redetermination, or renewal of eligibility because of agency error, or a finding of fraud or perjury attributed to the child or the child's responsible party. 430.3. If determined eligible, the enrollment date of a pregnant woman shall be effective as of the first of the month of the date of application or the first day of the month the pregnant woman becomes eligible. The enrollment span shall end on the last day of the month 12 months after the birth of the child or termination of the pregnancy. Once eligibility has been approved, coverage must be provided regardless of changes in the woman's financial circumstances, once the income verification requirements are met.

A. A pregnant women’s eligibility period will end effective the earliest possible month, if any of the following occur:

i) Fails to provide a reasonable explanation or paper documentation when self-attested income is not reasonably compatible with income information from an electronic data source, by the end of the 90-day reasonable opportunity period. This exception only applies the first-time income is verified following an initial eligibility determination or an annual redetermination. 430.4 An eligible person’s enrollment date in the selected MCO shall be no later than:

A. The first of the month following eligibility determination and MCO selection if eligibility is determined before the 17th of the month.

B. The first of the second month following eligibility determination and MCO selection if eligibility is determined on or after the 17th of the month. 430.5 A child born to a mother who is enrolled in the Children’s Basic Health Plan at the time of the child’s birth is guaranteed coverage for one year.

A. To receive Medical Assistance under the Children’s Basic Health Plan, the birth must be reported verbally or in writing to the County Department of Human Services or Eligibility site. Information provided shall include the baby’s name, date of birth, and mother’s name or Medical Assistance number. A newborn can be reported at any time by any person. Once reported, a newborn meeting the above criteria shall be added to the mother’s Medical Assistance case, or his or her own case if the newborn does not reside with the mother, according to timelines defined by the Department. If adopted, the newborn’s agent does not need to file an application or provide a Social Security Number or proof of application for a Social Security Number for the newborn.

440 DISENROLLMENT 440.1 An enrollee shall be disenrolled from an MCO for the following reasons:

A. Administrative error on the part of the Department, the Department’s designee, or the MCO, including but not limited to enrollment of a person who does not reside in the MCO’s service area; or, B. A change in the enrollee’s residence to an area not in the MCO’s service area; or, C. When an enrollee’s coverage is terminated as described in section 440.1A. 440.2 If an enrollee is disenrolled from an MCO for any of the reasons stated in section440.1 and there is another participating MCO available in the enrollee’s county of residence, the enrollee shall be allowed to select a new MCO. 440.3 If the enrollee is enrolled in a MCO as defined in section 50.15B and a MCO as defined in section 50.15A becomes available in the child’s county of residence, the enrollee will be disenrolled from the MCO as defined in section 50.15 B and enrolled in the MCO as defined in section 50.15A. 440.4 An enrollee may be disenrolled from both an MCO and/or the Children’s Basic Health Plan for the following reasons:

A. Fraud or intentional misconduct, including but not limited to knowing misuse of covered services, knowing misrepresentation of membership status; or, B. An enrollee’s receipt of other health care coverage will terminate a member’s coverage at renewal; or, C. The admission of an enrollee into any federal, state, or county institution for the treatment of mental illness, substance use disorder, or into any correctional facility; or, D. Ineligibility for the program, based on the guidelines set forth in the Children’s Basic Health Plan eligibility rules; or, E. Failure to comply with cost sharing requirements (copayments) set forth in the Children’s Basic Health Plan cost sharing rules; or, F. There is not another participating MCO as defined in section 50.14 available in the enrollee’s county of residence. 440.5 If an eligible person or an eligible person’s family displays an ongoing pattern of behavior that is abusive to provider(s), staff or other patients; or, disruptive to the extent that the provider’s ability to furnish services to the child or other patients is impaired, the eligible person may be disenrolled from his/her managed care organization. If there is another participating MCO available in the eligible person’s county of residence, the Department may allow the eligible person to select a new MCO. If there is not another MCO available in the eligible person’s county, the eligible person may be disenrolled from the Children’s Basic Health Plan.

500 FINANCIAL MANAGEMENT

The Children’s Basic Health Plan, being a non-entitlement program, must manage to its legislative appropriation. The Department shall track expenditures, caseload, and other financial information to make informed decisions on spending its appropriation.

Expenditures may exceed State appropriations with approval of the Governor, but any General Fund over expenditure shall be limited to $250,000. 510 The Department shall make quarterly assessments of projected expenditures. If it appears the program may overspend its appropriation due to changes in enrollment, health care costs, funding, legislation, or other factors, the Department shall consider if adjustments to the program are necessary. The program may use, but is not limited to, any of the following financial management tools: waiting lists, adjustments of eligibility criteria and/or levels, instituting open enrollment periods, or temporary closure of the program.

600 APPEALS PROCESS 600.1 Applicants shall be notified of any action regarding the eligibility and enrollment status and cost sharing requirements for the enrollees’ participation in the Children’s Basic Health Plan and appeal rights regarding those actions by the Department or its designee. 600.2 The Department or its designee shall notify the applicant within ten (10) business days of a decision regarding eligibility, enrollment and cost sharing. The notice shall:

A. Be in writing;

B. Be in his/her primary language, to the extent practicable;

C. Describe to the applicant the reasons for the decision;

D. Document the authority for the decision (e.g. rule citation); and E. Inform the applicant of his/her rights and responsibilities regarding the decision. 600.3 An applicant who disagrees with a denial regarding eligibility, enrollment, or cost sharing requirements may appeal in writing to the Children’s Basic Health Plan Eligibility Vendor within thirty (30) calendar days of the date of the notification of denial of eligibility, enrollment, or cost sharing. The appeal shall be reviewed and processed within thirty (30) calendar days of receipt and the results of the appeal shall be communicated to the applicant within ten (10) business days of the review. The following guidelines shall apply to the appeal process:

A. The Children’s Basic Health Plan Eligibility Vendor will coordinate the appeals process with the county or Eligibility site that determined the initial eligibility, enrollment, or cost sharing decision within ten (10) business days after receipt of the appeal.

B. The county or Eligibility site that determined the initial eligibility, enrollment, or cost sharing decision shall:

Review the data entry of the application in the Department’s eligibility system for accuracy and completeness within ten (10) business days after receipt of the appeal from the Children’s Basic Health Plan Eligibility Vendor;
Correct or complete information in the Department’s eligibility system if it is found to be incomplete or incorrect and re-run eligibility;
Maintain the original denial, if the information in the Department’s eligibility system is complete and correct; and 4. Notify the applicant and the Children’s Basic Health Plan Eligibility Vendor in writing once the review is complete with the results of the data entry review and the option of forwarding the appeal to the Grievance Committee. 600.4 If the applicant disagrees with the results of the appeal, the applicant may have their appeal reviewed by the Grievance Committee. The Grievance Committee’s decision shall be final.

A. The Grievance Committee shall be conducted by an independent panel appointed by the Executive Director of the Department. The panel shall include at least three people from the Department or its designee not previously involved with the grievance. A person previously involved with the grievance may be present at the conference and appear before the panel to present information and answer questions, but shall not have a vote. The Department shall ensure that those appointed to the panel have sufficient experience to make an informed decision regarding the grievance under review.

B. The applicant may attend the Grievance Committee in person or by telephone.

C. The applicant may be represented by the person of the applicant’s choice (i.e. legal counsel, friend, family member, etc.) during the Grievance Committee.

D. The applicant may have access to documents that were used by the Department or its designee in making the decision under appeal. 600.5 An enrollee who disagrees with a denial of benefits shall submit an appeal to the MCO he/she is enrolled in and shall follow the MCO’s appeal process. 610 [Repealed eff.12/30/2012] ______________________________________________________________________ Editor’s Notes

History Entire rule eff. 07/30/2007.

Rule 210 emer. rule eff. 11/01/2007.

Rule 210 eff. 12/30/2007.

Rules 50.17-50.21, 100-110.1E, 150.3-150.3E, 170-170.2 emer. rules eff. 01/01/2008.

Rules 50.17-50.21; 100-110.1E; 150.3-150.3E; 170-170.2 eff. 03/30/2008.

Rules 500-510 eff. 11/30/2008.

Rule 210 eff. 12/30/2008.

Rule 110 eff. 03/30/2009.

Rule 150 emer. rule eff. 04/10/2009.

Rule 150 eff. 06/30/2009.

Rules 110.1 B 4-5, 150.1 Q-R eff. 11/30/2009.

Rule 130.1 B emer. rule eff. 01/01/2010; expired 03/11/2010.

Rule 130.1 B eff. 03/30/2010.

Rules 110.1 D, 150.3, 170.1, 310.1 B, 320.1 D emer. rules eff. 05/01/2010. Rule 110.1 D expired 08/07/2010.

Rule 140.1 emer. rule eff. 06/11/2010.

Rules 150.3, 170.1, 310.1 B, 320.1 D eff. 06/30/2010.

Rules 110.1 D, 140.1 eff. 08/30/2010.

Rules 110.1 B 4-5 eff. 10/30/2010.

Rules 130.1 A, 150.2 eff. 12/30/2010.

Rule 140.1 B emer. rule eff. 09/09/2011.

Rule 180 emer. rule eff. 10/14/2011.

Rule 140 1B eff. 11/30/2011.

Rules 180, 430 eff. 12/30/2011.

Rules 300-330 eff. 01/01/2012.

Rules 430.1-430.2 emer. rules eff. 01/13/2012.

Rules 170, 430 eff. 04/01/2012.

Rules 410.1 A, 410.2-410.4 eff. 11/30/2012.

Rules 50.9, 50.15-50.16, 120, 150.1 O-Q, 400.1 eff. 12/30/2012. Rules 160, 220, 340, 450, 610 repealed eff. 12/30/2012.

Rules 170.5, 330.4 eff. 01/30/2013.

Rules 180.1 A.1, 180.1 A.6, 180.2 eff. 04/30/2013.

Rule 120 emer. rule eff. 05/10/2013.

Rule 120 eff. 07/30/2013.

Rules 50, 110.1.D-110.1.F, 130, 150, 170.1, 430 eff. 10/01/2013.

Rules 430.2-430.5 eff. 04/30/2014.

Rules 110.1 B.2, 170.1 C eff. 07/01/2015.

Rules 50-600.5 eff. 03/02/2017.

Rule 110 eff. 09/30/2017.

Rule 430.4 eff. 10/30/2017.

Rules 430.2-430.3 eff. 10/30/2018.

Rule 210 W emer. rule eff. 10/01/2019.

Rule 210 W eff. 12/30/2019.

Rules 110.1 D, 140.1 C, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 05/08/2020.

Rules 110.1 D, 140.1 C, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 09/04/2020.

Rules 110.1 D, 140.1 C, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 12/11/2020. 04/11/2021; expired 08/07/2021. 08/09/2021. 11/12/2021.

Rules 140.1, 430 eff. 03/10/2022.

Rules 110.1 C.2, 110.1 D, 140.1 D, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 03/11/2022.

Rules 110.1 E-F, 170.1 A-B, 170.3, 310.1, 430.2 B.ii, 430.3 eff. 06/30/2022.

Rules 50.4, 110.1 C.2, 110.1 D, 140.1 D, 320.1 C.3, 320.1 D.3, 440.4 E emer. rules eff. 07/08/2022. Rule 310 repealed emer. rule eff. 07/08/2022.

Rules 50.4, 110.1 C.2, 110.1 D, 140.1 D, 320.1 C.3, 320.1 D.3, 440.4 E emer. rules eff. 10/14/2022. Rule 310 repealed emer. rule eff. 10/14/2022.

Rules 50.4, 440.4 E, repealed rule 310 eff. 10/30/2022.

Rule 140.1 A emer. rule eff. 01/13/2023.

Rules 110.1 C.2, 110.1 D, 140.1 D, 320.1 C.3, 320.1 D.3 emer. rules eff. 02/10/2023.

Rules 140.1 A eff. 04/30/2023.

Rules 110.1 C.2, 110.1 D, 140.1 D, 320.1 C.3, 320.1 D.3 emer. rules eff. 05/12/2023; expired 09/09/2023.

Rules 110.1 C.2, 110.1 D, 140.1 D, 180.2 A, 210, 320.1, 440.4 C eff. 10/30/2023.

Rules 110.1 B.5.p, 110.1 C.3 eff. 12/30/2024.

Rules 1.20.1 A, 430.2 A.i), 430.2 B, 440.4 B eff. 03/02/2025.

Rule 140 eff. 06/30/2025.

Rules 50.17-19, 170 eff. 11/30/2025.

Rules 210 F.4, 210 Y.17-28 emer. rules eff. 01/01/2026.

Rules 1.20.1, 2.10.U eff. 03/02/2026.

Rules 1.20.1, 2.10.U eff. 04/14/2026.

Annotations

Rule 170.5 (adopted 12/14/2012) was repealed by Senate Bill 13-079 effective 05/15/2013.

10 CCR 2505-10 Medical Assistance - Statements of Basis and Purpose and Rule History {#sec-10-ccr-2505-10 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE - STATEMENTS OF BASIS AND PURPOSE AND RULE

HISTORY

10 CCR 2505-10 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

NOTICE OF STATUTORY CITATION CHANGES TO 10 CCR 2505-10

Senate Bill 06-219 reorganized and amended statutes relating to all programs administered by the Colorado Department of Health Care Policy and Financing (Department) included but not limited to:

The Colorado Medical Assistance Act;

The Colorado Indigent Care Program;

The Children’s Basic Health Plan;

The Old Age Pension Health and Medical Care Program; and The Comprehensive Primary and Preventive Care Grant Program.

SB 6-0219 also consolidated all statutes relating to the Department in Title 25.5, C.R.S. and duplicated in Title 25.5, C.R.S., existing county administrative and financial provision that were in Title 26, C.R.S., the Human Services Code and that relate to the programs the Department administers. Additionally, it repealed obsolete provisions and made conforming changes.

The rules listed below and found at 10 CCR 2505-10, reference statutory authority in the Colorado Revised Statutes. The table that follows lists the rules, the previous statutory citations, and the new statutory citations that were changed due to the implementation of SB 06-219, which went into effect on July 1, 2006. As these sections of the rules are updated for other reasons, the citations included in the rules will also be updated by the Medical Services Board to include the new statutory citations. 8.061.2 26-4-106(4) 25.5-4-205(4) 8.061.7 26-4-25.5-4- 403(1)(III)(A) 301(1)(III)(A) 8.061.9 26-4- 403(1)(III)(B) 25.5-4- 301(1)(III)(B) 8.061.3 26-4-403(3) 25.5-4-301(3) 8.063.20 26-4-506.5(3) 25.5-6-102.5(3) 8.100.53 26-4-203 25.5-5-103 8.110.5 (m) 26-4-506.3(3) 25.5-6-203.3(3) 8.300 26-4-522 25.5-6-106 8.400.103 26-4-103(8.5) 25.5-4-103(8.5) 8.482.52 26-4-504(3)(c) 25.5-6-206(3)(c) 8.482.52 C.1.b. 26-4-504(3)(c) 25.5-6-206(3)(c) 8.485.10 26-4-601 25.5-6-301 8.496.10 26-4-641 25.5-6-501 8.500.2 26-4-624 25.5-6-404 8.500.2 26-4-624(5) 25.5-6-404(5) 8.508.170 26-4-527(3) 25.5-5-306(3) 8.509.10.11 26-4-671 25.5-6-601 8.509.10.11 26-4-672 25.5-6-602 8.509.10.11 26-4-673 25.5-6-603 8.509.10.11 26-4-674 26.5-6-605 8.509.10.11 26-4-675 25.5-6-606 8.509.10.11 26-4-676 25.5-6-607 8.515.11 26-4-681 25.5-6-701 8.515.11 26-4-682 25.5-6-702 8.515.11 26-4-683 25.5-6-703 8.515.11 26-4-684 25.5-6-704 8.515.11 26-4-685 25.5-6-705 8.515.14 L 26-4-683(5) 25.5-6-703(5) 8.521 26-4-202 25.5-5-102 8.521 26-4-302(1) 25.5-5-202(1)

8.904 A.1. 26-4-103(8.5) 25.5-3-103(8.5)

8.904 B.2. 26-4-103(8.5) 25.5-3-103(8.5) 8.930 26-4-1001 25.5-3-201 8.930 26-4-1002 25.5-3-202 8.930 26-4-1003 25.5-3-203 8.930 26-4-1004 25.5-3-204 8.930 26-4-1005 25.5-3-205 8.930 26-4-1006 25.5-3-206 8.930 26-4-1007 25.5-3-207 8.930.1 26-4-1003(6) 25.5-3-203(6)

8.930.34 B.4. 26-4-1003(5) 25.5-3-203(5) 8.950.2.H. Article 4, Title

Article, Title 25.5

STATEMENT OF BASIS AND PURPOSE, FISCAL IMPACT, AND SPECIFIC

STATUTORY AUTHORITY OF REVISIONS MADE TO VOLUME 8

Revisions to sections 8.350b, 8.310.10(1)(3)(4), 8.351.20(a)(b)(c)(d)(e)(g), 8.351.30, 8.352, 8.354.10(b)(c)(e)(f) were finally adopted at the 10/4/85 State Board meeting, with an effective date of 12/1/85 (Document 5). Statement of basis and purpose, fiscal impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Revisions to section 8.059.14 were finally adopted at the 10/4/85 State Board meeting, with an effective date of 12/1/85 (Document 6). Statement of basis and purpose, fiscal impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Revisions to sections 8.059.15, 8.059.16, 8.400.12, 8.400.16, 8.402.33, 8.402.36, 8.402.61, 8.402.63, 8.484, 8.484.11, 8.484.18, 8.509 through 8.511, and 8.750 were adopted on an emergency basis at the 10/4/85 State Board meeting, with an effective date of 10/31/85 (Document 7). Statement of basis and purpose, fiscal impact, and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Social Services.

Revisions to sections 8.100.52(c) and 8.120.27 were adopted on an emergency basis at the 10/4/85 State Board meeting, with an effective date of 10/4/85 (Document 8).

Statement of basis and purpose, fiscal impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Social Services.

Revisions to sections 8.495.20, 8.495.50, 8.495.79 and 8.496 were finallly adopted at the 11/1/85 State Board meeting, with an effective date of 1/1/86 (Document 4).

Revisions to section 8.110.53 was adopted on an emergency basis at the 12/6/85 meeting with an effective date of 1/1/86 (Document 3). Statement of basis and purpose, emergency statement, fiscal impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions to sections 8.201.10, et seq. were finally adopted at the 1/3/86 State Board, with an effective date of 3/1/86 (Document 1). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Revisions to sections 8.350, 8.351, 8.351.20 and 8.351.10, were finally adopted at the 1/3/86 State Board meeting, with an effective date of 3/1/86 (Document 2). Statement of

These materials are available for review by the public during normal working hours at Revisions to section 8.120 - 8.120.21 to 8.120.22 - 8.120.27 and 8.100.36 - 8.100.42 to 8.100.43 - 8.110.52 were adopted as emergency revisions at the 2/7/86 State Board meeting, with an effective date of 4/1/86 (Document 2). Statement of Basis and

authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Social Services.

Revisions to sections 8.100.36 - 8.100.42, 8.100.52, 8.120 - 8.120.21, 8.120.27 were emergency adopted at the 4/11/86 State Board meeting, with an effective date of 4/11/86 (Document 18). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.058.73 - 8.059.146, LTC-201(a) - LTC-210, 8.200 - 8.200.30, 8.356 - 8.356.20-Concl. were finally adopted following publication at the 5/2/86 State Board meeting with an effective date of 7/1/86 (Documents 22, 23 and 24). Statements of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rules. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions to sections 8.110.53, 8.110.4, 8.110.44, 8.110.45, 8.110.46, 8.110.47, 8.358.1, 8.358.2, 8.358.3, 8.358.4, 8.415.15, 8.415.23, 8.482.52, 8.482.84, 8.441.3, 8.120.3, 8.100.5 were finally adopted at the 1/3/86 State Board, with an effective date of 8/1/86 (Documents 5, 8, 15, 16). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.110.53, 8.110.4, 8.110.44, 8.110.45, 8.110.46, 8.110.47, 8.358.1, 8.358.2, 8.358.3, 8.358.4, 8.415.15, 8.415.23, 8.482.52, 8.482.84, 8.441.3, 8.120.3, 8.100.5 were finally adopted at the 6/6/86 State Board, with an effective date of 8/1/86 (Documents 5, 8, 15, 16). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.100.15, 8.120.36, 8.448.7 were finally adopted as emergency revisions at the 7/11/86 State Board, with an effective date of 7/11/86 (Documents 9, 10). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Additions to sections 8.448.7 were emergency adopted at the 7/11/86 meeting and finally adopted at the 8/1/86 meeting with an effective date of 7/11/86 (Document 5).

Revisions to sections 8.100.5, 8.120.28 and 8.120.29 were finally adopted emergency at the 10/3/86 State Board meeting, with an effective date of 9/5/86 (Document 6).

These materials are available for review by the public during normal working hours at Revisions to section 8.332 were finally adopted emergency at the 12/5/86 State Board meeting, with an effective date of 11/7/86 (Document 1). Statement of Basis and

Revisions to sections 8.110.5 and 8.441.2 were finally adopted emergency at the 3/6/87 State Board meeting, with an effective date of 2/6/87 (Documents 3 and 13). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions to sections 8.110.2, 8.110.6 and 8.441.2 were adopted emergency at the 3/6/87 State Board meeting, with an effective date of 3/6/87 (Documents 5 and 14).

Revisions to sections 8.110.61 - 8.110.68 were emergency adopted at the 5/1/87 State Board meeting, with an effective date of 5/1/87 (Document 16). Statement of Basis and

Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions to sections 8.500 - 8.500.43 were finally adopted emergency at the 7/10/87 State Board meeting, with an effective date of 7/1/87 (Document 3). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions and additions to sections 8.463 through 8.645, 8.760 through 8.761, and 8.993 were finally adopted following publication at the 7/10/87 State Board meeting, with an effective date of 9/1/87 (Documents 1 and 2). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Revisions and additions to sections 8.100, 8.110, and 8.762 were adopted emergency at the 7/10/87 State Board meeting, with an effective date of 7/10/87 (Documents 4 and 20). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions and additions to sections 8.440 - 8.441.5, 8.443 - 8.446, 8.448 - 8.448.2, and 8.448.61 - 8.448.8 were adopted emergency at the 7/28/87 Special State Board meeting, with an effective date of 8/01/87 (Documents 1, 2, and 3). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions and additions to sections 8.100, 8.110, and 8.762 were finally adopted emergency at the 8/7/87 State Board meeting, with an effective date of 7/10/87 (Documents 1 and 7). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.120.3 and 8.993 were finally adopted following publication at the 8/7/87 State Board meeting, with an effective date of 10/1/87 (Documents 6 and 16).

Revisions to sections 8.100, 8.110, 8.120, 8.441, 8.532 - 8.534 and 8.762 were adopted emergency at the 9/11/87 State Board meeting, with an effective dates of 7/1/87 and 10/1/87 (Documents 4, 18, 19, 24, and 26). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Revisions to sections 8.120, 8.441, and 8.532 - 8.534 were final adoption of emergency at the 10/2/87 State Board meeting, with effective dates of 7/1/87, 9/11/87, and 10/1/87 (Documents 11, 12 and 17). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Social Services.

Revisions to sections 8.440, 8.441, 8.443, 8.445 and 8.448 were adopted emergency and final at the 10/2/87 State Board meeting, with an effective date of 10/2/87 (Documents 16 and 18). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.100, 8.110, and 8.762 were adopted emergency and final at the 11/6/87 State Board meeting, with an effective date of 11/6/87 (Documents 3 and 8).

Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions to sections 8.250 - 8.253 and 8.831 - 8.836 were adopted emergency at the 1/8/88 State Board meeting, with an effective date of 1/8/88 (Document 16). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions to sections 8.250 - 8.253 and 8.831 - 8.836 were final adoption of emergency at the 2/5/88 State Board meeting, with an effective date of 1/8/88. Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions to sections 8.011, 8.040, 8.057, 8.062, 8.200, 8.202, 8.250 - 8.253, 8.284 - 8.287, 8.303 - 8.311, 8.321 - 8.332, 8.482, 8.485 - 8.486, 8.487, 8.490, 8.491 - 8.494, 8.495 - 8.496, 8.532 - 8.537, 8.590 - 8.665, 8.754, and 8.733 were adopted emergency at the 2/5/88 State Board meeting (CSPR#'s 87-12-2-1, 88-1-19-2, and 88-1-19-3), with an effective date of 2/5/88. Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.011, 8.040, 8.057, 8.062, 8.200, 8.202, 8.250 - 8.253, 8.284 - 8.287, 8.303 - 8.311, 8.321 - 8.332, 8.482, 8.485 - 8.486, 8.487, 8.490, 8.491 - 8.494, 8.495 - 8.496, 8.532 - 8.537, 8.590 - 8.665, 8.754, and 8.733 were final adoption of emergency at the 3/4/88 State Board meeting (CSPR#'s 87-12-2-1, 88-1-19-2, and 88- 1- 19-3), with an effective date of 2/5/88 or 3/1/88. Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Department of Revisions to sections 8.100, 8.110, and 8.120 were finally adopted following publication at the 3/4/88 State Board meeting (CSPR#'s 87-11-12-1 and 87-11-13-3), with an effective date of 5/1/88. Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to section 8.754 were emergency and final adoption at the 4/1/88 State Board meeting, with an effective date of 2/5/88 (CSPR# 88-1-15-1). Statement of Basis and

These materials are available for review by the public during normal working hours at Revisions to sections 8.110 and 8.482 were adopted emergency at the 5/6/88 State Board meeting, with an effective date of 5/6/88 (CSPR# 88-3-8-2). Statement of Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions to sections 8.110 and 8.482 were final adoption of emergency at the 6/3/88 State Board meeting, with an effective date of 5/6/88 (CSPR# 88-3-8-2). Statement of

Basis and Purpose, Fiscal Impact, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Administrator, Revisions to sections 8.050, 8.440-8.441, 8.442-8.443, and 8.448 were adopted emergency at the 7/8/88 State Board meeting, with an effective date of 7/1/88 (CSPR# 88-5-19-2). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions to sections 8.050, 8.440-8.441, 8.442-8.443, and 8.448 were final adoption of emergency at the 8/5/88 State Board meeting, with an effective date of 7/1/88 (CSPR# 88-5-19-2). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions to sections 8.100, 8.110, 8.120, 8.287, 8.484 - 8.487, 8.489 - 8.490 and 8.493 were finally adopted following publication at the 8/5/88 State Board meeting, with an effective date of 10/1/88 (CSPR# 88-1-15-2, 88-2-29-1, 88-3-8-3 and 88-4-28-1).

Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department Revisions to sections 8.049, 8.200 and 8.287 were finally adopted following publication at the 9/9/88 State Board meeting, with an effective date of 11/1/88 (CSPR# 88-4-27-2 and 88-6-21-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions or additions to sections 8.000 - 8.011, 8.100 - 8.110, 8.202 - 8.211, 8.250 - 8.253, 8.300 - 8.303, 8.321 - 8.322, 8.330 - 8.332, 8.400, 8.520 - 8.523, 8.532 - 8.534, 8.540, 8.590, 8.680 - 8.681, 8.682, 8.750, 8.754, and 8.800 - 8.820 were emergency adopted at the 9/9/88 State Board meeting, with an effective date of 9/9/88 (CSPR#'s 88-7-22-3, 88-8-16-1) and with an effective date of 10/1/88 (CSPR#'s 88-7-12-1, 88-7- 22-2, 88-8-11-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions or additions to sections 8.000 - 8.011, 8.100 - 8.110, 8.202 - 8.211, 8.250 - 8.253, 8.300 - 8.303, 8.321 - 8.322, 8.330 - 8.332, 8.400, 8.520 - 8.523, 8.532 - 8.534, 8.540, 8.590, 8.680 - 8.681, 8.682, 8.750, 8.754, and 8.800 - 8.820 were final adoption of emergency at the 10/7/88 State Board meeting, with an effective date of 9/9/88 (CSPR#'s 88-7-22-3, 88-8-16-1) and with an effective date of 10/1/88 (CSPR#'s 88-7- 12-1, 88-7-22-2, 88-8-11-1). Statement of Basis and Purpose and specific statutory

authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Addition of section 8.401.4 was finally adopted following publication at the 10/7/88 State Board meeting, with an effective date of 12/1/88 (CSPR# 87-12-8-2). Statement of

Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department Revisions to sections 8.404 - 8.353, 8.374 and 8.732 - 8.733 were emergency adopted at the 11/4/88 State Board meeting, with an effective date of 11/4/88 (CSPR# 88-9-27-1 and 88-10-13-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions to sections 8.404 and 8.732 - 8.733 were final adoption of emergency at the 12/2/88 State Board meeting, with an effective date of 11/4/88 (CSPR# 88-9-27-1 and 88-10-13-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions and additions to sections 8.321-8.324 and 8.560-8.567 were finally adopted following publication at the 12/2/88 State Board meeting, with an effective date of 2/1/89 (CSPR#'s 88-5-19-1, 88-9-14-1). Statement of Basis and Purpose and specific statutory

These materials are available for review by the public during normal working hours at Revisions to sections 8.400 - 8.401, and 8.402 - 8.404 were adopted emergency and final at the 1/6/89 State Board meeting, with an effective date of 1/1/89 (CSPR# 88-11- 1- 1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by Revisions to sections 8.110 and 8.120 were final adoption of emergency at the 2/3/89 State Board meeting, with an effective date of 1/6/89 (CSPR# 88-9-15-1 and 88-12-8-1).

Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department of Social Revisions to sections 8.356 and 8.500 were finally adopted following publication at the 5/5/89 State Board meeting, with an effective date of 7/1/89 (CSPR#'s 89-1-25-1 and 89-3-15-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions to sections 8.486 and 8.532 - 8.533 were finally adopted following publication at the 6/2/89 State Board meeting, with an effective date of 8/1/89 (CSPR#'s 89-3-20-1 and 89-3-20-2). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions to sections 8.100, 8.111, 8.120, 8.484, 8.485 and 8.486 were adopted emergency at the 6/2/89 State Board meeting, with an effective date of 6/2/89 (CSPR# 89-4-20-1), and with an effective date of 7/1/89 (CSPR#'s 89-2-23-1, 89-4-4-1, 89-4-26- 1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by Revisions to sections 8.111 and 8.486 were final adoption of emergency at the 7/7/89 State Board meeting, with an effective date of 7/1/89 (CSPR#'s 89-4-4-1 and 89-4-26- 1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by Revisions to sections 8.100, 8.120, 8.484 and 8.485 were adopted emergency and final at the 7/7/89 State Board meeting, with an effective date of 7/7/89 (CSPR# 89-4-20-1), and with an effective date of 7/1/89 (CSPR# 89-2-23-1). Statement of Basis and

rule. These materials are available for review by the public during normal working hours Revisions to section 8.540 were final adoption of emergency at the 8/4/89 State Board meeting, with an effective date of 7/7/89 (CSPR# 89-5-24-1). Statement of Basis and

Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department of Social Revisions to sections 8.250 - 8.256 and 8.401 were final adoption following publication at the 8/4/89 State Board meeting, with an effective date of 10/1/89 (CSPR#'s 89-5-17-2 and 89-5-31-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions to sections 8.075, 8.400 and 8.401 were adopted emergency at the 8/4/89 State Board meeting, with an effective date of 8/4/89 (CSPR#'s 89-6-5-1 and 89-7-13- 1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by Revisions to section 8.075 were final adoption of emergency at the 9/8/89 State Board meeting, with an effective date of 8/4/89 (CSPR# 89-6-5-1). Statement of Basis and

rule. These materials are available for review by the public during normal working hours Revisions and additions to sections 8.420 - 8.425, 8.448, and 8.680 - 8.689 were final adoption following publication at the 12/1/89 State Board meeting, with an effective date of 2/1/90 (CSPR#'s 89-7-19-1 and 89-9-20-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours Revisions to sections 8.110, 8.358, 8.442, and 8.481 - 8.482 were final adoption following publication at the 1/5/90 State Board meeting, with an effective date of 3/1/90 (CSPR# 89-11-8-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions to section 8.485 were adopted emergency at the 1/5/90 State Board meeting, with an effective date of 1/5/90 (CSPR# 89-12-13-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working Revisions to section 8.485 were final adoption of emergency at the 2/2/90 State Board meeting, with an effective date of 1/5/90 (CSPR# 89-12-13-1). Statement of Basis and

Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department Revisions to sections 8.110 and 8.112 were final adoption of emergency at the 5/4/90 State Board meeting, with an effective date of 4/6/90 (CSPR#'s 90-3-9-1 and 90-3-20- 1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by Revisions to section 8.441 were final adoption following publication at the 5/4/90 State Board meeting, with an effective date of 7/1/90 (CSPR# 89-9-6-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department of Social Revisions and/or additions to sections 8.110, 8.112, 8.484, 8.501 - 8.502, and 8.504 were adopted emergency at the 5/4/90 State Board meeting, with an effective date of 5/4/90 (CSPR#'s 90-3-26-1 and 90-4-9-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions and/or additions to sections 8.484, 8.501 - 8.502, and 8.504 were final adoption of emergency at the 6/1/90 State Board meeting, with an effective date of 5/4/90 (CSPR# 90-3-26-1). Statement of Basis and Purpose and specific statutory

These materials are available for review by the public during normal working hours at Revisions and additions to sections 8.100, 8.121, and 8.850 - 8.870 were adopted emergency at the 6/1/90 State Board meeting, with an effective date of 6/1/90 (CSPR# 90-4-4-1) and with an effective date of 7/1/90 (CSPR#'s 90-4-9-3 and 90-4-24-1).

authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Revisions to sections 8.850 through 8.870 were adopted emergency and final at the 7/6/90 State Board meeting, with an effective dates of 7/1/90 and 7/6/90 (CSPR# 90-4- 9- 3). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by Revisions and additions to sections 8.100, 8.120, 8.441, and 8.533 - 8.535 were adopted emergency at the 7/6/90 State Board meeting, with an effective date of 7/6/90 (CSPR#'s 90-5-25-2 and 90-6-11-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions and additions to sections 8.100, 8.120, 8.441, and 8.533 - 8.535 were adopted emergency and final at the 8/3/90 State Board meeting, with effective dates of 7/6/90 and 8/3/90 (CSPR#'s 90-5-25-2 and 90-6-11-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working Revisions to sections 8.120, 8.201 and 8.570 - 8.571 were final adoption following publication at the 8/3/90 State Board meeting, with an effective date of 10/1/90 (CSPR#'s 90-4-20-1, 90-5-16-1, and 90-5-30-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours Addition of sections 8.700 - 8.711 were adopted emergency at the 9/7/90 State Board meeting with an effective date of 9/7/90 (CSPR# 90-6-29-1); and, revisions to sections 8.750 - 8.753 were adopted emergency at the 9/7/90 State Board meeting with an effective date of 10/1/90 (CSPR# 90-6-22-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours Revisions to sections 8.750 - 8.753 were final adoption of emergency at the 10/5/90 State Board meeting with an effective date of 10/1/90 (CSPR# 90-6-22-1). Statement of

Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department of Social Revisions to sections 8.430, 8.441, and 8.448 were final adoption following publication at the 10/5/90 State Board meeting, with an effective date of 12/1/90 (CSPR#'s 90-7-18- 1 and 90-8-10-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Addition and/or revisions to sections 8.700 through 8.711 were adopted emergency and final at the 10/5/90 State Board meeting, with an effective dates of 9/7/90 and 10/5/90 (CSPR# 90-6-29-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule: These materials are available for review by the public during normal working hours at the Office of the State Revisions and/or additions to sections 8.300 through 8.311, 8.355 through 8.356, and 8.374 were adopted emergency at the 10/5/90 State Board meeting, with an effective date of 10/5/90 (CSPR# 90-5-8-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions and/or additions to sections 8.300 through 8.311, 8.355 through 8.356, and 8.374 were final adoption of emergency at the 11/2/90 State Board meeting, with an effective date of 10/5/90 (CSPR# 90-5-8-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours Revisions to sections 8.100 and 8.110 were final adoption following publication at the 12/7/90 State Board meeting, with an effective date of 2/1/91 (CSPR# 90-9-17-3).

These materials are available for review by the public during normal working hours at Revisions to sections 8.111 and 8.374 were final adoption of emergency at the 2/1/91 State Board meeting, with effective dates of 1/1/91 (CSPR# 90-12-4-1) and 1/4/91 (CSPR# 90-11-7-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions to sections 8.100, and 8.120 were adopted emergency and final at the 2/1/91 State Board meeting, with effective dates of 1/1/91 and 2/1/91 (CSPR# 90-11-28-2).

Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department Revisions to section 8.465 and addition of section 8.585 were adopted emergency and final at the 2/1/91 State Board meeting, with an effective date of 3/1/91 (CSPR# 90-11- 20-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions to sections 8.100 and 8.211 were adopted emergency at the 3/8/91 State Board meeting, with an effective date of 3/8/91 (CSPR#'s 91-1-30-2 and 91-2-20-1), and addition of section 8.550 was adopted emergency (CSPR# 91-1-18-1), with an effective date of 3/31/91. Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Revisions to sections 8.100 and 8.211 were final adoption of emergency at the 4/5/91 State Board meeting, with an effective date of 3/8/91 (CSPR#'s 91-1-30-2 and 91-2-20- 1), and addition of section 8.550 was final adoption of emergency (CSPR# 91-1-18-1), with an effective date of 3/31/91. Statement of Basis and Purpose and specific statutory

authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Revisions to sections 8.317 - 8.325 were final adoption following publication at the 4/5/91 State Board meeting, with an effective date of 6/1/91 (CSPR# 90-11-7-2) and revisions to sections 8.330 - 8.332 were final adoption following publication (CSPR# 91- 1- 23-1), with an effective date of 7/1/91. Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.211, 8.401, 8.402, 8.405, 8.408, 8.409, 8.415, 8.486 - 8.487, 8.510, 8.520 - 8.527, 8.532 - 8.533, 8.540, and 8.550 were final adoption following publication at the 5/3/91 State Board meeting, with an effective date of 7/1/91 (CSPR#'s 90-11-14-1, 90-11-23-1, 91-1-7-1, 91-2-15-1, 91-2-25-1, and 91-3-11-1). Statement of

These materials are available for review by the public during normal working hours at Revisions to sections 8.330 - 8.332, 8.373 and 8.374 were adopted emergency and final at the 6/7/91 State Board meeting, with an effective dates of 5/3/91 and 6/7/91 (CSPR# 91-1-14-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions to sections 8.059, 8.112, 8.356, 8.400 - 8.401, 8.402 - 8.403, 8.484, 8.485, 8.486, 8.501, 8.504, and 8.550 were final adoption of emergency at the 6/7/91 State Board meeting, with an effective date of 5/3/91 (CSPR#'s 91-2-26-2, 91-4-1-1, 91-4-3-1, 91-4-5-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions to sections 8.061, 8.100, 8.110, and 8.120 were adopted emergency at the 6/7/91 State Board Meeting, with an effective date of 7/1/91 (CSPR# 91-3-1-1), and sections 8.800 - 8.850 were adopted emergency at the 6/7/91 State Board meeting, with an effective date of 6/7/91 (CSPR# 91-4-19-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours Revisions to sections 8.061, 8.100, 8.110, and 8.120 were final adoption of emergency at the 7/12/91 State Board Meeting, with an effective date of 7/1/91 (CSPR# 91-3-1-1), and sections 8.800 - 8.850 were final adoption of emergency at the 7/12/91 State Board meeting, with an effective date of 6/7/91 (CSPR# 91-4-19-1). Statement of Basis and

These materials are available for review by the public during normal working hours at Revisions to sections 8.441 and 8.533 - 8.536 were adopted emergency at the 8/2/91 State Board meeting, with an effective date of 8/2/91 (CSPR#'s 91-5-23-1 and 91-7-17- 1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by Revisions to section 8.533 - 8.536 were final adoption of emergency at the 9/6/91 State Board meeting, with an effective date of 8/2/91 (CSPR# 91-5-23-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department of Social Revisions to section 8.441 were adopted emergency and final at the 9/6/91 State Board meeting, with effective dates of 8/2/91 and 9/6/91 (CSPR# 91-7-17-1). Statement of

authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Revisions to or addition of sections 8.050, 8.356, 8.435, 8.430 and 8.754 were final adoption following publication at the 11/1/91 State Board meeting, with an effective date of 1/1/92 (CSPR#'s 91-1-10-2, 91-5-29-2, 91-9-13-1, 91-9-17-1 and 91-9-18-1).

Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department Revisions to section 8.332 were adopted emergency and final at the 11/1/91 State Board meeting, with an effective date of 12/1/91 (CSPR# 91-8-5-1. Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department of Social Revisions to and/or additions of Table of Contents and sections 8.014 and 8.020 through 8.040 were adopted emergency and final at the 12/6/91 State Board meeting, with an effective date of 1/1/92 (CSPR# 91-7-19-2). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working Revisions to sections 8.043, 8.461 - 8.464, and 8.800 - 8.834 were final adoption following publication at the 12/6/91 State Board meeting, with an effective date of 2/1/92 (CSPR#'s 91-9-23-1, 91-9-26-1, and 91-10-3-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours Revisions to section 8.110 and were adopted emergency at the 12/6/91 State Board meeting, with an effective date of 1/1/92 (CSPR# 91-11-8-2); and, to section 8.540 with an effective date of 12/6/91 (CSPR# 91-10-29-2). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours Revisions to section 8.540 were final adoption of emergency, with an effective date of 12/6/91 (CSPR# 91-10-29-2). Statement of Basis and Purpose and specific statutory

Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department Revisions to sections 8.300 - 8.302 and 8.330 - 8.332 were final adoption following publication at the 1/10/92 State Board meeting, with an effective date of 3/1/92 (CSPR# 91-9-27-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions to section 8.441.2 were adopted emergency and final at the 1/10/92 State Board meeting, with an effective date of 2/1/92 (CSPR# 91-11-8-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department of Social Revisions to sections 8.400 and 8.401 and addition of section 8.745 were final adoption following publication at the 2/7/92 State Board meeting, with an effective date of 4/1/92 (CSPR#'s 91-10-7-2 and 91-11-25-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.312 through 8.319 were adopted emergency and final at the 2/7/92 State Board meeting, with an effective date of 3/1/92 (CSPR# 91-9-30-1).

rule. These materials are available for review by the public during normal working hours Revisions to section 8.356 and addition of section 8.712 were final adoption following publication at the 6/5/92 State Board meeting, with an effective date of 8/1/92 (CSPR# 92-2-14-2). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Addition of section 8.500 was adopted emergency and final at the 6/5/92 State Board meeting, with an effective date of 6/5/92 (CSPR# 91-11-21-1). Statement of Basis and

rule. These materials are available for review by the public during normal working hours Revisions to sections 8.110.29 and 8.110.52 were adopted emergency at the 7/10/92 State Board meeting, with effective dates of 7/10/92 and 8/1/92 respectively (CSPR#'s 92-3-30-1 and 92-6-15-1). Statement of Basis and Purpose and specific statutory

These materials are available for review by the public during normal working hours at Revisions and additions to sections 8.356.20 and 8.441.2, 8.441.3 - 8.441.5, 8.441.8, 8.448.22, and 8.448.7 were adopted emergency at the 8/7/92 State Board meeting, with an effective date of 8/7/92 (CSPR#'s 92-7-2-1 and 92-7-13-1). Statement of Basis and

Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department Revisions to sections 8.200, 8.325, 8.330 - 8.332, 8.442, 8.500, 8.522 - 8.525, 8.560 - 8.571, 8.660 - 8.666, 8.700, and 8.740 - 8.744 were adopted emergency at the 9/4/92 State Board meeting, with an effective date of 9/4/92 (CSPR#'s 92-7-24-2 and 92-7-28- 1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by Revisions to sections 8.200, 8.325, 8.330 - 8.332, 8.442, 8.500, 8.522 - 8.525, 8.560 - 8.571, 8.660 - 8.666, 8.700, and 8.740 - 8.744 were final adoption of emergency at the 10/2/92 State Board meeting, with an effective date of 9/4/92 (CSPR#'s 92-7-24-2 and 92-7-28-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions to sections 8.020, 8.021, 8.023, 8.024, 8.486, and 8.495 were final adoption following publication at the 10/2/92 State Board meeting, with an effective date of 12/1/92 (CSPR#'s 92-3-18-1 and 92-3-20-2). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours Revisions to sections 8.120, 8.121 - 8.122, 8.200 - 8.201, 8.286 - 8.287, and 8.563 - 8.567 were final adoption following publication at the 11/6/92 State Board meeting, with an effective date of 1/1/93 (CSPR#'s 92-7-24-1, 92-8-11-1, and 92-9-15-1). Statement of

Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Liaison, Department of Social Revisions to sections 8.110, 8.487, and 8.502 were adopted emergency at the 1/8/93 State Board meeting, with an effective date of 1/8/93 (CSPR#'s 92-11-9-3 and 92-12-11- 1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by Revisions to sections 8.110, 8.487, and 8.502 were final adoption of emergency at the 2/5/93 State Board meeting, with an effective date of 1/8/93 (CSPR#'s 92-11-9-3 and 92-12-11-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of the State Board Revisions to sections 8.210, 8.211, and 8.253 were adopted emergency and final at the 2/5/93 State Board meeting, with an effective date of 3/1/93 (CSPR# 92-11-27-1).

These materials are available for review by the public during normal working hours at Revisions to sections 8.011 and 8.356 were adopted emergency at the 3/5/93 State Board meeting, with an effective date of 3/5/93 (CSPR#'s 93-1-19-1 and 93-2-9-1).

authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Revisions to sections 8.043, 8.049, and 8.356.40 were final adoption following publication at the 5/7/93 State Board meeting, with an effective date of 7/1/93 (CSPR#'s 93-1-21-1, 93-2-10-1, and 93-2-19-1). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.330 - 8.332, 8.442, 8.550, 8.560 - 8.563, 8.660 - 8.663, 8.700, and 8.742 - 8.744 were adopted emergency at the 5/7/93 State Board meeting, with an effective date of 5/7/93 (CSPR# 93-3-8-2). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rule.

These materials are available for review by the public during normal working hours at Revisions to sections 8.330 - 8.332, 8.442, 8.550, 8.560 - 8.563, 8.660 - 8.663, 8.700, and 8.742 - 8.744 were final adoption of emergency at the 6/4/93 State Board meeting, with an effective date of 5/7/93 (CSPR# 93-3-8-2). Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the

rule. These materials are available for review by the public during normal working hours Revisions to sections 8.373, 8.448 and 8.500 were final adoption following publication at the 6/4/93 State Board meeting, with an effective date of 8/1/93 (CSPR#'s 92-11-9-1, 93-3-8-1, and 93-3-29-1). Statement of Basis and Purpose and specific statutory

section 8.835 - 8.850 were adopted emergency and final at the 8/6/93 State Board meeting, with an effective date of 9/10/93 (CSPR# 93-5-26-3). Statement of Basis and

authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Revisions to Sections 8.356.40, 8.441, and 8.448 were approved by the Medical Services Board as emergency adoptions on June 9, 2000, final adoptions on July 14, 2000 and became effective July 1, 2000 (MSB 00-05-08-B and MSB 00-03-28-A, respectively). Revisions to Section 8.509 were approved initial adoption on May 12, 2000, final adoption on July 14, 2000, and becomes effective September 1, 2000 (MSB 00-02-08-A).

Revisions to Sections 8.110.5 and 8.110.3; 8.110.49 and 8.482; and 8.407 were approved by the Medical Services Board as initial adoptions on July 14, 2000. final adoptions on August 11, 2000 and become effective October 1, 2000 (MSB 00-01-28-A and MSB 00-05-08-A, MSB 00-05-04-A respectively). Revisions to Section 8.528 were approved emergency adoption on August 11, 2000, become effective September 1, 2000 (MSB 00-05-16-A, Option #2).

Revisions to Section 8.207 were approved emergency adoption on September 8, 2000, and become effective October 1, 2000 (MSB 00-08-23-A). Revisions to Sections 8.100 through 8.106 were approved by the Medical Services Board as initial adoptions on August 11, 2000, final adoptions on September 8, 2000 and become effective November 1, 2000 (MSB 00-03-13-A). Sections 8.214 and 8.900 were added and approved by the Medical Services Board as initial adoptions on August 11, 2000, final adoptions on September 8, 2000 and become effective November 1, 2000 (MSB 00-05- 23-A and MSB 00-06-28-A respectively) Revisions to Section 8.528 were approved emergency adoption on August 11, 2000, final adoption on September 8, 2000, and became effective September 1, 2000 (MSB 00-05-16-A, Option #2).

Revisions to Section 8.207 were approved emergency adoption on September 8, 2000, final adoption on October 13, 2000, and became effective October 1, 2000 (MSB 00-08- 23-A). Revisions to Sections 8.011, 8.100, and 8.205 were approved by the Medical Services Board as an emergency adoption on November 9, 2000, and becomes effective December 1, 2000 (MSB 00-09-19-A). Revisions to Section 8.205.2 were approved as an initial adoption on October 13, 2000, final adoption on November 9, 2000, and becomes effective January 1, 2001 (MSB 00-07-26-A). Section 8.930 was added and approved by the Medical Services Board as an initial adoption on October 13, 2000, a final adoption on November 9, 2000 and becomes effective January 1, 2001 (MSB 00-08-03-A)

Revisions to Section 8.110.5 were approved emergency adoption on December 8, 2000, and become effective January 1, 2001 (MSB 00-10-24-A). Revisions to Sections 8.011, 8.100, and 8.205 were approved by the Medical Services Board as an emergency adoption on November 9, 2000, final adoption on December 8, 2000 and become permanent February 1, 2001 (MSB 00-09-19-A). Revisions to Sections 8.050, 8.075, 8.076 were approved as an initial adoption on November 9, 2000, final adoption on December 8, 2000, and become effective February 1, 2001 (MSB 00-03-20-A).

The Statement of Basis and Purpose and specific statutory authority for these revisions were incorporated by reference into the rules. These materials are available for review by the public during normal working hours at the Medical Services Board Office of the Department of Health Care Policy and Financing, 1575 Sherman Street, Denver, CO 80203. ______________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first

section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 03/04/2007, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History

Rule 8.057 emer. rule eff. 04/13/2007.

Rule 8.941 emer. rule eff. 05/01/2007.

Rules 8.100.53.A2.1.c.-e, 8.1000.4.B.1.b. and 2.b. emer. rules expired 05/09/2007.

Rules 8.057, 8.100.53, 8.903, 8.1000.4 eff. 07/01/2007.

Rule 8.903 emer. rule eff. 07/01/2007.

Rule 8.443.11 emer. rule eff. 07/13/2007.

Rule 8.941.9 eff. 07/30/2007.

Rules 8.903.C.15-16 emer. rules eff. 08/01/2007.

Rules 8.057.9.A-D, 8.101.3 eff. 08/30/2007.

Rules 8.750, 8.903.C.14 eff. 08/30/2007.

Rules 8.212.4.A-A.11 eff. 09/01/2007.

Rule 8.280 eff. 10/01/2007.

Rules 8.443.11, 8.832, 8.890, 8.903.C.14-16 eff. 10/30/2007.

Rule 8.885 eff. 11/30/2007.

Rule 8.519.6 emer. rule eff. 12/14/2007.

Rules 8.042; 8.101.2; 8.485.30-40; 8.504; 8.509.12-13; 8.510 eff. 12/30/2007.

Rule 8.100.53 emer. rule eff. 01/01/2008.

Rules 8.101.1, 8.904 emer. rules eff. 01/01/2008.

Rules 8.100.53, 8.392.3, 8.895 eff. 01/30/2008.

Rule 8.1000.4 emer. rule eff. 03/14/2008.

Rules 8.101.1, 8.519.6, 8.904 eff. 03/30/2008.

Rule 8.837 eff. 04/01/2008.

Rules 8.837, 8.903.C.15 eff. 04/30/2008.

Rule 8.1000.4 eff. 05/30/2008.

Rules 8.895.3A, 8.904.G.2.b, 8.907.B eff. 06/30/2008.

Rule 8.290 emer. rule eff. 07/01/2008; expired 08/09/2008.

Rules 8.100.53, 8.101.2, 8.903.C.14 emer. rules eff. 7/11/2008; expired 10/11/2008.

Rules 8.110.1, 8.290 eff. 08/30/2008.

Rule 8.837 emer. rule eff. 10/01/2008.

Rules 8.100.53, 8.101.2, 8.903.C.14 eff. 10/30/2008.

Rule 8.837 eff. 11/30/2008.

Rules 8.040, 8.050, 8.076, 8.079, 8.130, 8.300.4, 8.885.9 eff. 12/30/2008.

Rules 8.064, 8.941.1, 8.941.9 emer. rules eff. 01/09/2009.

Rules 8.064, 8.100-8.123, 8.495, 8.800-8.821, 8.850, 8.885-8.890 eff. 03/30/2009.

Rules 8.440-8.441, 8.443, 8.941.1, 8.941.9 emer. rules eff. 04/10/2009.

Rules 8.040, 8.100.1, 8.100.3, 8.440-8.441, 8.443 emer. rules eff. 05/08/2009; 8.440- 8.441, 8.443 expired 08/08/2009.

Rules 8.079, 8.100.3 eff. 05/30/2009.

Rules 8.100.3, 8.100.5.H.2.h, 8.100.5.M.2 emer. rules eff. 06/12/2009.

Rules 8.800, 8.941.1, 8.941.9 eff. 06/30/2009 Rules 8.100.5.M.4, 8.302, 8.800.13 emer. rules eff. 07/01/2009.

Rules 8.040, 8.100.1, 8.100.3.H, 8.130.35 eff. 07/30/2009.

Rules 8.100.3.G.1.g.iv.3, 8.100.5.H.2.h, 8.100.5.M.2.e.vi, 8.100.5.M.4, 8.302.D, 8.440- 8.441, 8.443, 8.800, 8.800.13.D eff. 08/30/2009.

Rules 8.100.1, 8.100.4.G, 8.332, 8.494.50-8.494.55, 8.570.6.A-B, 8.590.7.I.1-3), 8.700.7.A-D, 8.700.8.A-B, 8.800.13.D, emer. rules eff. 09/01/2009; Rule 8.903.C.14-16 emer. rule repealed eff. 09/01/2009.

Rule 8.100.3.H.3.l eff. 10/30/2009.

Rules 8.100.1, 8.100.3.G.1.g.7.l, 8.100.3.L.1.aa, 8.100.3.L.1.ee, 8.100.4.G.10, 8.300- 8.300.12.C, 8.8.570.6.A-B, 8.590.7.I.1-3, 8.700.7.A-D, 8.700.8.A-B, 8.800.3.A.2.b, 8.800.13.D.1.a-b eff. 11/30/2009.

Rules 8.300.13-8.375.60, 8.903.C.14-16 repealed eff. 11/30/2009.

Rules 8.494.50-55, 8.570.6.B, 8.590.7.I.2-3 emer. rules eff. 12/01/2009.

Rules 8.057.4.B.1, 8.130.35.B eff. 12/30/2009.

Rule 8.300.6.A.1 emer. rule eff. 01/01/2010.

Rules 8.300.6.A.1, 8.494.50-55, 8.570.6.B, 8.590.7.I.2-3 eff. 01/30/2010.

Rule 8.215 eff. 03/30/2010.

Rules 8.300.8.B, 8.400-8.440.1.B, 8.440.1.D.1, 8.440.2, 8.442.2-2.A, 8.442.3, 8.443.1, 8.443.2, 8.443.3.A, 8.443.7.A, 8.443.7.C-E, 8.443.8.A, 8.443.8.D-E, 8.443.10-12, 8.443.17.A.vi, 8.903-8.903.C, 8.2000 emer. rule eff. 04/09/2010.

Rule 8.100.4.G emer. rule eff. 05/01/2010.

Rule 8.435 eff. 05/30/2010.

Rules 8.100.3.Q.1, 8.100.3.Q.4, 8.435.1, 8.435.2.B.4, 8.435.2.E.5-8 emer. rules eff . 06/11/2010; rules in 8.435 expired 10/09/2010.

Rules 8.100.4.G, 8.300.8.B, 8.400-8.440.1.B, 8.440.1.D.1, 8.440.2, 8.442.2-2.A, 8.442.3, 8.443.1, 8.443.2, 8.443.3.A, 8.443.7.A, 8.443.7.C-E, 8.443.8.A, 8.443.8.D-E, 8.443.10-12, 8.443.17.A.vi, 8.903-8.903.C, 8.2000 eff. 06/30/2010.

Rules 8.300.6.A, 8.570.6.B, 8.590.7.I.2-3 emer. rules eff. 07/01/2010.

Rules 8.100.3.Q.1, 8.100.3.Q.4, 8.100.5.M.1, 8.300.6.A, 8.570.6.B, 8.590.7.I.2-3 eff. 08/30/2010.

Rule 8.2000 emer. rule eff. 10/08/2010.

Rules 8.100.3.G.1.g.iii.7.k-l, 8.100.4.B, 8.100.5.B; 8.435.1, 8.435.2.B.4, 8.435.2.E.5-8 eff. 10/30/2010.

Rules 8.100.1, 8.100.3.A.1-10, 8.100.3.O.1-2, 8.100.4.A-B.2.d, 8.100.4.I, 8.100.5-5.A.3, 8.209 eff. 11/30/2010.

Rules 8.100.3.H.2.f, 8.747 emer. rules eff. 12/10/2010.

Rules 8.519, 8.2000 eff. 12/30/2010.

Rule 8.215.6.C emer. rule eff. 01/01/2011.

Rules 8.215.6.C, 8.290.1, 8.290.3.B, 8.290.7-8 eff. 01/30/2011.

Rules 8.050.1.2, 8.100.3.H.2.f, 8.510, 8.747 eff. 03/02/2011.

Rules 8.100.3.B.1, 8.100.3.C.6-7, 8.100.4.B.2.c, 8.100.7.A-B, 8.100.7.C.2.c-8.100.7.D eff. 03/30/2011.

Rules 8.528.14.D-F.2 emer. rules eff. 05/13/2011.

Rule 8.570.6 emer. rule eff. 06/01/2011.

Rule 8.100.3.H.1 emer. rule eff. 06/26/2011.

Rules 8.100.5.B.1.c, 8.100.5.B.1.h-i, 8.290.6.D-D.8, 8.580.3 eff. 07/01/2011.

Rules 8.300.6.A.1, 8.590.7.I, 8.748 emer. rule eff. 07/01/2011.

Rules 8.901.C-E; 8.903.A.1-3.a emer. rule eff. 07/08/2011.

Rule 8.2003.D.2.a.iv emer. rule eff. 08/12/2011.

Repeal rule 8.930 emer. rule eff. 08/12/2011.

Rule 8.100.3.Q.4-5 emer. rule eff. 08/29/2011.

Rules 8.100.3.H.1, 8.100.5.M, 8.300.6.A.1, 8.528.14.D-F.2, 8.570.6, 8.590.7.I, 8.748 eff. 08/30/2011.

Rule 8.800.13-8.800.13.I emer. rule eff. 09/01/2011.

Rules 8.100.6.C.10, 8.443.11.6, 8.443.12, 8.443.17.A.4.a, 8.800.13-8.800.13.P emer. rules eff. 09/09/2011.

Rules 8.523.11.G.1, 8.524.12-15, 8.525.10.C, 8.525.15, 8.527.13-14, 8.528.11.E, 8.528.13.A, 8.528.14.B.1-B.2, 8.528.14.C, 8.901.C-E, 8.903.A.1-3 a eff. 09/30/2011.

Rules 8.100.4.J, 8.2003.A.3, 8.2003.B.3, 8.2004.B.3, 8.2004.D.3, 8.2004.E.3, 8.2004.F.3.a.i-iii, 8.2004.G.3.a-e, 8.2004.I.2, 8.2004.J.1, 8.2004.J.3, 8.2004.K.2, 8.2004.L.3.b-c, 8.2004.M.3, 8.2004.N.2 emer. rules eff.10/14/2011.

Rules 8.100.3.Q.4-5, 8.212.1.A.5, 8.212.1.A.7, 8.212.1.A.10, 8.212.1.A.12-13, 8.212.2- 2.H.1, 8.212.4.A-B.8, 8.2003.D.2.a.iv eff. 10/30/2011; rule 8.930 repealed eff. 10/30/2011.

Rules 8.100.6.C, 8.443.11.6, 8.443.12, 8.443.17.A, 8.500.1-18, 8.500.90-108, 8.503, 8.590.7.D-F eff. 11/30/2011. Rule 8.766 repealed eff. 11/30/2011.

Rule 8.800.13 emer. rule eff. 12/09/2011.

Rules 8.100.4.J, 8.2003.A-B, 8.2004 eff. 12/30/2011.

Rules 8.015, 8.765 eff. 01/01/2012.

Rule 8.765.A.4.5 emer. rule eff. 01/01/2012.

Rule 8.100.3.H.1 emer. rule eff. 01/13/2012.

Rules 8.100.1, 8.100.3.F.1, 8.100.3.H.9, 8.100.3.M, 8.100.3.N.2.e, 8.100.5.A, 8.100.5.C.2, 8.100.5.F.1, 8.100.5.H.1, 8.100.5.H.2.c, 8.100.5.M.1, 8.100.6.O, 8.205, 8.765.4.A.5, 8.765.12.B, 8.800.13, 8.904.F.2.d eff. 03/01/2012.

Rule 8.100.6.O.1.f.3.c-e emer. rule eff. 03/09/2012.

Rules 8.100.1, 8.100.3.H.1, 8.100.3.J.4, 8100.3.M, 8.100.3.N.2, 8.100.5.E, 8.100.5.J-M, 8.100.5.O-P; 8.100.6.P; 8.100.7-7.B, 8.100.7.F-K, 8.100.7.V-V.3.j, 8.760, 8.761 eff. 04/01/2012.

Rules 8.100.1, 8.100.3.F.1.m, 8.100.3.H.9.c, 8.100.3.J.4, 8.100.3.M, 8.100.3.N.2.d, 8.100.5.H.1, 8.100.5.M.1, 8.100.6.P emer. rules eff. 05/11/2012.

Rules 8.010, 100.6.O.1.f.3.c-e, 8.550.1 eff. 06/01/2012.

Rules 8.443.11.3, 8.443.17.A.4.e, 8.907.A eff. 06/30/2012.

Rules 8.517 eff. 07/01/2012.

Rules 8.100.3.F.1.n, 8.100.3.H.9.c, 8.100.3.M.1, 8.100.3.N.2.e, 8.100.5.A.1.a, 8.100.5.C.1, 8.100.5.M.1, 8.100.6.Q emer. rules eff. 07/01/2012.

Rule 8.555 emer. rule eff. 08/30/2012.

Rules 8.100.1, 8.100.3.F.1.m-n, 8.100.3.H.9.c, 8.100.3.J.4, 8.100.3.M.1, 8.100.3.N.2.de, 8.100.5.A.1.a, 8.100.5.C.1, 8.100.5.H.1, 8.100.5.M.1, 8.100.6.P-Q eff. 08/30/2012.

Rules 8.517.5.A.4-5, 8.555 eff. 09/30/2012.

Rules 8.515, 8.700.8.B, 8.700.8.D.2 eff. 10/30/2012.

Rules 8.2003.A.3, 8.2003.B.3, 8.2003.D.2.a.v, 8.2004.B.1-2, 8.2004.C.3, 8.2004.D.3, 8.2004.E.3.a-8.2004.E.4, 8.2004.F.3.a-f, 8.2004.G.2, 8.2004.H.3, 8.2004.I.1, 8.2004.J.2, 8.2004.K.3.a-c, 8.2004.M.2-8.2004.N emer. rules eff. 11/09/2012.

Rules 8.100.B.1, 8.100.7B.2.c eff. 11/30/2012.

Rules 8.041, 8.522, 8.527 eff. 12/30/2012.

Rules 8.100.4.F.2.a-b, 8.100.4.G.7, 8.100.4.G.8.b, 8.800.4.G eff. 01/01/2013.

Rules 8.200, 8.482.33.C.1.d, 8.842.33.C.2.c, 8.510.3.B.2, 8.510.3.B.3, 8.565.A, 8.765.11.A-B, 8.800.1, 8.800.13, 8.2003.A.3, 8.2003.B.3, 8.2003.D.2.a.v, 8.2004.B.1-2, 8.2004.C.3, 8.2004.D.3, 8.2004.E.3.a-8.2004.E.4, 8.2004.F.3.a-f, 8.2004.G.2, 8.2004.H.3, 8.2004.I.1, 8.2004.J.2, 8.2004.K.3.a-c, 8.2004.M.2- 8.2004.N eff. 01/30/2013.

Rule 8.2003.A.3 emer. rule eff. 02/08/2013.

Rules 8.100.4.J, 8.907.C eff. 03/30/2013.

Rules 8.200.6, 8.440.2.C.4, 8.443.4.B, 8.443.8.A.19, 8.433.8.F emer. rules eff. 04/12/2013.

Rules 8.509, 8.570.6.A-B, 8.2003.A.3 eff. 04/30/2013.

Rules 8.200.6, 8.440.2.C.4, 8.442.3, 8.443.4.B, 8.443.8.A.19, 8.433.8.F eff. 06/30/2013.

Rules 8.300.6.A.1, 8.590.7.I, 8.700.7.B emer. rules eff. 07/01/2013.

Rule 8.580.4 eff. 07/30/2013.

Rules 8.200.3.C.2, 8.200.3.D, 8.295, 8.300.3.C, 8.300.6.A.1, 8.310, 8.570.3.D, 8.590.7.I, 8.700.1-8.700.6 eff. 08/30/2013.

Rules 8.443.17, 8.443.17.A.4.f, 8.443.20, 8.590.2.S eff. 09/30/2013.

Rules 8.100.1, 8.100.2, 8.100.3, 8.100.4, 8.100.5, 8.100.6 eff. 10/01/2013.

Rules 8.200.3.D.2, 8.519.1, 8.519.5.D-8.519.5.E, 8.519.7.B.3.a.v.5-8.519.7.B.3.a.v.8, 8.519.7.B.4, 8.550.4.C-8.550.4.D eff. 10/30/2013.

Rule 8.515.2 eff. 12/30/2013.

Rules 8.016-8.017, 8.100.4.H emer. rules eff. 01/01/2014.

Rule 8.551 repealed eff. 02/01/2014.

Rules 8.016-8.017, 8.100.4.G.2.a, 8.100.4.H, 8.754.5.G, 8.904.F.2, 8.907.B, 8.2001, 8.2002.A.1, 8.2003.A.3, 8.2003.B.3, 8.2003.D.2.a.vi, 8.2004.B, 8.2004.C.3, 8.2004.D, 8.2004.E.3.a, 8.2004.F.3, 8.2004.G.3, 8.2004.I.3, 8.2004.J.2, 8.2004.K.3, 8.2004.L.3, 8.2004.N eff. 03/02/2014.

Rules 8.2003.A.3, 8.2004.D.3, 8.2004.E.3.a.i-iii emer. rules eff. 03/14/2014.

Rules 8.205.4.A, 8.280, 8.485, 8.600-8.614 eff. 03/30/2014. Rule 8.496 repealed eff. 03/30/2014.

Rule 8.201 eff. 04/01/2014.

Rule 8.800.4.B.5-8, 8.800.4.E eff. 04/30/2014.

Rule 8.200.3.D.2 emer. rule eff. 05/12/2014.

Rules 8.050.3.A, 8.050.4.A.1-5, 8.440.2.A.3, 8.443.7.A.1, 8.443.7.A.2, 8.443.7.A.5, 8.443.7.A.7, 8.443.7.A.9, 8.443.7.A.11, 8.443.8.A.7, 8.940-8.941.10, 8.2003.A.3, 8.2004.D.3, 8.2004.E.3.a.i-iii eff. 05/30/2014.

Rule 8.212 eff. 06/01/2014.

Rules 8.504, 8.515.2, 8.515.5.A, 8.515.5.B.2, 8.516.30, 8.516.50, 8.516.60.A, 8.516.60.D.3, 8.516.70, 8.517 eff. 06/30/2014. Form MED-11E repealed eff. 06/30/2014.

Rule 8.201 eff. 07/01/2014. Rules 8.201.2.A.8.g-h, 8.201.2.B.1.d-p, 8.201.3.2.b, 8.201.6, 8.300.6.A.1, 8.590.7.I.2-3, 8.700.6.C emer. rules eff. 07/01/2014.

Rule 8.200.3.D.2 eff. 07/30/2014.

Rules 8.201, 8.300.6.A.1, 8.497, 8.590.7.I.2-3, 8.700.6.C eff. 08/30/2014.

Rules 8.063.11-8.063.12, 8.100.3.G.2-8.100.3.G.3.d, 8.100.3.H.9.a-8.100.3.H.9.c, 8.515.85 eff. 10/01/2014. Rule 8.063.20 repealed eff. 10/01/2014.

Rules 8.202.1-8.202.5, 8.570.1-8.570.3, 8.570.4.D, 8.570.5-8.570.9 eff. 11/30/2014.

Rule 8.100.4.C.1.d emer. rule eff. 12/12/2014.

Rules 8.300.3.C, 8.310, 8.493, 8.510, 8.564.B, 8.590.1, 8.590.2.G.17, 8.590.5.D, 8.590.7.L eff. 12/30/2014.

Rules 8.100.4.D.1, 8.100.7.V.3 eff. 01/01/2015.

Rules 8.960, 8.2001, 8.2003-8.2004 emer. rules eff. 01/09/2015.

Rules 8.100.4.C.1.d, 8.100.7.B.1.c, 8.100.7.B.2.c, 8.200.3.D.1, 8.535-8.535.7, 8.552- 8.552.8, 8.810-8.810.5 eff. 03/02/2015.

Rules 8.960, 8.2001, 8.2003-8.2004 eff. 03/30/2015.

Rules 8.100.1, 8.100.4.G.3-4 emer. rules eff. 04/01/2015.

Rules 8.018, 8.100.6.P.1.f.ii, 8.100.6.P.3, 8.100.6.Q.1.f.ii, 8.100.6.Q.4, 8.201, 8.400- 8.497 eff. 05/01/2015.

Rules 8.2003.A.3, 8.2004.E.1 emer. rules eff. 05/08/2015.

Rules 8.100.1, 8.100.4.G.3-4, 8.553.1-8.553.5.D, 8.570.5.A eff. 05/30/2015.

Rule 8.517 emer. rule eff. 06/30/2015.

Rules 8.013.1, 8.100.1, 8.100.4.G, 8.100.4.G.5.a, 8.100.4.G.6, 8.100.4.F.2.b, 8.125, 8.492.10.12, 8.492.30.31, 8.492.50.53, 8.492.50.55, 8.730-8.731, 8.770 eff. 07/01/2015. Rules 8.300.6.A.1, 8.590.7.I emer. rules eff. 07/01/2015.

Rules 8.555, 8.732, 8.2003.A.3, 8.2004.E eff. 07/30/2015.

Rules 8.300.6.A.1, 8.517, 8.590.7.I eff. 08/30/2015.

Rules 8.509.15.A.2.a-c, 8.515.3, 8.517.2-8.517.2.1, 8.517.5.A.2 emer. rules eff. 09/11/2015. Rule 8.535.4.H.13 repealed emer. rule eff. 09/11/2015; expired 01/09/2016.

Rules 8.100.3.Q, 8.100.4.C.1.a, 8.493.3.E, 8.493.4.B-C, 8.493.4.E, 8.493.6.D eff. 09/30/2015.

Rules 8.100.1, 8.100.3.A, 8.100.3.D.1, 8.100.3.G.2.a-8.100.3.G.3, 8.100.3.H.2.d, 8.100.3.H.9, 8.100.3.J.2-3, 8.100.K.6, 8.100.K.8.b.i)1), 8.100.3.K.10.a.i)1), 8.100.3.N.7.g, 8.100.3.N.7.i, 8.100.4.A-8.100.4.C, 8.100.4.E-8.100.4.G, 8.100.4.I, 8.100.4.J.1.a.iii, 8.100.4.J.2.a.iii, 8.746, 8.746 Appendix A eff. 10/30/2015.

Rules 8.100.7.A.2, 8.100.7.F.2, 8.100.7.H.5, 8.100.7.I.3.a.iv), 8.100.7.I.3.b.iv), 8.100.7.I.5.a, 8.100.7.I.5.g.v)3)b), 8.100.7.J, 8.100.7.V.3.g, 8.509.15.A.2.a-c, 8.515.3, 8.517.2-8.517.2.1, 8.517.5.A.2 eff. 11/30/2015.

Rules 8.510.1, 8.510.5.B, 8.510.6.B, 8.510.6.C, 8.510.6.D, 8.510.85, 8.510.9.C, 8.510.10.C, 8.510.11.B, 8.510.12.B, 8.510.13.C, 8.510.14.H emer. rules eff. 12/11/2015. Rule 8.510.86.C emer. rule repealed eff. 12/11/2015.

Rules 8.506, 8.516.10, 8.700.1 eff. 12/30/2015.

Rules 8.535, 8.500-8.599 Appendix A eff. 01/30/2016.

Rules 8.200-8.200.2.D emer. rules eff. 02/12/2016.

Rules 8.491.13, 8.491.14, 8.491.15.A, 8.491.20, 8.491.30, 8.510.1, 8.510.5.B, 8.510.6.B-D, 8.510.6.D.6, 8.510.85, 8.510.86.B, 8.510.9.C, 8.510.10.C, 8.510.11.B, 8.510.12.B, 8.510.13.C, 8.510.14.H, 8.740.7.B.2.a, 8.740.7.C eff. 03/30/2016. Rules 8.491.32-.35, 8.510.86.C repealed eff. 03/30/2016.

Rule 8.125.10 emer. rule eff. 04/08/2016.

Rules 8.200-8.200.2.D, 8.300.1, 8.960.1, 8.960.3.E, 8.960 Appendix A eff. 04/30/2016.

Rules 8.100.1, 8.100.3.G.1.g-G.2, 8.100.3.K.1.a, 8.100.4.C.1.e.xi)-f, 8.100.4.C.4.a, 8.100.4.G.6, 8.125.10, 8.443.13.A, 8.443.13.C-E, 8.515.85.A, 8.515.85.D, 8.515.85.G.2, 8.515.85.G.6, 8.515.85.I, 8.2001, 8.2002.A, 8.2002.B, 8.2003.A.3, 8.2003.B.3, 8.2004.A.2, 8.2004.B.3, 8.2004.C.3, 8.2004.D-F eff. 06/30/2016.

Rule 8.493 eff. 07/30/2016.

Rules 8.057.1, 8.057.4.B.1, 8.057.10.D, 8.057.10.E emer. rules eff. 08/12/2016; expired 12/10/2016.

Rules 8.076.1.8, 8.076.1.8.1, 8.280.1, 8.280.4.E eff. 08/30/2016.

Rules 8.904.C, 8.904.F.1.b emer. rules eff. 09/09/2016.

Rules 8.515.85.J.7.a, 8.515.85.N.3, 8.515.85.O eff. 09/30/2016. Rule 8.518 repealed eff. 09/30/2016.

Rules 8.100.1, 8.100.4.G.3, 8.100.4.G.4.a eff. 10/01/2016.

Rules 8.300.1, 8.300.6, 8.443.9.A.1, 8.494, 8.800.2.B-8.800.3.A eff. 10/30/2016.

Rule 8.746 eff. 11/01/2016. Rule 8.746 Appendix A repealed eff. 11/01/2016.

Rules 8.500.1, 8.500.14.F-G, 8.517.11.C.1.b-d, 8.904 C, 8.904 F.1.b, 8.960.1, 8.960.3.E.3, 8.960 Appendix A eff. 11/30/2016.

Rules 8.057, 8.100.3.G, 8.100.4.G.6 eff. 12/30/2016.

Rules 8.200.1-8.200.2.E emer. rules eff. 02/10/2017.

Rules 8.100.3.B.1, 8.100.3.G.1.b, 8.100.5.C, 8.200.1-8.200.2.E, 8.700.6, 8.800 eff. 03/30/2017.

Rule 8.100.5.H.4.a eff. 04/30/2017.

Rules 8.100.1, 8.100.7.B.1.c.i, 8.209, 8.215.6.C.3, 8.390, 8.500.90, 8.500.94, 8.500.102, 8.590, 8.900 eff. 06/30/2017.

Rules 8.523-8.526.21, 8.700.1-8.700.6 emer. rules eff. 07/01/2017.

Rules 8.300.8.B, 8.905 B.1, 8.3000 emer. rules eff. 07/14/2017. Rule 8.2000 emer. rule repealed eff. 07/14/2017.

Rule 8.100.7.E emer. rule eff. 09/08/2017.

Rules 8.520-8.520.11.B.5, 8.700.1-8.700.8.D.2, 8.735.5.D-8.735.7.A, 8.612.3 eff. 09/15/2017.

Rules 8.057.1-8.057.9.F, 8.100.1, 8.100.3.G.1, 8.100.5.M, 8.203, 8.601.1, 8.603.7 eff. 09/30/2017.

Rules 8.300.8.B, 8.401.1, 8.400-499 Appendix A, 8.504, 8.506, 8.800.7.B, 8.905.B.1, 8.3000 eff. 10/30/2017. Rule 8.2000 repealed eff. 10/30/2017.

Rules 8.100.5.B.1.e, 8.100.7.b.1.c.i, 8.100.7.E.6.b.i) c), 8.100.7.E.6.b.i) f), 8.100.7.E.6.c.i) h), 8.300.6.A.1.k(5), 8.300.6.A 2, 8.600.4, 8.603.9 F, 8.608.8 D eff. 12/30/2017.

Rules 8.754.1-8.754.2, 8.960 Appendix A emer. rules eff. 01/01/2018.

Rule 8.960 Appendix A emer. rule eff. 02/09/2018.

Rule 8.300.6.A emer. rule eff. 03/11/2018.

Rules 8.754.1-8.754.6, 8.960 Appendix A eff. 03/30/2018.

Rules 8.746, 8.800.4.C.5.a emer. rules eff. 04/13/2018.

Rules 8.482.33, 8.552 eff. 04/30/2018.

Rules 8.100.3.H-8.100.3.H.10, 8.550.1-8.550.9 eff. 05/31/2018.

Rules 8.100.5.B.1.c, 8.100.7.V.3.g.ii, 8.300.6.A, 8.590.7, 8.700, 8.746, 8.800.4.C.5.a, 8.960 Appendix A eff. 06/30/2018. Rule 8.3000 emer. rule eff. 06/30/2018.

Rule 8.590.7 emer. rule eff. 07/01/2018.

Rules 8.800.7.B, 8.3000 eff. 07/30/2018.

Rules 8.300.1, 8.300.6.A 3, 8.700.1-8.700.5.A emer. rules eff. 08/10/2018.

Rules 8.590.7, 8.745, 8.902 D eff. 08/30/2018. Rule 8.613.1 repealed eff. 08/30/2018.

Rule 8.495 eff. 09/30/2018. Rule 8.519 repealed eff. 09/30/2018.

Rules 8.100.3.Q, 8.100.4.G, 8.200.2, 8.491, 8.800.1-8.800.12, 8.815 eff. 10/30/2018.

Rules 8.700.1-8.700.5.A emer. rules eff. 11/09/2018.

Rules 8.300.1, 8.100.3.C, 8.100.3.P, 8.300.6.A 3, 8.320 eff. 11/30/2018.

Rules 8.470.7.A-8.470.7.D.2, 8.700.1-8.700.5.A, 8.504, 8.515.85.A-8.515.85.O eff. 12/30/2018.

Rules 8.485.30, 8.485.40, 8.500.5, 8.500.94, 8.509.12, 8.509.13, 8.515.2, 8.516.10 D, 8.517.1, 8.519.27, 8.553, 8.763 emer. rules eff. 01/01/2019; expired 04/13/2019.

Rules 8.800.4.C.5, 8.960 Appendix A eff. 01/30/2019.

Rules 8.200.3.D, 8.290.6.D, 8.300.1, 8.300.5.A, 8.300.5.C, 8.300.5.D, 8.503.40.A, 8.800.4.B-8.800.4.D eff. 03/02/2019.

Rules 8.100.3.G.1.g.vii, 8.100.3.G.2, 8.100.3.G.3, 8.100.4.B.1.e, 8.800.7.D, 8.800.7.E, 8.800.16.A.5, 8.800.16.B.3 eff. 03/30/2019.

Rules 8.485.30 - 8.485.60, 8.500.5, 8.500.6, 8.500.94, 8.509.11-8.509.14, 8.515.1- 8.515.4, 8.516.10- 8.516.70, 8.517.1-8.517.3, 8.519.27, 8.553, 8.590.1, 8.590.7.N.1-2 , 8.763 eff. 04/30/2019.

Rules 8.300.5.D, 8.505-8.505.4, 8.500.7.F, 8.500.7.I, 8.700.1-8.700.8.B, 8.3003.A- 8.3003.B, 8.3004.D-8.3004.F.6 eff. 05/30/2019.

Rules 8.440, 8.443.1.A-8.443.1.B 7, 8.443.10-8.443.13.D 3, 8.443.17.A-8.443.17.A 8, 8.494.50, 8.501, 8.515.85, 8.613, 8.735, 8.904 G, 8.905 B.2.d, 8.960 Appendix A eff. 06/30/2019.

Rules 8.201.6, 8.508-8.508.190 K , 8.590.7.K emer. rules eff. 07/01/2019.

Rules 8.100.3.I.1, 8.100.4.B.1.a, 8.100.5.B.1.a, 8.510, 8.515.1, 8.552 eff. 07/30/2019.

Rules 8.590.7.K, 8.960.1-8.960.3.E, 8.960 Appendix A emer. rules eff. 08/09/2019.

Rules 8.040, 8.050.1-8.050.7.B, 8.076.1-8.076.7.B, 8.393.1.A, 8.500.1, 8.500.6, 8.500.12, 8.500.16, 8.500.90, 8.500.95, 8.500.101, 8.500.106, 8.503, 8.503.50, 8.503.120, 8.503.160, 8.519-8.519.23.D, 8.519.27.A, 8.600.2, 8.600.4, 8.607- 8.607.8, 8.608.4, 8.608.8, 8.609.1, 8.609.2, 8.609.5, 8.611 E, 8.612.1-8.612.3 H, 8.760.1, 8.761.1-8.761.4.46 eff. 08/30/2019.

Rules 8.201.6, 8.508-8.508.190 L emer. rules eff. 09/13/2019.

Rules 8.500.6.D, 8.500.9.B, 8.500.14.H, 8.500.95.D, 8.500.98.C, 8.500.104.G, 8.503- 8.503.170, 8.700.1, 8.700.3.A 1, 8.700.5.B 3, 8.700.6.D 1-8.700.6.D 9 eff. 09/30/2019. Rule 8.503.210 repealed eff. 09/30/2019.

Rules 8.201.6, 8.508-8.508.190 L, 8.590.7.K eff. 10/30/2019. Rule 8.800.4.C.5.a repealed eff. 10/30/2019.

Rules 8.552.1 B-C emer. rules eff. 11/08/2019.

Rules 8.014, 8.018, 8.126, 8.960.1-8.960.3.E, 8.960 Appendix A, 8.3004.F.2 eff. 11/30/2019.

Rules 8.100.1, 8.100.3.K, 8.100.4.C.1, 8.100.4.I.5, 8.485.60, 8.500.94.B.6, 8.503.40.A.5, new rule 8.507, 8.553.2, 8.553.3 C, 8.553.4 D, 8.553.5 C, 8.553.6 D, 8.609.5, 8.609.7, new rule 8.4000 eff. 12/30/2019.

Rules 8.500.1, 8.500.90, 8.503, 8.503.160, 8.519.1-8.519.22.F eff. 01/30/2020.

Rules 8.552.1 B-C, 8.735.4.F.1.d.i, 8.800.18.C.1.a, new rule 8.5000 eff. 03/02/2020.

Rules 8.520.4.B.1.g, 8.700.1 B, 8.730.3.B.12, 8.740.1, 8.750.3.B.2-3, 8.800.11.E.1.c emer. rules eff. 03/20/2020.

Rules 8.300.3.A 6, 8.300.4, 8.300.5.E, 8.6000 emer. rules eff. 04/23/2020.

Rules 8.200.3.D 2.f, 8.300.5 D-E, 8.470-8.470.9.B 2, 8.580-8.580.8 A.6.d, 8.750.3.B.3 eff. 04/30/2020. Rules 8.585-8.585.06 repealed eff. 04/30/2020.

Rules 8.014.1 N, 8.014.3.C.2, 8.014.3.D, 8.014.4, 8.014.6.A.3, 8.018.1.F, 8.018.4.D.1, 8.100.3.D, 8.100.3.F, 8.100.3.I, 8.100.3.J, 8.100.3.K, 8.100.3.L, 8.100.3.P, 8.100.4.B, 8.100.4.C, 8.100.4.G, 8.100.5.A, 8.100.5.B, 8.100.6.P, 8.100.6.Q, 8.580.5.C.1 emer. rules eff. 05/08/2020. Rules 8.125.11-8.125.13 emer. rules repealed eff. 05/08/2020.

Rules 8.300.1, 8.300.6.A.1.l, 8.500.102.B, 8.508.20-8.508.190, 8.730.1, 8.730.3, 8.730.4.A.1, 8.730.4.C.1, 8.730.6-8.730.8 eff. 05/30/2020. Rule 8.500.102.G repealed eff. 05/30/2020.

Rules 8.014.1 N, 8.014.3.C.2, 8.014.3.D, 8.014.4, 8.014.6.A.3 emer. rules eff. 06/12/2020.

Rules 8.041.2.B, 8.100.4.G.4, 8.100.7.E 6.b.i, 8.125, 8.300.1, 8.300.3.A 3, 8.300.4, 8.700.6.D 2.c, 8.700.6.D 7, 8.761.2-8.761.5, 8.800.11.E.1.c eff. 06/30/2020.

Rules 8.443.1.B 1, 8.520.4.B.1.g, 8.700.1 B, 8.730.3.B.11, 8.740.1, 8.750.3.B.2-3, 8.3000 emer. rules eff. 07/10/2020.

Rule 8.001 eff. 08/14/2020.

Rules 8.300.3.A 6, 8.300.4, 8.300.5.E, 8.6000 emer. rules eff. 08/20/2020.

Rules 8.000.18, 8.290, 8.950.2.E, 8.950.2.T eff. 08/30/2020.

Rules 8.014.1 N, 8.014.3.C.2, 8.014.3.D, 8.014.4, 8.014.6.A.3, 8.018.1.F, 8.018.4.D, 8.100.1-8.100.7.V.6, 8.580.5.C.1 emer. rules eff. 09/04/2020. Rules 8.125.11- 8.125-13 repealed emer. rules eff. 09/04/2020.

Rules 8.200.3.B 3, 8.200.3.D.2 c.i.7, 8.520.4.B.1.g, 8.700.1 C, 8.730.3.B.11, 8.740.1, 8.750.3.B.2-3 , 8.800.1, 8.800.13 eff. 10/15/2020.

Rules 8.126.1 J.30, 8.733-8.733.2.C 8 eff. 10/30/2020.

Rules 8.443.1.B.1, 8.3000 emer. rules eff. 11/07/2020; expired 02/06/2021.

Rule 8.520.1.N emer. rule eff. 11/13/2020; expired 03/13/2021.

Rules 8.014.4.A, 8.508.20.A-8.508.30, 8.508.100, 8.508.101 D, 8.508.102 H, 8.508.103 A.6, 8.508.160 A, 8.508.180 F, 8.580.5.C eff. 11/30/2020.

Rules 8.014.1.N, 8.014.3.C.2, 8.014.3.D, 8.014.4, 8.014.6.A.3, 8.018.1.F, 8.018.4.D, 8.100.1-8.100.7.V.6, 8.300.3.A 6, 8.300.4, 8.300.5.E, 8.700.6.D.4.c, 8.815, 8.6000 emer. rules eff. 12/11/2020. Rules 8.125.11-8.125.13 repealed emer. rules eff. 12/11/2020.

Rules 8.443.7 A.5.a, 8.815.4.C.1.a emer. rules eff. 01/08/2021. Rule 8.815.4.C.1.a emer

rule expired 05/08/2021.

Rules 8.001.2.A, 8.200.1.A-8.200.3.C, 8.390-8.390.3, 8.392, 8.393, 8.400-8.405.42, 408.76, 409.56, 8.423, 8.430.3, 8.443.2-8.443.20, 8.443.21, 8.449.1-8.449.2, 8.470, 8.485.50-8.485.72, 8.485.90, 8.486.20-8.486.41, 8.486.80, 8.486.100, 8.486.301, 8.486.400, 8.486.500, 8.487.10, 8.489, 8.490.5, 8.493.4, 8.495, 8.500-8.500.9, 8.500.13-8.500.18, 8.500.90-8.500-108 E, 8.501, 8.503, 8.504, 8.505, 8.506, 8.507-8.510.18.D, 8.515, 8.516.10-8.516.10 D, 8.516.30- 8.517.11.C, 8.519-8.519.18.D, 5.520.5.A, 8.520.9.B-8.520.11.B, 8.550.1- 8.550.2.B. 8.550.5.A-8.550.6.B, 8.550.8.D-8.550.9.A, 8.600.1-8.600.5 H, 8.607.2-8.607.6, 8.607.8, 8.608.6, 8.608.8, 8.612.1, 8.613, 8.761.14 eff. 01/10/2021. Rules 8.555, 8.600.6 repealed eff. 01/10/2021.

Rules 8.700.6.B 9-10 emer. rules eff. 02/12/2021.

Rules 8.300.4, 8.443.1.B.1, 8.3001, 8.3003.A-8.3003.C, 8.3004.B- 8.3004.G eff. 02/15/2021.

Rules 8.740.4.A.1.a, 8.740.6.A.3, 8.960.1-8.960.3.F emer. rules eff. 03/12/2021. Rules 8.740.4.A.1.a, 8.740.6.A.3 emer rules expired 07/10/2021.

Rules 8.100.3.H, 8.100.3.Q, 8.100.4.C, 8.100.5.B, 8.100.5.F, 8.520.1.N, 8.520.1.Q, 8.520.5.B.10, 8.520.5.B.13, 8.520.5.C.1.c, 8.520.7.D.1-8.520.7.D.4, 8.520.8.E, 8.520.11.B eff. 03/15/2021.

8.018.4.D.1, 8.100.3.D, 8.100.3.F, 8.100.3.H.9, 8.100.3.I, 8.100.3.K, 8.100.3.L,

8.100.6.Q, 8.126.1, 8.300.3.A 6, 8.300.4, 8.300.5.F, 8.443.7.A.5, 8.520.8.C.1, 8.540.2.A, 8.815.1, 8.815.3.A.1.c, 8.815.4, 8.815.6.A.1, 8.6000 emer. rules eff. 04/11/2021; expired 08/07/2021. Rules 8.125.11-8.125.13 repealed emer. rules eff. 04/11/2021; expired 08/07/2021.

Rules 8.201.6.2-3, 8.613.G.2.b, 8.700.6.D.4.c eff. 04/15/2021.

Rules 8.300.5.G, 8.700.6.B 9-10 emer. rules eff. 05/14/2021; rule 8.300.5.G expired 09/11/2021.

Rules 8.800.1-8.800.18.C, 8.810.4.A, 8.815.3.A.1.b, 8.960.1, 8.960.2, 8.960 Appendix A eff. 05/15/2021.

Rules 8.491.1-8.491.5, 8.515.70.A-8.515.70.F, 8.941.1-8.943.4 eff. 06/10/2021.

Rules 8.100.3.N.7.f, 8.100.4.B, 8.100.4.C.1-8.100.4.C.2, 8.100.5.B.1, 8.100.5.F.5, 8.200.7, 8.300.5.A.3.e, 8.300.7.A-8.300.7.B, 8.700.6.B, 8.732.4.E, 8.732.6.A, 8.960, 8.960 Appendix A eff. 06/30/2021.

Rule 8.960 Appendix A emer. rule eff. 07/30/2021; expired 11/27/2021. 8.018.4.D.1, 8.100.3.D, 8.100.3.F, 8.100.3.G.1.g.iv, 8.100.3.H.9, 8.100.3.I, 8.100.5.B, 8.100.6.P, 8.100.6.Q, 8.126.1, 8.300.3.A 6, 8.300.4, 8.300.5.F, 8.443.7.A 5, 8.520.8.C.1, 8.540.2.A, 8.815.1, 8.815.3.A.1.c, 8.815.4, 8.815.6.A.1, 8.6000 emer. rules eff. 08/09/2021. Rules 8.125.11-8.125.13 repealed emer. rules eff. 08/09/2021.

Rules 8.700.6.D 4.d, 8.740.4.A.1.a, 8.740.6.A.3 emer. rules eff. 08/13/2021.

Rules 8.516.30 D.2, 8.516.30 I, 8.615-8.615.6, 8.3001, 8.3003.A-B, 8.3004.D, 8.3004.F- I eff. 08/14/2021.

Rules 8.300.A 6, 8.300.4, 8.300.5.F 8.550.9.C, 8.765, 8.765.14 emer. rules eff. 09/10/2021.

Rules 8.393.1.J, 8.519.5.A.- 8.519.5.B.4.b, 8.520.8.C, 8.540.2.A, 8.540.7, 8.603.9 E emer. rules eff. 10/08/2021.

Rules 8.300.5.G, 8.700.6.D 4.d, 8.740.4.A.1.a, 8.740.6.A.3, 8.900-8.900 Appendix A eff. 10/30/2021.

Rules 8.126.1 J.11, 8.320 eff. 11/10/2021. 8.018.4.D.1, 8.100.3.D, 8.100.3.F, 8.100.3.G.1.g.iv, 8.100.3.G.1.g.vii-viii, 8.100.3.G.2, 8.100.3.H.9, 8.100.3.I, 8.100.3.K, 8.100.3.L, 8.100.3.P, 8.100.4.B, 8.100.4.C, 8.100.4.G, 8.100.5.A, 8.100.5.B, 8.100.6.P, 8.100.6.Q, 8.126.1, 8.443.7.A 5 , 8.800.16.B, 8.815.1, 8.815.3.A.1.c, 8.815.4, 8.815.6.A.1, 8.6000 emer. rules eff. 11/12/2021. Rules 8.125.11-8.125.13 repealed emer rules eff. 11/12/2021.

Rules 8.100.3.G.1.g.iv, 8.815.1, 8.815.3.A.1.c, 8.815.4, 8.815.6.A.1, 8.960 Appendix A eff. 12/10/2021.

Rules 8.300.A 6, 8.300.4, 8.300.5.F, 8.550.9.C, 8.535.2, 8.765, 8.765.14-8.765.14.F emer rules eff. 12/10/2021; rule 8.550.9.C expired 04/09/2022.

Rules 8.300.6.A.1, 8.511 emer. rules eff. 01/01/2022; expired 04/09/2022.

Rules 8.130, 8.201.6, 8.484, 8.488, 8.494, 8.500.94.A, 8.500.94.B.17, 8.500.102, 8.611 eff. 01/10/2022.

Rules 8.200.2.B-8.200.C, 8.590.2.A, 8.700.6.B 11, 8.800.5.A emer. rules eff. 01/14/2022.

Rules 8.393.1.J. 8.510.1-8.510.18.D, 8.519.5.A-8.519.5.B.4.b, 8.520.8.C, 8.540.2.A, 8.540.7, 8.552.2-8.552.7.C, 8.603.9 E, 8.740 eff. 01/30/2022.

Rules 8.520.8.C, 8.770.4.C emer. rules eff. 02/11/2022.

Rules 8.100.3.G.1.g.vii-viii, 8.100.3.G.2, 8.100.3.K.14, 8.100.3.P, 8.100.4.G.5.a.i, 8.800.16.B eff. 03/10/2022.

8.018.4.D.1, 8.100.3.D, 8.100.3.F, 8.100.3.H.9, 8.100.3.I, 8.100.3.K, 8.100.3.L

8.100.6.Q, 8.126.1, 8.443.7.A 5, 8.765-8.765.1, 8.765.14.F, 8.815.1 F, 8.815.3.A.1.c, 8.815.4, 8.815.6.A.1, 8.900-8.929, 8.6000 emer. rules eff. 03/11/2022. Rules 8.125.11-8.125.13, 8.520.8.C repealed emer. rules eff. 03/11/2021.

Rules 8.300.A 6, 8.300.4, 8.300.5.F, 8.443.22 emer. rules eff. 04/08/2022.

Rules 8.100.1, 8.100.3, 8.100.7 8.205, 8.209, 8.215, 8.300.6, 8.511, 8.535.2, 8.800.1, 8.800.13, 8.3001, 8.3003.A-C, 8.3004.B- D,F eff. 04/14/2022. Rule 8.212 repealed eff. 04/14/2022.

Rules 8.200.2.B-C 8.506, 8.550.9.C, 8.590.2.A, 8.700.6.B.11, 8.765-8.765.1, 8.765.14, 8.800.5 eff. 04/30/2022.

Rules 8.300.5 A.3.e, 8.430.1-8.430.6.A, 8.440.17, 8.440.30, 8.443.9 A.1.b, 8.443.9 A.5, 8.510.8 A, 8.552.6 K, 8.609.5 A, 8.609.7, 8.770.4.B-E eff. 05/30/2022.

Rules 8.100.1, 8.100.3.F.1.a, 8.100.3.F.1.l, 8.100.3.G.1, 8.100.3.I.1, 8.100.4-8.100.4.G, 8.100.6.P, 8.100.6.P.1.a, 8.100.6.Q, 8.212, 8.300.1.I, 8.320.1.D, 8.517, 8.613.C, 8.754.2.A, 8.754.5.E, 8.765.8.F, 8.765.13.A, 8.900-8.929 eff. 06/30/2022.

Rules 8.511.2-8.511.3, 8.732.4.E, 8.754.2, 8.943 repealed, 8.960.1 emer. rules eff. 07/01/2022.

8.018.4.D.1, 8.100.3.D, 8.100.3.F, 8.100.3.H.9, 8.100.3.I, 8.100.3.K, 8.100.3.L,

8.100.6.Q, 8.126.1, 8.300.3.A.6, 8.300.4, 8.300.5.F, 8.300.6.A.4, 8.443.7.A 5, 8.815.1 F, 8.815.3.A.1.c, 8.815.4, 8.815.6.A.1, 8.6000 emer. rules eff. 07/08/2022. Rules 8.125.11-8.125.13, 8.520.8.C, repealed emer. rules eff. 07/08/2022.

Rules 8.443.22, 8.733 eff. 07/30/2022.

Rules 8.520.8.C, 8.540.2.D, 8.960.1, 8.960 Appendix A emer. rules eff. 08/12/2022; expired 12/10/2022.

Rules 8.013-8.013.2, 8.300.6.A.1, 8.700.6.D 4.e eff. 08/30/2022.

Rules 8.511.2-8.511.3, 8.700.1.B.1, 8.732.4.E, 8.754.2, Rule 8.943 repealed, 8.960.1 eff. 09/30/2022.

8.100.5.B, 8.100.6.P, 8.100.6.Q, 8.126.1, 8.300.3.A.6, 8.300.4, 8.300.5.F, 8.443.7.A 5, 8.815.4.C, 8.6000 emer. rules eff. 10/14/2022. Rules 8.125.11- 8.125-13 repealed emer rules eff. 10/14/2022.

Rules 8.095, 8.200.3.B, 8.200.3.D 2.c.i.7, D, 8.300.6.A.4, 8.520.4.B.1.g, 8.700.1.C, 8.730.3.B.11, 8.740.1, 8.750.3.B eff. 10/30/2022.

Rule 8.8000 emer. rule eff. 12/09/2022.

Rules 8.300.5.G, 8.520.8.C, 8.540.2.D, 8.960, 8.960 Appendix A eff. 12/15/2022.

Rules 8.125, 8.126, 8.300.5.D emer. rules eff. 01/01/2023.

Rule 8.100.3.P.3 emer. rule eff. 01/13/2023.

Rule 8.100.7.B.1.c.i eff. 01/15/2023.

Rule 8.100.4.H.2 eff. 01/30/2023.

8.100.5.B, 8.100.6.P, 8.100.6.Q, 8.126.1, 8.300.3.A.6, 8.300.4, 8.300.5.F, 8.443.7.A 5, 8.470.7, 8.754.1.H, 8.815.4.C, 8.6000 emer. rules eff. 02/10/2023.

Rules 8.125.11-8.125.13 repealed emer rules eff. 02/10/2023.

Rules 8.300.5.D, 8.8000 emer. rules eff. 03/10/2023.

Rules 8.484.1-8.484.5.H, 8.500.5.B-8.500.5.B.11, 8.500.94.B-8.500.94.B.22, 8.609.4- 8.609.4.C, 8.609.9-8.609.C, 8.610-8.610.D eff. 03/15/2023.

Rules 8.553-8.553.7, 8.612.1-8.612.5, 8.8000 eff. 04/15/2023.

Rules 8.080, 8.100.3.P.3, 8.125.3.M, 8.125.4.E-8.125.4.I, 8.125.10.A, 8.125.15- 8.125.15.A, 8.126.1-8.126.1 N, 8.300.5.D, 8.508.100-8.508.100 H.9 eff. 04/30/2023. 8.100.5.B, 8.100.6.P, 8.100.6.Q, 8.125.11-8.125.13, 8.126.1 J.31.h repealed, 8.201.1, 8.300.3.A 6 repealed, 8.300.4 4 emer rules eff. 05/12/2023.

Rules 8.443.7.A.5, 8.815.1, 8.815.3.A, 8.815.4, 8.815.6, 8.6000, 8.8000 emer. rules eff. 06/09/2023.

Rules 8.019, 8.470.7.A.8, 8.470.7.C, 8.590.1 M-8.590.2.A.2, 8.590.2.S-8.590.2.S.3.a, 8.590.3.D-8.590.3.D.9, 8.590.3.F, 8.590.4.E, 8.590.7.N-8.590.7.N.8, 8.754.1.H, 8.960.A-8.960.C.6.b 5 , 8.960 Appendix A eff. 06/15/2023.

Rules 8.020, 8.200.7.A 5-6, 8.200.7.E 1.a-c, 8.300.1.K.10-12, 8.300.5.A, 8.300.5.E 3, 8.300.7.A 1, 8.300.7.B 1, 8.443.21, 8.500.5.A, 8.500.5.B 2-13, 8.500.94.A, 8.500.94.B 2-24, 8.500.102.B, 8.615.2 A, 8.700.6.D 6-10, 8.3000 eff. 06/30/2023.

Rules 8.440.1-8.440.39, 8.443-8.443.1.B, 8.443.6.A-B, 8.443.10.A-B, 8.511, 8.535, 8.535.2 repealed, 8.754.1, 8.960 Appendix A emer. rules eff. 07/01/2023.

Rules 8.300.3.C, 8.3000.1, 8.3000.4.B, 8.3000.4.C emer. rules eff. 07/14/2023.

Rules 8.390.1, 8.393.1.M, 8.393.2.B- 8.393.2.H, 8.393.5, 8.393.6.A, 8.393.6.B, 8.400.12-8.400.17, 8.401-8.401.16.B, 8.402.10-8.402.54, 8.405.2-8.405.42, 8.470.2-8.470.5.D, 8.485.50-8.485.90, 8.486.20-8.486.40, 8.486.200-8.486.500, 8.491.4, 8.400-8.499, Appendix A, 8.500.1-8.500.4.A, 8.500.90-8.500.91.F, 8.500.93.A, 8.500.103.A, 8.501.A, 8.503, 8.503.30, 8.503.60-8.503.80, 8.504.1, 8.504.5, 8.506.2-8.506.4, 8.506.6.A, 8.506.7.H, 8.506.10, 8.508.20, 8.508.40- 8.508.70, 8.508.121, 8.509.14-8.509.16, 8.509.31-8.509.33.A.1, 8.510.1, 8.515.3-8.515.85.B, 8.517.6, 8.519.1, 8.550.6.B, 8.600.4, 8.615.1, 8.8000 eff. 07/30/2023.

Rule 8.100.3.D emer. rule eff. 08/07/2023.

Rule 8.201.1 emer. rule eff. 08/11/2023.

Rules 8.100.4.I.3, 8.735, 8.800.4.D eff. 08/30/2023.

Rules 8.443.7.A.5, 8.815.1, 8.815.3.A, 8.815.4, 8.815.6, 8.6000 emer. rules eff. 09/08/2023; expired 01/06/2024.

Rules 8.201.1, 8.440.1-8.440.39, 8.443-8.443.1.B, 8.443.6.A-B, 8.443.10.A-B, 8.509.50, 8.511, 8.535, 8.535.2 repealed, 8.754.1, 8.960 Appendix A eff. 09/30/2023.

Rules 8.590.1 F, 8.590.5.E emer. rules eff. 10/01/2023.

Rules 8.100.3.D, 8.300.1, 8.300.2, 8.300.3.A-B, 8.300.3.C, 8.300.12.A-B, 8.300.12.A-B, 8.320.1, 8.580.1, 8.580.5.C, 8.580.8.A, 8.800.1 KK-OO, 8.800.7.D , 8.3000.1, 8.3000.4.B, 8.3000.4.C eff. 10/30/2023.

Rules 8.486.60, 8.509.17, 8.515.85, 8.700.1.B eff. 11/30/2023.

Rules 8.017.F 1-2 emer. rules eff. 12/09/2023.

Rules 8.590.1 F, 8.590.5.E eff. 12/30/2023.

Rule 8.4000 emer rule eff. 12/31/2023.

Rules 8.300.5.D 3, 8.553.6.C.2 emer. rules eff. 01/01/2024; expired 03/08/2024.

Rules 8.014, 8.125 emer. rules eff. 01/12/2024.

Rules 8.095, 8.200.3.D.2.e.iii-8.200.3.D.2.e.iv.1.h, 8.400, 8.401.1 B, 8.401.182, 8.406.2, 8.406.3, 8.408.41 6, 8.408.44 A.2, 8.408.75 2, 8;409, 8.409.55 2, 8.415.11, 8.415.20, 8.420, 8.424, 8.430.3.A.5.k.ii, 8.435, 8.435.2, 8.440.2, 8.441.5.C.2, 8.441.5.F.4, 8.445.5.I.4, 8.442.1.B.1, 8.443.9.A, 8.443.15, 8.443.19, 8.470.8.A, 8.482.1, 8.482.2, 8.482.3, 8.482.32-8.482.34, 8.482.42, 8.482.43, 8.482.45, 8.482.46, 8.482.5, 8.482.51, 8.482.52-8.482.55, 8.482.6, 8.482.7, 8.482.71, 8.482.72, 8.8500 eff. 01/30/2024. Rules 8.400.103-.104, 8.443.22, 8.482.53 B-C repealed eff. 01/30/2024.

Rules 8.443.7.A.5.a, 8.815.4.C.1.a emer. rules eff. 02/09/2024; expired 06/08/2024.

Rules 8.295, 8.553.6.C.2, 8.7000 eff. 03/16/2024.

Rules 8.300.5.D 3 , 8.519.27.A-H, 8.763.A-8.763.D 1 , 8.4000 eff. 03/30/2024.

Rule 8.300.5.D 2 emer. rule eff. 04/12/2024.

Rules 8.014, 8.125, 8.401.182, 8.401.201 B, 8.401.203 C, 8.401.213 B, 8.401.42, 8.440.13, 8.443.23-8.443.24, 8.482.33, 8.497, 8.800.A, 8.800.7 eff. 04/30/2024.

Rules 8.800.4.A-8.800.4.B.1.e emer. rules eff. 05/10/2024; expired 09/07/2024.

Rule 8.202.1 eff. 05/30/2024.

Rules 8.001.2.A, 8.300.1, 8.440.2.A.18, 8.441.5.H.2.c.iii, 8.441.5.L, 8.443.12, 8.540.1- 8.540.8.G, 8.750-8.750.4.A, 8.900-8.900 Appendix A, 8.4001.A-8.4004.A 2 eff. 06/30/2024.

Rules 8.200.2.D, 8.734 emer. rules eff. 07/01/2024; expired 09/07/2024.

Rules 8.960 Appendix A, 8.3001, 8.3003, 8.3004.D.3 emer. rules eff. 07/01/2024.

Rules 8.100.3.P, 8.300.5.D 2, 8.5000 eff. 08/30/2024.

Rules 8.014.1.L-R, 8.014.3.C-D, 8.014.6.A.8, 8.057.1-8.057.1.8, 8.057.3.A, 8.057.3.F, 8.057.4.B, 8.057.5.A-B, 8.100.6.P.1.f.vi, 8.100.6.Q.1.f.vii, 8.519.27.A- 8.519.27.H.1, 8.763-8.763.C.1.d, 8.800.4.A-8.800.4.B.1.e eff. 09/15/2024.

Rules 8.390-8.393.6.B.1.i, 8.405.30-8.405.32, 8.484-8.484.5.H, 8.485-8.485.98, 8.485.200-8.485.301, 8.486-8.486.50, 8.486.70-8.495.7.D.2, 8.500-8.500.6.D, 8.500.8-8.500.17.E, 8.500.90-8.500.101, 8.500.104-8.500.107.F, 8.501-8.501.7, 8.503-8.503.170, 8.504-8.504.9.A.2, 8.506-8.506.12.D, 8.508-8.508.102.H, 8.508.165-8.508.190.L, 8.509-8.509.16.D, 8.509.19-8.509.31.D.2, 8.509.31.F- 8.509.40.A, 8.510.1-8.510.18.D, 8.515-8.515.85.N.3.a, 8.516.10-8.516.70.E.5, 8.517-8.517.11.D.6, 8.600-8.607.1.E, 8.607.3-8.608.6.G, 8.608.8-8.611.C.6, 8.613-8.614.I.6, 8.615-8.615.6.B repealed eff. 09/15/2024.

Rules 8.200.2.D, 8.201.6, 8.555-8.555.5 2, 8.734, 8.960 Appendix A, 8.3001, 8.3003.A.3, 8.3003.B.3, 8.3004.D.3 eff. 09/30/2024. Rules 8.700.6.B.9- 8.700.6.B.11 repealed eff. 09/30/2024.

Rules 8.450, 8.960 Appendix A eff. 11/15/2024.

Rules 8.200.2.D.1, 8.732.7-8.732.10.B, 8.7001.A-8.7001.C.5.d, 8.7402-7418.D.6, 8.7502-8.7562.D.2 eff. 11/20/2024. Rules 8.486.60, 8.500.18, 8.500.108, 8.505, 8.507, 8.508.103, 8.509.17, 8.509.50, 8.511, 8.515.85.O repealed eff. 11/30/2024.

Rules 8.100.3.G.1.g.viii, 8.100.3.H.1.b.viii , 8.401.183, 8.401.21.211, 8.405.10-8.405.32, 8.607.2, 8.612-8.612.4.E, 8.7100.A, 7.7100.G, 8.7101.J 6.d.i.5), 8.7200.B, 8.7201.A, 8.7201.I 1, 8.7201.L 1, 8.7202.B 8, 8.7202.C 4, 8.7202.G 7-8, 8.7202.J 1.a, 8.7202.J 12, 8.7202.Q 10, 8.7202.R 4, 8.7202.Y.2, 8.7202.BB-DD, 8.7524- 8.7524.E.3 eff. 12/30/2024.

Rules 8.500.7, 8.500.102-8.500.103.D, 8.504, 8.517.9, 8.519.1-8.519.23.D, 8.608.7, 8.612.5, 8.7534.C 2.a repealed eff. 12/30/2024.

Rules 8.100.6.L, 8.125.2-8.125.14.C, 8.126.1-8.126.5, 8.7100.A 45-B, 7.7100.A 59-B, 8.7101.C 2, 8.7522.D eff. 02/15/2025.

Rules 8.100.3.Q, 8.435.2.A-8.435.2.D, 8.443.24-8.443.24.3, 8.482.43-8.482.43.C.5, 8.482.55 B.1, 8.920-8.928.A, 8.3001.48, 8.3003.A.3-8.3003.B.4.a.ii, 8.3004.D.3.g eff. 03/02/2025. Rule 8.435.2.E repealed eff. 03/02/2025.

Rules 8.203, 8.280.5 emer. rules eff. 04/11/2025.

Rules 8.765-8.765.13.A, 8.765.14.C-8.765.14.G, 8.7556 eff. 04/14/2025. Rules 8.100.6.P.1.f.vi, 8.100.6.Q.1.f.vii, 8.212-8.212.1.B.1 repealed eff. 04/14/2025.

Rules 8.013.1-8.013.5.A.2.c, 8.100.5.H, 8.100.6.Q, 590.2.B, 8.590.7.K eff. 05/15/2025.

Rules 8.095.1.A 5, 8.095.1.A 9, 8.095.4.C, 8.205.2 A-B, 8.209.2.E, 8.209.3, 8.209.5, 8.715.2, 8.7100.A 26, 8.7100.A 53, 8.7202.AA eff. 06/14/2025. Rule 8.612 repealed eff. 06/14/2025.

Rules 8.057-8.057.15.A 2 , 8.096-8.096.5.A, 8.100.3.P, 8.300.1.L.8, 8.300.5, 8.400- 8.401.1.16.B, 8.520-8.520.11.B.5, 8.550.3.A.1, 8.800.9.D, 8.800.17, 8.921.C- 8.950.5.B, 8.960.A-8.960 Schedule A. 8.3000-8.3004.D.3.a, 8.7000-8.7001, 8.7100.A, 8.7101.A, 8.7101.D, 8.7200.B, 8.7201.F 3, 8.7202.C, 8.7202.E, 8.7202.J, 8.7202.R, 8.7202.Z, 8.7202.CC, 8.7401, 8.7500, 8.7511, 8.7515, 8.7520, 8.7521, 8.7522, 8.7523, 8.7526-8.7528, 8.7531, 8.7536, 8.7538, 8.7544, 8.7546, 8.7551, 8.7552, 8.7556, 8.7600-8.7608.3 eff. 06/30/2025. Rules 8.900- 8.900 Appendix A repealed eff. 06/30/2025.

Rules 8.300.6.A.1.j, 8.960.A, 8.960.B, 8.960.C.5, Schedule A eff. 07/01/2025.

Rules 8.3003.A-B emer. rules eff. 07/03/2025.

Rules 100.5.F.5.k, 100.5.F.6, 8.200.2.D, 8.540.1, 8.540.2.A, 8.540.3.B, 8.540.5.B-C, 8.540.5.F, 8.540.6, 8.540.8.A, 8.732.4, 8.7514.C eff. 08/14/2025. Rule 8.221 repealed eff. 08/14/2025.

Rules 8.203, 8.280.5 emer. rules eff. 08/30/2025.

Rules 8.019, 8.020 A-D, 8.203, 8.280.5, 8.555.1-5, 8.731, 8.800.13 eff. 08/30/2025.

Rules 8.300.5.A.3.g, 8.300.5.E.1.b, 8.300.5.E.3.d.iii, 8.300.6.A.1.k.(7), 8.3001.52, 8.3003.A.3, 8.3003.B.3, 8.3004.D.3, 8.3004.G.3 emer. rules eff. 09/12/2025.

Rules 8.014.3.D, 8.014.4, 8.014.4.B, 8.014.6, 8.100.5.F, 8.100.7.E, 8.300.3.C, 8.300.6.A, 8.590.1-7, 8.740.7.E, 8.960, 8.7200.A-B, 8.7202.B-E, 8.7525.C eff. 09/30/2025. Rule 8.726 repealed eff. 09/30/2025.

Rules 8.660, 8.970 emer. rules eff. 10/10/2025.

Rules 8.043.01, 8.076.2.G-I, 8.770, 8.7502.K, 8.7538.C.1.n, emer. rules eff. 11/14/2025.

Rules 8.020.E.1.a, 8.125, 8.126.1, 8.200.2.D.b, 8.401.183-.184, 8.401.19.192.B.3.b, 8.401.21.211, 8.402.30.32-.38, 8.545, 8.7403.A, 8.7506.B.1, 8.7506.F, 8.754.1, 8.754.6, 8.762.30, 8.762.40, 8.765.1, 8.765.4-.5, 8.799 eff. 11/30/2025.

Rules 100.1, 8.100.3.R, 8.100.4.F, 8.100.3.Q.2.d, 8.497, 8.800.A, 8.800.13.B-C, 8.800.13.N, 8.800.13.P, 8.922.A.4-11, 8.923.A.1, 8.923.B.1, 8.927.B, 8.928.2 eff. 11/30/2025. Rules 8.552, 8.553 repealed eff. 11/30/2025.

Rules 660, 8.800.13.P, 8.800.13.N, 970 emer. rules eff. 12/12/2025.

Rules 8.043.01, 300.5.A.g, 8.300.5.E.1.b, 8.300.5.E.3.d, 8.300.6.A.1.k.(7), 8.3001.52, 8.3003.A.3, 8.3003.B.3, 8.3004.D.3 eff. 01/14/2026.

Rules 8.7502.O, 7.7502.W, 8.7502.HH-KK, 8.7514.B-D, 8.7515.B, 8.7515.E, 8.7515.I, 8.7515.Q, 8.7515.S, 8.7523.B, 8.7523.D, 8.7527.C-F, 8.7528.B, 8.7528.E, 8.7528.J, 8.7538.C-E, 8.7607 emer. rules eff. 02/13/2026.

Rules 8.076.2.G-I, 8.203.A-B, 8.203.4.A, 8.300, 8.770, 8.7502.K, 8.7538.C.1 eff. 03/02/2026.

Rules 8.660, 8.970, 7545.C, 8.7545.D.3, 8.7546.E.1.f, 8.7546.E.1.h-j, 8.7546.E.2-3 eff. 03/02/2026.

Rules 8.100.3.G, 8.700.6.B, 8.800.A, 8.800.13.B-C, 8.800.13.H-K, 8.800.13.P, 8.7532.A, 8.7532.C-F eff. 04/14/2026.

Rule 8.470 eff. 05/15/2026.

Rules 8.200.1.A, 8.200.2.D.1, 8.200.2.F, 8.200.3.D, 8.950.1, 8.950.2.H-U, 8.950.4.B, 8.950.5, 8.7202.B , 8.7202.D eff. 05/15/2026.

Rules 8.7502.K, 8.7502.0, 8.7502.W, 8.7502.HH-LL, 8.7514.B-D, 8.7515.B.12, 8.7515.E, 8.7515.I.2-9, 8.7515.Q.12, 8.7515.S, 8.7523.B, 8.7523.D.1, 8.7527.C.3-4, 8.7527.D-F, 8.7528.B.4, 8.7528.E, 8.7528.J.7-8, 8.7538.C.2-3, 8.7538.D-E, 8.7607, 8.7607.A eff. 05/30/2026.

Rules 8.100.3.G, 8.520.9.A, 8.7419, 7.515.E, 8.7515.J, 8.7515.I.10, 8.7515.Q.13, 8.7523.D.2, 8.7527.E.4, 8.7527.F.6, 8.7528.H.4, 8.7528.I.10, 8.7528.J.5, 8.7538.D.7, 8.7538.E.2, 8.7515.E.8, 8.7515.S.1.c, 8.7527.D.2.b, 8.7527.F.5, 8.7528.J.7 emer. rules eff 06/12/2026.

Rules 8.057.9-11, 8.057.13, 8.7202.BB eff. 06/30/2026.

Rules 8.014.1.U-Y, 8.014.3.B, 8.014.3.F, 8.014.5.A.1, 8.014.8, 8.960 SCHEDULE A emer. rules eff. 07/10/2026.

Rules 8.400.12, 8.401.B, 8.430.1-4, 8.430.6, 8.440, 8.441, 8.442, 8.443, 8.7101.A, 8.7200.B, 8.7203.A, 8.7414 A-D, 8.7515.A-B, 8.7515.H, 8.7515.J, 8.7515.M, 8.7522.01, 8.7526.A-F, 8.75228.C, 8.7528.H-I, 8.7549 A-Q, 8.7552.C, 8.7552 E- H, 8.7556, 8.7558, 8.7560 A-H, 8.7604.2.g eff. 08/14/2026. Rules 8.449.1-2 , 8.7524 A-E repealed eff. 08/14/2026.

Rules 8.100.3.G, 8.520.9.A.3, 8.7419, 8.7515.E.8-9, 8.7515.J.1.i, 8.7515.I.10, 8.7515.Q.13, 8.7515.S.1.c, 8.7523.D.2, 8.7527.D.4, 8.7527.E.4, 8.7527.F.5-6, 8.7528.J.7, 8.7527.D.4, 8.7527.E.4, 8.7527.F.6, 8.7528.H.4, 8.7528.I.10, 8.7528.J.5, 8.7528.J.7, 8.7538.D.7, 8.7538.E.2 emer. rules eff 08/14/2026.

Annotations Emergency rules 8.200.6, 8.440.2.C.4, 8.443.4.B, 8.443.8.A.19, 8.433.8.F received after filing deadline (see § 24-4-103 (11)(d)(II) C.R.S.). Agency explanation dated 05/03/2013 on file with the Secretary of State.

Rule 8.550.4.C (adopted 09/13/2013) was not extended by House Bill 14-1123 and therefore expired 05/15/2014.

Rule 8.010 (adopted 04/13/2012) was repealed by House Bill 14-1123 effective 05/15/2014.

The definition of “deficiency” in Rule 8.435.1, Rules 8.435.2.B.5., 8.435.2.C.3.c., 8.443.9.A.1.a., 8.443.9.A.1.h., 8.481, 8.481.1, 8.482.46.A., 8.497.1.C., 8.497.2.B.

(adopted 03/13/2015) were not extended by House Bill 16-1257 and therefore expired 05/15/2016.

10 CCR 2505-10 8.000 MEDICAL ASSISTANCE - SECTION 8.000 Emergency Medical Transportation, Program Integrity {#sec-10-ccr-2505-10-8.000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.000}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE – SECTION 8.000 EMERGENCY MEDICAL TRANSPORTATION, PROGRAM INTEGRITY 10 CCR 2505-10 8.000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

8.001 ELECTRONIC VISIT VERIFICATION (EVV) 8.001.1 Definitions 8.001.1.A. Alternate Location means any location entered into the EVV Record that was not automatically collected as a part of the EVV record. 8.001.1.B. Colorado Medicaid ID means the Colorado Medicaid identification number assigned to each Medicaid member by the Department. 8.001.1.C. Department means the Colorado Department of Health Care Policy & Financing. 8.001.1.D. Direct Care Worker means the person providing a service to a client. The Direct Care Worker may be an employee of a Provider. 8.001.1.E. Direct Care Worker ID means the last five digits of the Direct Care Worker’s social security number. 8.001.1.F. Edited EVV Entry means an EVV record that has had any element modified via Visit Modification as defined in Section 8.001.3.C.1.b. 8.001.1.G. Electronic Visit Verification (EVV) means the use of technology, including mobile device technology, telephony, or Manual Visit Entry, to verify the required data elements related to the delivery of a service mandated to be provided using EVV by the “21st Century Cures Act,” P.L. No. 114-255, or this rule. 8.001.1.H. Electronic Visit Verification Record (EVV Record) means a record of a visit recorded by an EVV System containing all data points in Section 8.001.3.A.1.b. of this rule. 8.001.1.I. Electronic Visit Verification System (EVV System) means the State EVV Solution or a Provider Choice System used by a Provider to comply with the EVV requirements in this rule. 8.001.1.J. Exception means a data integrity alert identified by the State EVV Solution or Provider Choice System. 8.001.1.K. Geo-fencing means the practice of utilizing a virtual perimeter in a geographic area. 8.001.1.L. Live-in Caregiver means a caregiver who permanently or for an extended period of time resides in the same residence as the Medicaid member receiving services. Live-in Caregiver status is determined by meeting requirements established by the U.S. Department of Labor, Internal Revenue Service, or Department-approved extenuating circumstances. Documentation of Live-in Caregiver status must be collected and maintained by Provider or Financial Management Services Vendor. 8.001.1.M. Manual Visit Entry means an EVV recorded after the time of service delivery, including all data elements as defined in Section 8.001.3.A.1.b. 8.001.1.N. Mobile Visit Verification Application (MVV Application) means a mobile device application that is used by the Direct Care Worker to record visit data at the start and end of the visit. 8.001.1.O. Provider means an actively enrolled Medicaid provider in good standing as defined in Section 8.076. 8.001.1.P. Provider Choice System means an alternative to the State EVV Solution made available by the Department. A Provider Choice System is provided by a Provider and satisfies all requirements as defined in this rule, is compatible with the State EVV Solution, and is consistent with Federal and State law. 8.001.1.Q. Provider EVV Portal means the web-based administrative tool used by Providers using the State EVV Solution to manage EVV activity and add Manual Visit Entry data elements and to monitor all activity recorded in the EVV System for Provider Choice Systems. 8.001.1.R. Reason Codes means standard codes established by the Department used to explain a Manual Visit Entry, Visit Modification, or acknowledge an Exception for missing required visit information. 8.001.1.S. State EVV Solution means the portion of the EVV System that manages data related to the visit and includes the MVV Application, TVV System, and the Provider EVV Portal made available by the Department. 8.001.1.T. Telephonic Visit Verification System (TVV System) means a toll-free telephone number system used by Direct Care Workers to record visit data at the start and end of a visit. 8.001.1.U. Threshold means the Departmentally-defined acceptable limit, determined as a percent, of EVV data recorded after the time of service delivery through Visit Modification or Manual Visit Entry. 8.001.1.V. Visit Modification means the edit of required visit data elements, as defined in Section 8.001.3.A.1.b, after the time of service delivery. 8.001.2 Provider Applicability 8.001.2.A. When providing services in the home or community, Providers of the following services reimbursed by the Department as fee-for-service must utilize EVV:

Behavioral Services, as defined in Sections 8.212, and 8.500.94.B.3;
Consumer Directed Attendant Support Services as defined in Sections 8.510 and 8.500.90.I;
Home Health Services as defined in Section 8.520.1.K;
Homemaker Services as defined in Sections 8.490.1 and 8.500.94.B.9;
Independent Living Skills Training as defined in Section 8.516.10.A.1;
In-Home Support Services as defined in Sections 8.506.4.C and 8.552.1.M;
Life Skills Training as defined in Section 8.553.1.I;
Pediatric Behavioral Therapies provided under Early, Periodic Screening, Diagnosis and Treatment (EPSDT) Services as defined in Section 8.280.1;
Pediatric Personal Care as described in Appendix A to Sections 8.500- 8.599;
Personal Care Services provided as defined in Sections 8.489.10.11 and 8.500.94.B.14;

a. Personal Care Services provided in a Provider-owned residential type setting and paid via per diem are excluded from the EVV requirements outlined in this rule.

Physical Therapy and Occupational Therapy as described in Section 8.200.3.A.6;
Private Duty Nursing as defined in Section 8.540.1;
Respite as defined in Sections 8.492.10.11 and 8.508.100.F;
Speech Therapy, as described in Section 8.200.3.D.2; and 15. Youth Day Services when provided in the home or community as defined in Section8.503.40.A.13. 8.001.3 Provider Responsibilities 8.001.3.A. The Department will make available the State EVV Solution to all Providers of services specified in Section 8.001.2.A. of this rule. The State EVV Solution will include an MVV Application, TVV System, and Provider EVV Portal.
The State EVV Solution made available by the Department must be used by all Providers except for Providers using a Provider Choice System pursuant to Section 8.001.3.B. of this rule. Providers using the State EVV Solution must do the following:

a. Utilize the MVV Application or the TVV System made available by the Department as the primary method for collecting visit data.

i. If the visit did not take place at the location captured by MVV or TVV, the Provider must indicate the actual visit location as an Alternate Location.

ii. If the MVV Application and TVV System are unavailable during an EVV visit, the Direct Care Worker and the Direct Care Worker’s associated Provider, as applicable, are responsible for entering any uncaptured data elements for that visit via Manual Visit Entry. Manual Visit Entry must be used as the last alternative for recording the visit data.

b. Collect, for each visit, the following data:

i. The Colorado Medicaid ID of the client receiving the service;

ii. Information to identify the Direct Care Worker providing the service;

iii. The time the visit begins and ends;

iv. The EVV-required service performed;

v. The date the visit occurs; and vi. The location of the visit. 8.001.3.B. The Department will allow all Providers of services specified in Section 8.001.2.A. of this rule to utilize a Provider Choice System.

Providers using a Provider Choice System must utilize an EVV Provider Choice System that satisfies all technical specifications as identified by the Department to:

a. Collect and submit to the Department, for each visit, the data elements contained in Section 8.001.3.A.1.b. of this rule;

i. When a Provider enters visit data via Manual Visit Entry, the Provider Choice System must indicate that the data was entered manually.

ii. When a Provider modifies existing visit data, the Provider must indicate the reason code for modification and enter reason code notes, if pertinent or required.

b. Utilize a Direct Care Worker ID for all individuals providing services to clients, as identified in Section 8.001.1.E. of this rule;

c. Identify all Exceptions using standard codes identified by the Department;

d. Utilize the Reason Codes identified by the Department;

e. Resolve any Exceptions noted in the State EVV Solution; and f. Submit data to the State EVV Solution in a format and at a frequency identified by the Department.

A Provider Choice System must maintain compliance with the requirements identified in this rule, including incorporating into the system any changes in data requirements that must be transmitted to the State EVV Solution. It is the responsibility of providers using a Provider Choice System to ensure successful interaction between their Provider Choice System and the State EVV Solution.
Any costs related to the development of a Provider Choice System will not be the responsibility of the Department.
The Department will not provide training or support on the interaction of individual Provider Choice Systems with the State EVV Solution.
If a Provider is unable to obtain a compatible Provider Choice System, the Provider must use the State EVV Solution made available by the Department. 8.001.3.C. Visit Entry and Visit Modifications 1. All visit data points as defined in Section 8.001.3.A.1.b. must be completed at time of service delivery.

a. If a visit is entered administratively, and not by a caregiver at the time of service, the visit is considered a Manual Visit Entry.

b. If any data elements are edited after the time of service delivery, the edits are considered to be a Visit Modification resulting in an Edited EVV Entry.

Manual Visit Entries and Edited EVV Entries are subject to Department audit based on published Department Thresholds, in accordance with

Section 8.076.

Providers must maintain all documentation required to substantiate the data elements required by Section 8.001.3.A.1.b of this rule to support Manual Visit Entries, Visit Modifications, and Exceptions. If this documentation cannot be maintained in the EVV System utilized by the Provider, the documentation must be maintained outside of the EVV System. The documentation must be made available to the Department or the Department’s designee upon request, as required by Section 8.130.2.
Providers must resolve any Exceptions associated with Manual Visit Entries and Visit Modifications.
Exemptions a. Live-in Caregivers who have completed Department required documentation are not mandated to collect EVV data, unless otherwise required by their Provider as defined by 8.001.1.O. of this

rule.

i. Falsification or misrepresentation of information on Live-in Caregiver documentation may result in Department revocation of an individual’s Live-in Caregiver exemption. If Live-in Caregiver exemption is revoked, the caregiver and provider must complete EVV pursuant to this rule.

EVV Record Restrictions a. The Department will not allow or accept biometric data, pictures, video, or voice recordings to identify clients or substantiate Medicaid visit data.

i. Visit data that includes biometric data, pictures, video, or voice recordings is not required and must not be submitted.

b. The Department will not allow or accept visit data that includes continual GPS tracking during a visit. The Department will only accept location information at the beginning and/or end of a Medicaid visit.

i. Visit data that includes continual GPS tracking is not required and must not be submitted.

c. The Department will not utilize geo-fencing to restrict location of Medicaid service delivery.

i. Visit data that restricts location of service delivery using geofencing is not required and must not be submitted 8.001.3.D. Providers of the services specified in Section 8.001.2.A. of this rule must adhere to the following:

Comply with all provisions of this rule.
Use the State EVV Solution or a Provider Choice System to collect and maintain EVV data as required in Sections 8.001.3.A.1.b. and 8.001.3.B.1.a.
Consistent with Section 8.130, maintain a record of clients subject to EVV requirements to whom they are providing services and the required data elements pertaining to these clients. The required data elements include:

a. Colorado Medicaid ID;

b. Last name;

c. First name;

d. One known address at which the client may routinely receive services; and e. Telephone number.

Maintain a current list of Direct Care Workers who are providing services subject to EVV requirements to clients enrolled in Colorado Medicaid and the required data elements pertaining to the Direct Care Workers. The required data elements include:

a. Last name;

b. First name; and c. Direct Care Worker ID.

Maintain all documentation certifying the status of Live-in Caregivers providing services otherwise subject to EVV requirements set forth in this

rule. Evidence of valid Live-in Caregiver status must be available upon Department request.

Utilize EVV for all services subject to the provisions of this rule.
Report any known or suspected falsification of EVV data to the Department within two business days of discovery.
Complete all required EVV training. 8.001.3.E. Compliance 1. Providers are required to comply with the requirements of this rule beginning on August 3, 2020.

a. Providers that fail to comply with this rule after August 3, 2020 may be subject to Compliance Monitoring and a Request for Written Response in accordance with Section 8.076.

b. Providers that fail to comply with this rule after October 1, 2020 may be subject to Compliance Monitoring, Request for Written Response, or Overpayment Recovery.

c. Providers that fail to comply with this rule after January 1, 2021 may be subject to Compliance Monitoring, Request for Written Response, Overpayment Recovery, Denial of Claims, Suspension, Termination, or Nonrenewal of their Colorado Medicaid Provider Agreement in accordance with Section 8.076.

If the Department determines that there is a credible allegation of fraud, the Provider may be subject to a Suspension of Payments in accordance with Section 8.076.4. 8.010 [Repealed 05/15/2014 per House Bill 14- 1123]

8.011.1 GENERAL EXCLUSIONS FROM COVERAGE

The paragraphs which follow set forth the general exclusions from coverage of the Medical Assistance Program. 8.011.11 Excluded from coverage are items and services which generally enhance the personal comfort of the eligible person, but are not necessary in the diagnosis of, nor contribute meaningfully to the treatment of an illness or injury, or the functioning of a malformed body member; this exclusion does not apply to inoculations and immunizations provided. 12 Also excluded are items and services for which neither the eligible person, nor any other person or organization, incurs a legal obligation to pay; an example of such an exclusion is the free chest X-rays provided by health organizations. In applying this particular exclusion, the determining factor is that there is a not legal obligation to pay for the items or services, and not merely the fact that the patient is not charged because of other considerations. A legal obligation to pay exists even when reimbursement is expected only to the extent of the patient's insurance coverage.

This exclusion, therefore does not prohibit program payment for such services rendered to the following persons:

a. Indigents who because of their inability to pay are not charged by an institution which customarily charged for such services;

b. Patients whose need for services resulted from the act or negligence of another who is or may be legally liable for the patient's medical expenses.

The existence of a third party's liability does not affect the patient's obligation to pay for the services he received nor the ability of the Medical Assistance Program to provide such coverage in his behalf. (The additional consideration, however, is that such third-party liability and possible benefits must be sought, explored, and secured wherever possible);

c. Individuals resident in homes for the aged when the agreement under which such residency is provided is inclusive of medical services and no payment is accepted from any person residing in the home regardless of their ability to pay. Payment could be made for services rendered by a source independent of such home or institution if that source customarily charges for such services. Thus, payment could be made for services furnished by a hospital or long-term care facility to which a resident of the home is sent (or for home health services by an agency), or for the services of a physician who is not an employee of such home. In addition, this sort of situation is true in certain types of nonprofit homes, certain homes operated by labor unions, and homes for members of religious orders, etc. 13 Also excluded as benefits are items and services paid for by a governmental entity, including federal programs such as the National Institutes of Health, the Veterans' Administration medical care program and other similar types of government sponsored medical care. 14 Neither can payment be made for services in hospitals which serve only a special category of the population, such as prisoners, nor for services furnished to prisoners in hospitals serving the general community. 15 Also excluded as a benefit are items and services which are not provided within the United States. This is inclusive of the 50 states of the Union, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam and American Samoa. 16 Also, specifically excluded from coverage are items and services which are required as a result of war or of an act of war occurring after the effective date of the patient's current eligibility. 17 Also, specifically excluded from coverage under the Medical Assistance Program are injuries received by individuals who are engaged in riots, civil disobedience, or other acts specifically excluded by the congressional statute relating thereto. 18 Specific non-benefit items and services in each of the benefit categories are identified in that section of this manual relating to each category. 19 Payment for prenatal services delivered through “The Prenatal Care for Undocumented Women Pilot Program” shall not be made under any circumstances other than through a contracted Managed Care Organization as specified in 8.011.02, Section B.

8.012 PROVIDERS PROHIBITED FROM COLLECTING PAYMENT FROM

RECIPIENTS

8.012.1 DEFINITIONS 8.012.1.A. Providers, for the purposes of this section 8.012, means any person, group or entity that renders services or provides items to a medical assistance recipient, regardless whether the person, group or entity is enrolled in the Colorado medical assistance program, excluding long-term care facilities licensed pursuant to Section 25-3-101, C.R.S. Section 25-3-101, C.R.S. is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1714. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library. 8.012.1.B. Claim for Penalty means the documented notification by a recipient or estate of a recipient that a Provider collected or attempted to collect payment from the recipient for medical assistance covered items or services.

8.012.2 PROVIDER LIABILITY 8.012.2.A. Providers are explicitly prohibited from collecting payment, or attempting to collect payment through a third party, from a recipient or the estate of the recipient for the cost or the cost remaining after payment by Medicaid, Medicare, or a private insurer of Medicaid covered items or services rendered to Medicaid recipients. 8.012.2.B. Providers shall be liable to a recipient or the estate of the recipient if the Provider knowingly receives or seeks collections through a third party of an amount in payment for Medicaid covered items or services. 8.012.2.C. Providers are prohibited from collecting, or attempting to collect, payment from recipients for Medicaid covered items or services regardless of whether Medicaid has actually reimbursed the Provider and regardless of whether the Provider is enrolled in the Colorado medical assistance program. 8.012.2.D. Providers shall be liable for the amount unlawfully received, statutory interest on the amount received from the date of receipt until the date of repayment, plus a civil monetary penalty equal to one half of the amount unlawfully received.

8.012.3 RECIPIENT CLAIMS 8.012.3.A. To establish a Claim for Penalty, a recipient or the estate of a recipient shall forward a written notice of Claim for Penalty to the Department and to the Provider within one hundred and twenty (120) calendar days from the date the Provider unlawfully received payment from the recipient. Department correspondence shall be sent to Program Integrity, 1570 Grant Street, Denver, CO 80203. 8.012.3.B. The Claim for Penalty shall establish Provider liability to the recipient or estate of the recipient for repayment of the amount unlawfully collected plus interest and a civil penalty equal to one-half the repayment 8.012.3.C. The notice of Claim for Penalty shall be a written document submitted by a recipient or estate of the recipient to the Department and the Provider describing (1) what Medicaid covered items or services were rendered, (2) how much money the Provider collected from the recipient or the estate of the recipient for those covered items or services and (3) dates of service the items or services were rendered. 8.012.3.D. The written notice of Claim for Penalty from the recipient or the estate of the recipient shall be legible and include detailed documents to substantiate the Claim for Penalty that payment was given to and unlawfully received by the Provider.

Detailed documents to substantiate the Claim for Penalty may include but are not limited to credit card receipts, cash receipts or documentation of processed checks.
The recipient or estate of the recipient is responsible for providing supporting documentation at the same time the notice of Claim for Penalty is sent to the Department.
Claim for Penalty sent to the Department must include written documentation showing that notice of the Claim for Penalty was sent to the Provider.
Documentation showing the Claim for Penalty was sent to the Provider may include but is not limited to copies of the certified mail signature card, post office return receipt, courier service confirmation of delivery, signature of receipt by the Provider or representative of the Provider’s office or successful transmission report from a facsimile.
The Department may request additional information from the recipient or the estate of the recipient. It shall be the responsibility of the recipient or the estate of the recipient to satisfy the Department’s requests for information within ten (10) calendar days from the date of request for the Claim for Penalty to be evaluated by the Department.
The Department shall review the Claim for Penalty and documents substantiating the Claim for Penalty submitted by the recipient or the estate of the recipient.
Any notice of Claim for Penalty that is not legible or is submitted without documents to substantiate that payment was made to and unlawfully received by the Provider shall be considered unfounded and shall be dismissed by the Department.

8.012.4 PROVIDER RESPONSE 8.012.4.A. Within ten (10) calendar days from the date of the recipient’s written Claim for Penalty, the Provider named in the recipient’s Claim for Penalty shall present the Department with either a signed written position statement with supporting documentation pertaining to the recipient’s Claim for Penalty, or a signed written request for a telephone conference in which to be heard.

The written position statement with supporting documentation or the signed written request for a telephone conference shall be sent via certified mail, return receipt or FedEx/UPS so there is no dispute that Program Integrity, 1570 Grant Street, Denver, CO 80203 received them. 8.012.4.B. Provider requests for a telephone conference or signed written position statements received after ten (10) calendar days from the date of the recipient’s or the estate of the recipient’s Claim for Penalty, or failure to respond shall be considered a waiver of the Provider’s right to be heard and the Claim for Penalty shall be found in the recipient’s favor. 8.012.4.C. The Department shall determine whether the Claim for Penalty has been substantiated and shall send the recipient and the Provider named in the Claim for Penalty a written determination within thirty (30) calendar days from the date of the recipient’s or the estate of the recipient’s Claim for Penalty.

8.013 OUT-OF-STATE MEDICAL CARE

8.013.1. COLORADO RESIDENTS TEMPORARILY OUT-OF-STAT E

An eligible Colorado member, temporarily out of the state but still a resident of Colorado, receives the same Medicaid benefits as members located in the state of Colorado only under the following conditions:

A. Medical services are needed because of a medical emergency.

For these services no prior authorization is needed. Whether an emergent condition exists is determined by the provider rendering service. The emergency must be indicated on the claim submission.

B. Medical services are needed because the member's health would be endangered if he/she were required to travel to Colorado for medical care and treatment.

The determination as to whether the member's health would be endangered is made by the provider rendering service.

C. The Department determines, on the basis of medical advice, that the needed medical services, or necessary supplemental resources, are more readily available where the member is temporarily located.

Prior authorization from the Medicaid Program's medical consultant must be obtained for services provided under this paragraph.

D. It is the general practice for members in a particular locality to use medical resources in another state.

Prior authorization from the Medicaid Program's medical consultant may be required if the recipient is receiving services from any other out-of-state provider not in a neighboring locale.

E. The Section 8.013.1.A-D. limitations on access to out-of-state medical care, for members temporarily out-of-state, do not apply to children who reside out of the state for whom Colorado makes adoption assistance payments or foster care maintenance payments.

8.013.2. COLORADO RESIDENTS SEEKING OUT-OF-STATE CARE

If a member requires services that are only available out-of-state at the time services are medically necessary, then those services will be approved by the Department.

8.013.3 PRIOR AUTHORIZATION

All services that require prior authorization in-state also require prior authorization outof-state. Some services may require additional prior authorization to have the services rendered out-of-state, even if the underlying service does not require prior authorization.

8.013.4. PROVIDER ENROLLMENT

To receive reimbursement, all out-of-state providers must enroll in the Colorado Medicaid Program. Out-of-state providers are subject to the same enrollment and screening rules, policies and procedures as in state providers, as specified in Section 8.125 Provider Screening. Some out-of-state providers are not eligible to enroll in Colorado Medicaid and cannot receive reimbursement.

8.013.5. REIMBURSEMENT PRINCIPLES

A. Out-of-state nursing home claims must be paid in accordance with Section 8.443.19. The Department may utilize single case agreements to negotiate a higher reimbursement rate for the following services:

Hospital services a. The Department may negotiate a single case agreement with an out-of-state hospital under the following circumstances:

i. The hospital services are not available in Colorado;

ii. The hospital services must be prior authorized; and, iii. The member's physician may suggest where the member should be sent, but the medical consultant for the Department is responsible for making the final determination based on the most cost effective institution consistent with quality of care.

b. The reimbursement rate for out-of-state hospital services in accordance with single case agreements will be negotiated between the Department and the out-of-state facility providing the services. When negotiating the rate, the Department will take into consideration the following:

i. The actual costs of the facility;

ii. The Medicare rate for the same or similar services, if any; and, iii. The Medicaid rate for the same or similar services in the state where the facility is located, when available.

c. The reimbursement rate for out-of-state hospital services in accordance with single case agreements may not exceed the usual and customary charges of the facility for such services.

Physician services a. The Department may negotiate a higher reimbursement rate for out-of-state physician services in accordance with single case agreements under the following circumstances:

i. The physician services are either:

I. Included in an approved single case agreement with a hospital in accordance with Section 8.013.2.D.1.; or II. Provided by an out-of-state physician rendering services not available in Colorado.

ii. The member’s physician may suggest where the member should be sent, but the medical consultant for the Department is responsible for making the final determinations based on the most cost-effective physician consistent with quality of care.

b. The reimbursement rate for out-of-state physician services in accordance with single case agreements will be negotiated between the Department and the out-of-state physician providing the services. When negotiating the rate, the Department will take into consideration the following:

i. The actual costs of the facility or the physician;

ii. The Medicare rate for the same or similar services, if any; and, iii. The Medicaid rate for the same or similar services in the state where the facility or physician is located, when available.

c. The reimbursement rate for out-of-state physician services in accordance with single case agreements may not exceed the usual and customary charges for the facility or physician for such 8.014 NON-EMERGENT MEDICAL TRANSPORTATION 8.014.1. DEFINITIONS 8.014.1.A. Access means the ability to make use of. 8.014.1.B. Air Ambulance means a Fixed-Wing or Rotor-Wing Air Ambulance 8.014.1.C. Ambulatory Vehicle means a passenger-carrying vehicle available for those clients able to walk and who do not rely on wheelchairs or other mobility devices, during boarding or transportation, which would necessitate a vehicle with a lift or other accommodations. 8.014.1.D. Ancillary Services mean services incurred indirectly when a client authorized to receive NEMT also requires the assistance of an Escort or financial assistance for meals or lodging. 8.014.1.E. At-Risk Adult means an adult who is unable to make personal or medical determinations, provide necessary self-care, or travel independently. 8.014.1.F. Child means a minor under the age of 18. 8.014.1.G. Day Treatment means facility-based services designed for Children with complex medical needs. Services include educational or day care services when the school or day care system is unable to provide skilled care in a school setting, or when the Child's medical needs put them at risk when around other Children. 8.014.1.H. Emergency Medical Transportation means Ground Ambulance or Air Ambulance transportation under Section 8.018 during which clients who are ill, injured, or otherwise mentally or physically incapacitated receive needed emergency medical services en route 8.014.1.I. Escort means a person who accompanies an At-Risk Adult or minor client. 8.014.1.J. Fixed-Wing Air Ambulance means a fixed wing aircraft that is certified as a Fixed-Wing Air Ambulance by the Federal Aviation Administration. 8.014.1.K. Ground Ambulance means a ground vehicle, including a water ambulance, 8.014.1.L. Mode means the method of transportation. 8.014.1.M. Non-Emergent Medical Transportation (NEMT) means transportation to or from medically necessary non-emergency treatment. Non-emergency care may be scheduled or unscheduled. This may include Urgent Care transportation and hospital discharge transportation. 8.014.1.N. Program of All Inclusive Care for the Elderly (PACE) is a capitated rate benefit which provides all-inclusive long-term care to certain individuals as defined in Section 8.497. 8.014.1.O. Rotor-Wing Air Ambulance means a helicopter that is certified as an ambulance by the Federal Aviation Administration. 8.014.1.P. State Designated Entity (SDE) means the organization responsible for administering NEMT. 8.014.1.Q. “Sibling ” means a person 18 years of age or under, or an At-Risk Adult, who is one of two or more individuals descended from one or two mutual parents.

The term also includes stepsiblings, former stepsiblings, and/or adoptive siblings.

This also includes an individual that is considered by state or tribal law to be a sibling of the member or the individual would have been considered a sibling of the member under state or tribal law but for a termination or other disruption of parental rights, such as the death of a parent. 8.014.1.R Stretcher Van means a vehicle that can legally transport a member in a prone or supine position when the member does not require medical attention en route. This may be by stretcher, board, gurney, or another appropriate device. 8.014.1.S. Taxicab means a motor vehicle operating in Taxicab Service, as defined in 4 CCR 723-6, § 6001(2019), which is hereby incorporated by reference. 8.014.1.T. Taxicab Service has the same meaning as defined in 4 CCR 723-6, § 6001(yyy) (2019), which is hereby incorporated by reference. 8.014.1.U. Transportation Broker means an entity contracted with the Department to administer non-emergent medical transportation for Health First Colorado (Colorado Medicaid) members. 8.014.1.V. Transportation Network Companies, commonly referred to as rideshares, means a corporation, partnership, sole proprietorship, or other entity, permitted as described under 8.014.3.F and operating in Colorado, that uses a digital network to connect riders to drivers for the purpose of providing transportation. 8.014.1.W. Trip means one-way transportation from the point of origin to the point of destination. 8.014.1.X. Urgent Care means an appointment for a covered medical service with verification from an attending physician or facility that the client must be seen or picked up from a discharged appointment within 48 hours. 8.014.1.Y. Wheelchair Vehicle means a motor vehicle designed and used for the nonemergent transportation of individuals with disabilities who use a wheelchair.

These vehicles include vans modified for wheelchair Access or wheelchair accessible minivans.

8.014.2. CLIENT ELIGIBILITY AND RESPONSIBILITIES 8.014.2.A. All Colorado Medical Assistance Program clients are eligible for NEMT services unless the client falls within the following eligibility groups on the date of the Trip:

Qualified Medicaid Beneficiary (QMB) Only 2. Special Low Income Medicare Beneficiary (SLMB) Only 3. Medicare Qualifying Individual-1 (QI-1) Only 4. Old Age Pension- State Only (OAP-state only) 8.014.2.B. Child Health Plan Plus clients are not eligible for NEMT. 8.014.2.C. PACE clients receive transportation provided by their PACE organization and are not eligible for NEMT. 8.014.2.D. NEMT services may be denied if clients do not observe the following responsibilities:
Comply with applicable state, local, and federal laws during transport.
Comply with the rules, procedures and policies of the Department, its designees, or the SDE.
Obtain authorization from their SDE.
Clients must not engage in violent or illegal conduct while utilizing NEMT 5. Clients must not pose a direct threat to the health or safety of themselves or others, including drivers.
Clients must cancel their previously scheduled NEMT Trip if the ride is no longer needed, except in emergency situations or when the client is otherwise unable to cancel.

8.014.3. PROVIDER ELIGIBILITY AND RESPONSIBILITIES 8.014.3.A. Providers must enroll with the Colorado Medical Assistance Program as an NEMT provider. 8.014.3.B. Enrolled NEMT providers must comply with the requirements of this

section. Transportation Network Companies holding a valid Public Utility Commission (PUC) permit are exempt from sections 8.014.3.B.6-9. because the PUC permit requirements described at 8.014.3.F take the place of the requirements contained in section 8.014.3.B.6-9.

Meet all provider screening requirements in Section 8.125;
Comply with commercial liability insurance requirements and, if applicable, PUC financial responsibility requirements established in the PUC statute at C.R.S. § 40-10.1-107;
Not directly solicit individual clients known to have already established NEMT service with another provider;
Maintain and comply with the following appropriate licensure, or exemption from licensure, requirements:

a. PUC common carrier certificate as a Taxicab;

b. Ground Ambulance license as required by Department of Public Health and Environment (CDPHE) rule at 6 CCR 1015-3, Chapter Four;

c. Air Ambulance license as required by CDPHE rule at 6 CCR 1015- 3, Chapter Five; or d. Exemption from licensure requirements in accordance with PUC statute at C.R.S. § 40-10.1-105.

Provide only NEMT services appropriate to their current licensure(s), within applicable geographic limitations, and in accord with statutes, rules, and guidance ; and 6. Ensure vehicles used during the provision of NEMT meet federal, state, and local statutes and regulations. Vehicles shall be safe and in good working order. To ensure safety and proper functioning, all vehicles must pass a safety inspection prior to being used to render services to members.

a. Safety inspections shall include the inspection of items as described in Rule Regulating Transportation by Motor Vehicle, 4 C.C.R. 723-6; § 6104.

b. Vehicles must be inspected on a schedule commensurate with their age:

i. Vehicles manufactured within the last five (5) years: no inspection.

ii. Vehicles manufactured within the last six (6) to ten (10) years: inspected every 24 months.

iii. Vehicles manufactured eleven (11) years or longer: inspected annually.

iv. Vehicles for wheelchair transportation: inspected annually, regardless of the manufacture date of vehicle.

c. The vehicle inspector must be trained to conduct the inspection and be employed by an automotive repair company authorized to do business in Colorado.

d. The vehicle inspector and automative repair company must not be owned or controlled by an individual who also has an ownership or controlling interest in the NEMT provider entity.

e. Providers must maintain liability insurance with the following automobile liability minimum limits:

i. Bodily injury (BI) $300/$600K per person/per accident; and 1) Property damage $50,000.

Drivers that utilize their personal vehicle on behalf of a provider agency to provide NMT must maintain the following minimum automobile insurance limits, in addition to the insurance maintained by the provider agency:
Bodily injury (BI) $25/$50K per person/per accident;
Property damage $15,000Member Eligibility.

Create and maintain documentation of, and train staff on, the following policies and procedures:

a. Fraud, waste, and abuse identification and preventions;

b. Compliance with 42 C.F.R. § 403.812, the Health Insurance Portability and Accountability Act (HIPAA);

c. Compliance with vehicle maintenance and safety requirements 8. Ensure that each driver meets the following requirements:

a. Drivers must be 18 years of age or older to render services;

b. Have at least one year of driving experience;

c. Possess a valid Colorado driver’s license;

d. Provide a copy of their current Colorado motor driving vehicle record, with the previous seven years of driving history;

e. Complete a Colorado or National-based criminal history record check; and f. Has received training and obtained certification in CPR and Naloxone administration.

Maintain documentation regarding drivers must be maintained by the provider and provided to the Department or its designees on request:

a. Name b. Valid Driver’s License c. 10 Panel Drug screen prior to hire and annually there after d. State sex offender check prior to hire and annually there after e. National sex offender check prior to hire and annually there after f. Criminal background check without disqualification found below:

i. A conviction of substance abuse occurring within the seven (7) years preceding the date the criminal history record check is completed;

ii. A conviction in the State of Colorado, at any time, of any Class 1 or 2 felony under Title 18, C.R.S.;

iii. A conviction in the State of Colorado, within the seven (7) years preceding the date the criminal history record check is completed, of a crime of violence, as defined in C.R.S. § 18- 1.3-406(2);

iv. A conviction in the State of Colorado, within the four (4) years preceding the date the criminal history record check is completed, of any Class 4 felony under Articles 2, 3, 3.5, 4, 5, 6, 6.5, 8, 9, 12, or 15 of Title 18, C.R.S.;

vi. A conviction in the State of Colorado, at any time, of a felony or misdemeanor unlawful sexual offense against a child, as defined in § 18-3-411, C.R.S., or of a comparable offense in any other state or in the United States at any time;

vii. A conviction in Colorado within the two (2) years preceding the date the criminal history record check is completed of driving under the influence, as defined in § 42-4-1301(1)(f), C.R.S.; driving with excessive alcoholic content,as described in §42-4-1301(1)(g), C.R.S;

viii. A conviction within the two (2) years preceding the date the criminal history record check is completed of an offense comparable to those included in subparagraph (f)(III)(B), 4 C.C.R. 723-6; § 6114 in any other state or in the United States; and ix. For purposes of 4 C.C.R. 723-6; § 6114(f)(IV), a deferred judgment and sentence pursuant to § 18-1.3-102, C.R.S., shall be deemed to be a conviction during the period of the deferred judgment and sent. 8.014.3.C. NEMT transportation providers must maintain a Trip report for each NEMT Trip provided and must, at a minimum, include:

The pick-up address;
The destination address;
Date and time of the Trip;
Client’s name or identifier, and the name of any additional passengers authorized under Section 8.014.3.D;
Confirmation that the driver verified the client’s identity;
Confirmation by the client, Escort, or medical facility that the Trip occurred;
The actual pick-up and drop off time;
The driver’s name; and 9. Identification of the vehicle in which the Trip was provided. 8.014.3.D. Multiple Loading 1. NEMT providers may not transport more than one member at the same time, unless the additional passenger is an Escort, with the following exceptions:

a. If the member does not have access to childcare for the member’s Child(ren), or access to care for an At-Risk Adult the member is responsible for, for the duration of the trip to and from the medically necessary non-emergency services, the Child(ren) or At-Risk Adult, or both, may accompany the member.

b. If an Escort does not have access to childcare for the member’s Sibling(s) for the duration of the trip to and from the member’s medically necessary nonemergency services, the Sibling(s) may accompany the member and the Escort.

c. If an Escort does not have access to childcare for the Escort’s Child(ren), or access to care for an At-Risk Adult the Escort is responsible for, for the duration of the trip to and from the member’s medically necessary non-emergency services, the Child(ren) or At- Risk Adult, or both, may accompany the member and the Escort.

Providers may refuse to transport members that require multiple loadings in accordance with Sections 8.014..3.D.1.a-.c when such loading is either not possible due to vehicle constraints or it conflicts with their internal policy.
The names of additional passengers authorized under this Section 8.014.3.D. must be included in the Trip report required under Section 8.014.3.C.
For trips with multiple members authorized under this section, the provider must only bill one member ID. Multiple claims for a single trip are prohibited. 8.014.3.E. The Section 8.014.3 requirements do not apply to client reimbursement or bus or rail systems. 8.014.3.F. Transportation Network Companies (TNC)
TNC must be approved by the Department to provide NEMT services.
TNC must meet the Public Utility Commission driver, vehicle, safety, permitting and credentialing requirements at 4 C.C.R. 723-6:6700 to 723- 6:6799 to render NEMT services.
TNC may provide NEMT services if:

a. The NEMT provider originally assigned to complete a trip is unable to fulfill the assignment and no other enrolled NEMT provider is available to complete the trip within the time frame necessary to ensure the member arrives at their appointment; or b. No NEMT provider is available to serve the member in the member’s county or service area at the time the trip is requested.

NEMT services rendered by TNCs under section 8.014.3.F. must be documented by the Transportation Broker in writing or electronic records.

Documentation must include:

a. The reason for using the TNC, b. The reason a NEMT provider was unable to complete the trip, and c. The date and time of the request for NEMT services.

The Transportation Broker must make Section 8.014.3.F documentation available to the Department or its designee upon request.

8.014.4. COVERED PLACES OF SERVICE 8.014.4.A. NEMT must be provided to the closest provider available qualified to provide the service the member is traveling to receive. With the exception of rural providers that meet the requirements of section 8.014.4.A.1., the closest provider is defined as a provider within a 25-mile radius of the member’s residence, or the nearest provider if one is not practicing within a 25-mile radius of the member’s residence.

For providers located in designated rural counties, as determined by the Department based on rural geography, the closest provider is a provider within 62.5-mile radius of the member’s residence, or the nearest provider if one is not practicing within a 62.5-mile radius of the member’s residence. The Department lists the designated rural counties on its website. 8.014.4.B Exceptions may be made if a rationale and certification from the member’s treating provider as to why the member cannot be treated by the closest provider within 25 miles of the member’s residence is provided to and approved by Exceptions may be made by the Department, its designees, or the SDE and one of in the following circumstances applies:
If the closest provider is not willing to accept the member, the member may use NEMT to access the next closest qualified provider.
If the member has complex medical conditions that restrict the closest medical provider from accepting the patient, the Department, its designees, or the SDE may authorize NEMT to be used to travel to the next closest qualified provider. The treating medical provider must send the Department, its designees, or the SDE written documentation indicating why the member cannot be treated by the closest provider.
If a member has moved within the three (3) months preceding an NEMT transport, the member may use NEMT to their established medical provider seen in their previous locale. During these three (3) months, the member and medical provider must transfer care to the closest provider as defined at Section 8.014.4.B. or determine transportation options other than NEMT.

8.014.5. COVERED SERVICES 8.014.5.A. Transportation Modes 1. Covered Modes of transportation include:

a. Bus and public rail systems i. Transit passes may be issued by the SDE when the cumulative cost of bus tickets exceeds the cost of a pass.

b. Personal vehicle mileage reimbursement c. Ambulatory Vehicles d. Wheelchair Vehicles e. Taxicab Service f. Stretcher Van g. Ground Ambulance h. Air Ambulance i. Commercial plane j. Train k. Transportation Network Companies 8.014.5.B. NEMT Services 1. NEMT is a covered service when:

a. The client does not have Access to other means of transportation, including free transportation;

b. Transportation is required to obtain a non-emergency service(s) that is medically necessary, as defined in Section 8.076.1.8.; and c. The client is receiving a service covered by the Colorado Medical Assistance Program.

NEMT services may be covered for clients even if the medical procedure is paid for by an entity other than the Colorado Medical Assistance Program.
Non-emergent ambulance service (Ground and Air Ambulance), from the client’s pickup point to the treating facility, is covered when:

a. Transportation by any other means would endanger the client’s life; or b. The client requires basic life support (BLS) or advanced life support (ALS) to maintain life and to be transported safely.

i. BLS includes:

Cardiopulmonary resuscitation, without cardiac/hemodynamic monitoring or other invasive techniques;
Suctioning en route (not deep suctioning); and 3. Airway control/positioning.

ii. ALS includes ALS Levels 1 and 2 in accordance with 42 CFR § 414.605 (2019), which is hereby incorporated by reference.

ALS Level 1 includes the provision of at least one ALS intervention required to be furnished by ALS personnel.
ALS Level 2 includes:

a. Administration of at least three medications by intravenous push/bolus or by continuous infusion, excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer's Lactate); or b. The provision of at least one of the following ALS procedures:

i. Manual defibrillation/cardioversion.

ii. Endotracheal intubation.

iii. Central venous line.

iv. Cardiac pacing.

v. Chest decompression.

vi. Surgical airway.

vii. Intraosseous line.

NEMT may be provided to an Urgent Care appointment under the following circumstances:

a. A provider is available;

b. The appointment is for a covered medical service with verification from an attending physician that the client must be seen within 48 hours; and c. The client is transported to an Urgent Care facility, which may include a trauma center if it is the nearest and most appropriate facility. 8.014.5.C. Personal Vehicle Mileage Reimbursement 1. Personal vehicle mileage reimbursement is covered for a privately owned, non-commercial vehicle when used to provide NEMT services in accordance with Section 8.014.5.B and owned by:

a. A client, a client’s relative, or an acquaintance; or b. A volunteer or organization with no vested interest in the client.

Personal vehicle mileage reimbursement will only be made for the shortest Trip length in miles as determined by an internet-based map, Trip planner, or other Global Positioning System (GPS).

a. Exceptions can be made by the SDE if the shortest distance is impassable due to:

i. Severe weather;

ii. Road closure; or iii. Other unforeseen circumstances outside of the client’s control that severely limit using the shortest route.

b. If an exception is made under Section 8.014.5.C.2.a., the SDE must document the reason and pay mileage for the actual route traveled.

To be reimbursed for personal vehicle mileage, the client must provide the following information to the SDE within forty-five (45) calendar days of the final leg of the Trip:

a. Name and address of vehicle owner and driver (if different from owner);

b. Name of the insurance company and policy number for the vehicle;

c. Driver’s license number and expiration date. 8.014.5.D. Ancillary Services 1. Escort a. The Colorado Medical Assistance Program may cover the cost of transporting one Escort when the client is:

i. A Child.

An Escort is required to accompany a client if the client is under thirteen (13) years old, unless the Child:

a. Is traveling to a Day Treatment program (Children are not eligible for NEMT travel to and from school-funded day treatment programs);

b. The parent or guardian signs a written release;

c. An adult will be present to receive the Child at the destination and return location; and d. The Day Treatment program and the parents approve of the NEMT provider used.

Clients who are at least thirteen (13) years old, but younger than eighteen (18) years old, may travel without an Escort if:

a. The parent or guardian signs a written release; and an adult will be present to receive the Child at the destination and return location.

ii. An At-Risk Adult unable to make personal or medical determinations, or to provide necessary self-care, as certified in writing by the client’s attending Colorado Medical Assistance Program enrolled NEMT provider.

b. The Escort must be physically and cognitively capable of providing the needed services for the client.

i. If a client’s primary caregiver has a disability that precludes the caregiver from providing all of the client’s needs during transport or extended stay, a second Escort may be covered under Section 8.014.5.D.1.c.ii.

c. The Colorado Medical Assistance Program may cover the cost of transporting a second Escort for the client, if prior authorized under

Section 8.014.7. A second Escort will only be approved if:

i. The client has a behavioral or medical condition which may cause the client to be a threat to self or to others if only one Escort is provided; or ii. The client’s primary caregiver Escort has a disability that precludes the caregiver from providing all of the client’s needs during transport or extended stay.

Meals and Lodging a. Meals and lodging for in-state treatment may be reimbursed when:

i. Travel cannot be completed in one calendar day; or ii. The client requires ongoing, continuous treatment and:

The cost of meals and lodging is less than or equal to the cost of traveling to and from the treatment facility and the client’s residence; or 2. The client’s treating medical professional determines that traveling to and from the client’s residence would put the client’s health at risk.

b. Meals and lodging may be covered for the Escort(s) when the client is a Child or an At-Risk Adult who requires the Escort’s continued stay under Section 8.014.5.D.1.

c. Reimbursement will only be made for meals and lodging for which clients and Escorts are actually charged, up to the per diem rate established by the Colorado Medical Assistance Program.

d. Meals and lodging will not be paid or reimbursed when those services are included as part of an inpatient stay.

8.014.6. NON-COVERED NEMT SERVICES AND GENERAL LIMITATIONS 8.014.6.A. The following services are not covered or reimbursable to NEMT providers as part of a NEMT service:

Services provided only as a convenience to the member.
Charges incurred while the member is not in the vehicle, except for lodging and meals in accordance with Section 8.014.5.D.2.
Transportation to or from non-covered medical services, including services that do not qualify due to coverage limitations.
Waiting time.
Cancellations.
Transportation which is covered by another entity.
Metered taxi services.
Charges for additional passengers, including Siblings, Children or At-Risk Adults authorized under Section 8.014.3.D, not receiving a medical service, except when acting as an Escort under Section 8.014.5.D.1.
Transportation for nursing facility or group home residents to medical or rehabilitative services required in the facility’s program, unless the facility does not have an available vehicle.
Transportation to emergency departments to receive emergency services.

See Section 8.018 for Emergency Medical Transportation services.

Providing Escorts or the Escort’s wages.
Trips to receive Home and Community Based Services a. Non-medical transportation (NMT) should be utilized if other transportation options are not available to the member.
Transportation of a provider’s family member or household member.

a. If a provider’s family member or household member is an enrolled member requiring NEMT service, another unrelated NEMT provider must provide that transportation, or the personal mileage reimbursement in section 8.014.5.C may be used. 8.014.6.B. General Limitations 1. The Provider and the SDE are responsible for ensuring that the member utilizes the least costly Mode of transportation available that is suitable to the member’s condition. This must be documented and available upon request by the Department, its designees, or the SDE.

8.014.7. AUTHORIZATION 8.014.7.A. If the Provider is rendering services in the SDE area, all NEMT services must be authorized as required by the SDE.

Authorization requests submitted more than three months after an NEMT service is rendered will be denied.
NEMT services may be denied if proper documentation is not provided to the SDE. 8.014.7.B. If a client requests transportation via Wheelchair Vehicle, Stretcher Van, or ambulance, the SDE must verify the service is medically necessary with the client’s medical provider 1. Medical or safety requirements must be the basis for transporting a client in the prone or supine position. 8.014.7.C. Out-of-State NEMT 1. NEMT to receive out of state treatment is permissible only if treatment is not available in the state of Colorado.
The following border towns are not considered out of state for the purposes of NEMT prior authorization:

a. Arizona: Flagstaff and Teec Nos Pos.

b. Kansas: Elkhart, Goodland, Johnson, Sharon Springs, St. Francis, Syracuse, Tribune.

c. Nebraska: Benkelman, Cambridge, Chappell, Grant, Imperial, Kimball, Ogallala, and Sidney.

d. New Mexico: Aztec, Chama, Farmington, Raton, and Shiprock.

e. Oklahoma: Boise City.

f. Utah: Monticello and Vernal.

g. Wyoming: Cheyenne and Laramie. 8.014.7.D. Prior Authorization 1. The following services require prior authorization by Colorado Medical Assistance Program:

a. Out-of-state travel, except to the border towns identified at section 8.014.7.C.2.

b. Air travel, both commercial air and Air Ambulance.

c. Train travel via commercial railway.

d. Second Escort.

Prior authorization requests require the following information:

a. NEMT prior authorization request form completed by SDE and member’s physician and submitted to Colorado Medical Assistance Program according to form instructions.

i. The Colorado Medical Assistance Program will return requests completed by non-physicians and incomplete requests to the SDE.

ii. The Colorado Medical Assistance Program’s determination will be communicated to the SDE. If additional information is requested, the SDE must obtain the information and submit to the Colorado Medical Assistance Program. If the request is denied, the SDE must send the client a denial notice.

8.014.8. INCORPORATIONS BY REFERENCE

The incorporation by reference of materials throughout section 8.014 excludes later amendments to, or editions of, the referenced materials. Pursuant to C.R.S. § 24-4- 103(12.5), the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours, at: Colorado Department of Health Care Policy and Financing, 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

8.015 ELECTRONIC HEALTH RECORD INCENTIVE PAYMENT PROGRAM

8.015.1 INCORPORATION BY REFERENCE

Title 42 of the Code of Federal Regulations, Part 495 (2010) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. These regulations are available for public inspection at the Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203 8.015.2 DEFINITIONS Pediatrician means a medical doctor who holds a board certification in Pediatrics from the American Board of Pediatrics or provides greater than 50% of services to patients who are 18 years of age or younger.

8.015.3 ELIGIBLE PROVIDERS 8.015.3.A. To qualify for incentive payments, a provider must be an eligible professional or eligible hospital as specified in 42 CFR §495.4 and 42 CFR §495.304, and must have an active Colorado Medicaid provider identification number that has been assigned and is maintained by the Department. 8.015.3.B. An eligible professional participating in the Medicare electronic health record incentive program is not eligible to receive the Medicaid incentive payment through the Colorado Medicaid Electronic Health Record Incentive Payment Program in the same participation year.

8.015.4 ACTIVITIES REQUIRED TO RECEIVE THE INCENTIVE PAYMENT 8.015.4.A. Eligible professionals and eligible hospitals must register with the Department in order to be eligible to participate in the incentive program. 8.015.4.B. An eligible professional or eligible hospital in the first participation year under the Colorado Electronic Health Record Incentive Payment Program must attest to adopting, implementing or upgrading electronic health record technology that has been certified by the Office of the National Coordinator for Health Information Technology, as defined in 42 CFR §495.302, in order to be eligible to receive payment for the first year of participation. 8.015.4.C. Eligible professionals in their second through sixth participation years and eligible hospitals in their second and third participation years must attest to meaningful use of certified Electronic Health Record technology for each year of participation in order to be eligible to receive payment for that year.

For eligible professionals, attestation to meaningful use means that the eligible professional meets the meaningful use criteria set forth in 42 CFR §495.6(a), (c) and (d).
For eligible hospitals, attestation to meaningful use means that the eligible hospital meets the meaningful use criteria set forth in 42 CFR §495.6(b), (c) and (e). 8.015.4.D. Eligible professionals and eligible hospitals must submit all statements of attestation and retain documentation to support attestations.

8.015.5 ESTABLISHING MEDICAID PATIENT VOLUME 8.015.5.A. Eligible professionals and eligible hospitals must establish and demonstrate the Medicaid patient volume necessary for participation in the Colorado Medicaid Electronic Health Record Incentive Payment Program, using the patient volume methodologies defined in 42 CFR §495.306(c) or (d). Eligible professionals and eligible hospitals must attest to meeting Medicaid patient volume requirements and demonstrate evidence of attested patient volume upon the request of the Department.

8.015.6 INCENTIVE PAYMENTS 8.015.6.A. Payments to eligible professionals are calculated in the manner defined in 42 CFR §495.310 once for each year of eligibility after the eligible professional has submitted the required attestation. Payments are disbursed one time per year of eligibility. 8.015.6.B Payments to eligible hospitals are calculated one time only, when the eligible hospital registers to participate in the Incentive Program and makes the appropriate attestation. Payments are calculated in the manner defined in 42 CFR §495.310. These payments are disbursed one time per year of eligibility over a three-year period.

8.015.7 SUSPENSION, EXCLUSION AND OFFSET OF PAYMENTS 8.015.7.A The Department may suspend payment of incentive payments to an eligible provider under any of the following conditions:

The provider fails to timely and completely comply with the audit obligations contained in the Audit section of these rules;
The provider is under an active audit at the time of payment;
The provider has a deficiency finding resulting from an audit or review and is required, at the time of payment, by the Department or duly authorized agent of the Department, to initiate or to complete a Corrective Action Plan;
There is a credible allegation that the provider has falsified documents or made false or misleading attestations;
There is a credible allegation of fraud related to the provider’s participation in the medical assistance program;
There is a credible allegation that the provider has retaliated against an employee for whistle blowing about a provider’s non-compliance with program requirements or about a provider’s false attestations;
The provider is on the federal Office of Inspector General exclusion list at the time of payment;
The provider is indicted for, or found guilty of, an action in any state or federal court that could qualify for exclusion on the federal Office of Inspector General exclusion list;
The provider has been served and is subject to any civil or false claims action seeking the return of medical assistance benefits or another incentive payment;
The provider’s medical assistance benefits are suspended;
The provider owes the Department a refund of medical assistance benefits, or is subject to offset or collection activities;
The federal government requests a suspension;
The provider has been terminated for cause from Colorado’s medical assistance program, the medical assistance program of another State, or from Medicare; or 14. The Department determines that suspension is in the best interests of the public. 8.015.7.B. An eligible provider may be excluded from participation in the program under any of the following conditions:
The provider repeatedly fails to comply with the audit obligations contained in the Audits section of these rules;
There a judicial finding that the provider has falsified documents or made false or misleading attestations;
The provider is listed on the federal Office of Inspector General exclusion list;
The federal government requests exclusion;
The provider has failed to satisfactorily or timely complete a Corrective Action Plan; or 6. The provider has been terminated for cause from participation in Colorado’s medical assistance program, the medical assistance program of another State, or from participation in Medicare. 8.015.7.C. The Department may recoup by offset any incentive payments that did not meet program requirements from other incentive payments due to the eligible provider, from medical services benefits payments due to the eligible provider or from medical services benefits due to another Medicaid provider who is billing for the eligible provider’s services. 8.015.7.D. The Department may recoup by offset any improper or overpaid medical services benefits paid to or on behalf of an eligible provider from any incentive payment to that eligible provider under this program.

8.015.8 AUDITS 8.015.8.A. Eligible providers shall maintain all program-related records including documentation to support attestations and use and expenditures for seven years for audit purposes 8.015.8.B. Eligible providers shall permit the Department, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency:

To audit, inspect, examine, excerpt, copy and/or transcribe the records related to this incentive program, to assure compliance with the program requirements, Corrective Action Plans and attestations.
To access the provider’s premises, to inspect and monitor, at all reasonable times, the provider’s compliance with program requirements, Corrective Action Plans and attestations. Monitoring includes, but is not limited to, internal evaluation procedures, examination of program data, special analyses, on-site checking, observation of employee procedures and use of electronic health information systems, formal audit examinations, or any other procedure. 8.015.8.C. Eligible providers shall cooperate with the State, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency seeking to audit a provider’s compliance with program requirements, Corrective Action Plans and attestations. Upon request, and at the provider’s expense, providers shall make available all necessary and complete records for audit purposes and shall deliver copies of purchase receipts and other documentation to the Department or any other duly authorized agent as specified in the request. 8.015.8.D. Upon request, eligible providers shall demonstrate to the State, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency, that the provider can perform those actions and activities:
to which the provider has attested, or 2. which are required by a Corrective Action Plan.

8.015.9 CORRECTIVE ACTION PLANS 8.015.9.A. An eligible provider who fails to conform to program requirements or for whom deficiencies have been identified may be required to initiate and complete a Corrective Action Plan, as approved by the Department or its duly authorized agent. The purpose of the Corrective Action Plan is to assure that the eligible provider comes into conformity with program requirements and corrects deficiencies, at the provider’s sole expense. 8.015.9.B. The Corrective Action Plan shall be provided to the auditor at the completion of the audit or within two weeks of a when requested by the Department or its duly authorized agent, unless an extension is granted. The plan shall identify:

The actions or corrective measures that the Provider will take to correct the identified deficiencies, to bring the providers operations into compliance with program requirements, or will take to achieve recommended improvements; 2 The name of the contact person responsible for corrective action; and 3. The anticipated completion date.

8.015.10 APPEALS 8.015.10.A. A provider may request informal reconsideration of any of the following Electronic Health Records Incentive Payment Program decisions that the provider disputes:

Eligibility determinations. A provider excluded from participation in the program may challenge that denial by mailing, or hand delivering, to the Department a written request for an informal reconsideration of the denial within 30 days of its issuance. A copy of the denial, if written, must be enclosed with the request.
Incentive payments, including payment amounts.

a. An eligible provider dissatisfied with a decision to deny the eligible provider all or part of an incentive payment, or dissatisfied with the amount of an incentive payment, may challenge that decision by mailing, or hand delivering, to the Department a written request for informal reconsideration of the decision within 30 days of the issue date of the decision. A copy of the decision must be enclosed with the request for informal reconsideration with an explanation of the

basis for the appeal.

b. An eligible provider dissatisfied with a decision to suspend payment of an incentive payment or to an offset of incentive payments, may challenge those actions by mailing, or hand delivering, to the Department a written request to review the action taken within 30 days of the action.

Demonstration of adopting, implementing, and upgrading technology, or demonstration of meaningful use. An eligible provider dissatisfied with findings regarding attestations for adopting, implementing or upgrading technology, or meaningful use of technology, may appeal the audit by mailing, or hand delivering, to the Department a written request to review the audit results within 30 days of the action.
Audit results. An eligible provider dissatisfied with the results of an audit may appeal the audit by mailing, or hand delivering, to the Department a written request to review the audit results within 30 days of the action.
Corrective action plan. An eligible provider dissatisfied with issues related to a Corrective Action Plan, may appeal by mailing, or hand delivering, to the Department a written request to review the Corrective Action Plan within 30 days of the action. 8.015.10.B. A provider dissatisfied with the Department’s informal reconsideration decision may submit a written appeal of the decision by mailing, or hand delivering, to the Department a written request to review the informal reconsideration decision within 30 days of the date of the decision. This result of this review is the final agency decision. 8.015.10.C. All written requests for informal reconsideration or appeal of the informal reconsideration decision must be mailed to:

Department of Health Care Policy and Financing, ATTN: Internal Audit Section, 1570 Grant St, Denver, CO 80203. 8.015.10.D. A provider dissatisfied with a Department’s final agency decision may appeal that decision according to the procedures set forth in 10 CCR 2505-10

Section 8.050, 3, PROVIDER APPEALS.

8.016 ALTERNATIVE BENEFIT PLAN 8.016.A Pursuant to § 1937 of the Social Security Act, effective January 1, 2014, all Medicaid clients in the following eligibility categories shall receive the Alternative Benefit Plan:

adults whose total household income does not exceed 133% of the federal poverty level and 2. parents and caretaker relatives whose total household income is between 69% and 133% of the federal poverty level. 8.016.B The Alternative Benefit Plan includes the services offered in Colorado Medicaid’s Approved State Plan and Habilitative Services.

8.017 HABILITATIVE SERVICES

8.017.A DEFINITION

Habilitative services means services that help a person retain, learn, or improve skills and functioning for daily living that are offered in parity with, and in addition to, any rehabilitative services offered in the Alternative Benefit Plan. Parity in this context means of like type and substantially equivalent in scope, amount, and duration.

8.017.B COVERED SERVICES

Habilitative therapy services shall have parity in amount, scope, and duration to rehabilitative therapies and will only consist of physical, occupational, and speechlanguage pathology services.

8.017.C ELIGIBLE MEMBERS

All Medicaid members are eligible for habilitative services deemed medically necessary, as defined in Sections 8.076.1.8 and 8.280.4.E.2.

8.017.D ELIGIBLE PROVIDERS 8.017.D.1 Habilitative Physical Therapy services shall only be provided by a licensed physical therapist who is an approved Health First Colorado provider or a physical therapist assistant under the general supervision of a licensed physical therapist who is an approved Health First Colorado provider. 8.017.D.2 Habilitative Occupational Therapy services shall only be provided by a licensed occupational therapist who is an approved Medicaid provider or an occupational therapy assistant under the general supervision of a licensed occupational therapist. 8.017.D.3 Habilitative Speech Language Pathology services shall only be provided by any of the following:

a. A certified speech-language pathologist with a current certification issued by the Department of Regulatory Affairs;

b. A clinical fellow under the general supervision of an American Speech- Language-Hearing Association (ASHA) certified speech-language pathologist; or c. A speech-language pathology assistant with an associate degree from a program in which the individual received technical training in the scope of work recommended by ASHA for speech-language pathology assistants.

8.017.E PRIOR AUTHORIZATION OF SERVICES

An order by a physician or other licensed practitioner of the healing arts that is within the scope of their practice is required for covered services. The provider must submit a prior authorization request that includes the clinician's order to the Department’s designee for all covered services in Section 8.017.B. Following the receipt of a complete request, the Department’s designee shall approve or deny all requests for prior authorization and shall determine the length of time that the service is medically necessary. A prior authorization request shall be effective for a length of time not to exceed 12 months.

8.017.F LIMITATIONS 8.017.F.1 For Habilitative Speech-Language Pathology:

a. Diagnostic procedures provided by an audiologist for the purpose of determining general hearing levels or for the distribution of a hearing device are not a covered benefit except for individuals eligible for the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT). 8.017.F.3 All services described in Section 8.017.B Covered Services shall be provided in accordance with 42 CFR § 440.110 (2024) which is hereby incorporated by reference. The incorporation by reference of this regulation excludes later amendments to, or editions of, the reference material. The

regulation is available from the U.S. Government Printing Office at http://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol4/pdf/CFR-2010-title42-vol4sec440-110.pdf. Pursuant to § 24-4-103 (12.5), C.R.S., the Department inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 303 E. 17th Ave., Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

8.018 EMERGENCY MEDICAL TRANSPORTATION

8.018.1. DEFINITIONS 8.018.1.A. Air Ambulance means a Fixed-Wing or Rotor-Wing Air Ambulance 8.018.1.B. Client means a person enrolled in the Medical Assistance Program. 8.018.1.C. Emergency Medical Services (EMS) Provider means an individual who has a current and valid emergency medical service provider certificate issued by the Department of Public Health and Environment (CDPHE) and includes Emergency Medical Technician (EMT), Advanced Emergency Medical Technician (AEMT), Emergency Medical Technician Intermediate (EMT-I), and Paramedic, in accordance with the Rules Pertaining to EMS Practice and Medical Director Oversight at 6 CCR 1015-3, Chapter Two. 8.018.1.D. Emergency Medical Technician (EMT) means an individual who has a current and valid EMT certificate issued by CDPHE and who is authorized to provide basic emergency medical care in accordance with the Rules Pertaining to EMS Practice and Medical Director Oversight at 6 CCR 1015-3, Chapter Two. 8.018.1.E. Emergency Medical Transportation means Ground Ambulance or Air Ambulance transportation during which Clients who are ill, injured, or otherwise mentally or physically incapacitated receive needed emergency medical services en route. 8.018.1.F. Facility means a general hospital, hospital unit, psychiatric hospital, rehabilitation hospital, Acute Treatment Unit (ATU), or Crisis Stabilization Unit (CSU), 8.018.1.G. Fixed-Wing Air Ambulance means a fixed-wing aircraft that is certified as a Fixed-Wing Air Ambulance by the Federal Aviation Administration. 8.018.1.H. Ground Ambulance means a ground vehicle, including a water ambulance, 8.018.1.I. Interfacility Transportation means transportation of a Client from one Facility to another Facility. 8.018.1.J. Life-Sustaining Supplies means oxygen and oxygen supplies required for life-sustaining treatment during transport via ambulance. 8.018.1.K. Mileage means the number of miles the Client is transported in the ambulance. 8.018.1.L. Non-Emergent Medical Transportation (NEMT) means transportation to or from medically necessary non-emergency treatment that is covered by the Colorado Medical Assistance Program under Section 8.014. Non-emergency care may be scheduled or unscheduled. This may include urgent care transportation and hospital discharge transportation. 8.018.1.M. Paramedic means an individual who has a current and valid Paramedic certificate issued by CDPHE and who is authorized to provide acts of advanced emergency medical care in accordance with the Rules Pertaining to EMS Practice and Medical Director Oversight at 6 CCR 1015-3, Chapter Two. For the purposes of these rules, Paramedic includes the historic Emergency Medical Service Provider level of EMT-Paramedic (EMT-P). 8.018.1.N. Paramedic with Critical Care Endorsement means an individual who has a current and valid Paramedic certificate issued by CDPHE and who has met the requirements in CDPHE rule to obtain a critical care endorsement from CDPHE and is authorized to provide acts in accordance with the Rules Pertaining to EMS Practice and Medical Director Oversight relating to critical care, as set forth in C.R.S. § 25-3.5-206. 8.018.1.O. Rotor-Wing Air Ambulance means a helicopter that is certified as an ambulance by the Federal Aviation Administration. 8.018.1.P. Specialty Care Transport (SCT) means interfacility Ground Ambulance transportation of a critically injured or ill Client from a stabilizing hospital to a hospital with full capabilities to treat the Client’s case. SCT is necessary when a Client’s condition requires ongoing care during transport at a level of service beyond the scope of the EMT, that must be furnished by one or more health professionals in an appropriate specialty area including, but not limited to, nursing, emergency medicine, respiratory care, cardiovascular care, or a Paramedic with Critical Care Endorsement.

8.018.2. CLIENT ELIGIBILITY 8.018.2.A. Emergency Medical Transportation is a benefit for all Colorado Medical Assistance Program Clients who are ill, injured, or otherwise mentally or physically incapacitated and in need of immediate medical attention to prevent permanent injury or loss of life.

8.018.3. PROVIDER ELIGIBILITY 8.018.3.A. Providers must enroll with the Colorado Medical Assistance Program as an Emergency Medical Transportation provider to be eligible for reimbursement.

Enrolled Emergency Medical Transportation providers must:

Meet all provider screening requirements in Section 8.125.
Comply with commercial liability insurance requirements.
Maintain and comply with the appropriate licensure:

a. Ground Ambulance license as required by CDPHE statute at C.R.S. § 25-3.5-301 and 6 CCR 1015-3, Chapter Four.

b. Air Ambulance license as required by CDPHE statute at C.R.S. § 25-3.5-307 and 6 CCR 1015-3, Chapter Five.

License, operate, and equip Ground and Air Ambulances in accordance with federal and state regulations.

8.018.4. COVERED SERVICES 8.018.4.A. Emergency Medical Transportation is a covered service when medically necessary, as defined in Section 8.076.1.8., and in accordance with this Section 8.018.4. 8.018.4.B. Ground Ambulance 1. The following Ground Ambulance Emergency Medical Transportation services are covered:

a. Transportation to the closest, most appropriate Facility.

b. Basic life support (BLS) or advanced life support (ALS) required to maintain life during transport from the Client’s pickup point to the treating Facility.

i. BLS includes:

Cardiopulmonary resuscitation, without cardiac/hemodynamic monitoring or other invasive techniques;
Suctioning en route (not deep suctioning); and 3. Airway control/positioning.

ii. ALS includes ALS Levels 1 and 2 in accordance with 42 CFR § 414.605 (2019), which is hereby incorporated by reference. This incorporation by reference excludes later amendments to, or editions of, the referenced materials.

Pursuant to C.R.S. § 24-4-103(12.5), the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours, at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon 1. ALS Level 1 includes the provision of at least one ALS intervention required to be furnished by ALS personnel.

ALS Level 2 includes:

i. Manual defibrillation/cardioversion.

ii. Endotracheal intubation.

iii. Central venous line.

iv. Cardiac pacing.

v. Chest decompression.

vi. Surgical airway.

vii. Intraosseous line.

c. Specialty Care Transport when medically necessary to reach the closest, most appropriate Facility.

d. Department-approved supplies used during Emergency Medical Transportation, including Life-Sustaining Supplies, are separately reimbursable when medically necessary. 8.018.4.C. Air Ambulance 1. Air Ambulance Emergency Medical Transportation services are covered when:

a. They meet the criteria at Section 8.018.4.B.1.a.-b.; and b. The point of pick up is inaccessible by a Ground Ambulance, or great distances or other obstacles prohibit transporting the Client by land to the nearest appropriate medical Facility. 8.018.4.D. Interfacility Transportation 1. Interfacility Transportation is covered when:

a. The Client requires a transfer from one Facility to another; and b. The Client requires ALS or BLS services.

Interfacility Transportation can be provided via Ground or Air Ambulance.

8.018.5. NON-COVERED SERVICES AND GENERAL LIMITATIONS 8.018.5.A. The following services are not covered or reimbursable to Emergency Medical Transportation providers as part of an Emergency Medical Transportation service:

Waiting time and cancellations.
Transportation of additional passengers.
Response calls when determined no transportation is needed or approved.
Charges when the Client is not in the vehicle.
Non-benefit services (e.g., first aid) provided at the scene when transportation is not necessary.
Transportation which is covered by another entity.
Transportation to local treatment programs not enrolled in Colorado Medical Assistance Program.
Transportation of a Client who is deceased prior to transport.
Pick up or delivery of prescriptions or supplies.
Transportation arranged for a Client’s convenience when there is no reasonable risk of permanent injury or loss of life.
Transportation to non-emergency medical appointments or services. See

Section 8.014 for NEMT services.

8.018.6. PRIOR AUTHORIZATION 8.018.6.A. Prior Authorization is not required for Emergency Medical Transportation.

8.019 SECURE TRANSPORTATION

8.019.A DEFINITIONS

“Behavioral Health” means an individual’s mental and emotional well-being and actions that affect an individual’s overall wellness. Behavioral health issues and disorders include substance use disorders, serious psychological distress, suicide, and other mental health disorders, and range from unhealthy stress or subclinical conditions to diagnosable and treatable diseases. The term “behavioral health” is also used to describe service systems that encompass prevention and promotion of emotional health and prevention and treatment services for mental health and substance use disorders.
“Behavioral Health Crisis” means a significant disruption in a person’s mental or emotional stability or functioning resulting in an urgent need for immediate assessment and treatment to prevent a further or serious deterioration in the person’s mental or physical health.
“Secure Transportation” or “Secure Transportation Services” means urgent transportation services provided to individuals experiencing a Behavioral Health Crisis as further defined at 6 C.C.R. 1011-4: 2.22. 6 C.C.R. 1011-4: 2.22 is incorporated by reference. The incorporation of 6 C.C.R. 1011-4: 2.22 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E.

Ave., Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.sos.state.co.us.

8.019.B CLIENT ELIGIBILITY

A Health First Colorado member is eligible for Secure Transportation Services if the member is in a Behavioral Health Crisis. A Behavioral Health Crisis may be established by an intervening professional as defined in Section 27-65-102(20), C.R.S.; crisis professional as defined in 2 C.C.R. 502-1: 1.3; independent professional person as defined in Section 27-65-102(19), C.R.S.; certified peace officer as defined in 4 C.C.R. 901-1:1(k), Section 21.400.1; or by an Emergency Medical Services (EMS) provider as defined in 6 C.C.R. 1015-3:1, 2.22.Section 27-65-102(20), C.R.S.; 2 C.C.R. 502-1:1.3; Section 27-65-102(19), C.R.S.; 4 C.C.R. 901-1:1(k); and 4 CCR 21.400.1 are incorporated by reference. The incorporation of Section 27-65-102(20), C.R.S.; 2 C.C.R. 502-1:1.3; Section 27- 65-102(19), C.R.S.; 4 C.C.R. 901-1; and 4 CCR 21.400.1 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave., Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.leg.colorado.gov or www.sos.state.co.us.

8.019.C PROVIDER ELIGIBILITY

A Health First Colorado enrolled provider that is licensed and meets all requirements set forth at 6 C.C.R. 1011-4 may provide secure transportation services. 6 C.C.R. 1011-4 is incorporated by reference. The incorporation of 6 C.C.R. 1011-4 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during Ave., Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.leg.colorado.gov.

8.019.D COVERED SERVICES

Secure Transportation includes:

a. Transportation of an individual from the community to a facility for treatment and evaluation pursuant to Section 27-65-103 or 27-65-105(1), C.R.S. and Article 65 of Title 27, which are incorporated by reference. The incorporation of Section 25-65-103, C.R.S.; Section 27-65-105(1), C.R.S.; and Article 65 of Title 27 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department inspection during regular business hours at 303 E. 17 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.leg.colorado.gov;

b. Transportation of an individual from any location to an approved treatment facility or to a walk-in crisis center that is in operation as part of the behavioral health crisis response system as described in Articles 81 and 82 of Title 27; Section 27-81-106, C.R.S., which are incorporated by reference. The incorporation of Articles 81 and 82 of Title 27 and Section 25-81-106, C.R.S. excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department inspection during regular business hours at 303 E. 17 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.leg.colorado.gov.; or c. An individual who is receiving transportation across levels of care or to a higher or lower level of care, transportation between any of the following types of facilities:

i. An emergency medical services facility;

ii. A facility designated by the Executive Director of the Colorado Department of Human Services (DHS) for treatment and evaluation pursuant to Article 65 of Title 27;

iii. An approved treatment facility, as described in Section 27-81-106, C.R.S., which is incorporated by reference. The incorporation of

Section 25-81-106, C.R.S. excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17 Ave., Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

Incorporated materials may also be obtained from the original issuer at www.leg.colorado.gov;

iv. A walk-in crisis center that is operating as part of the behavioral health crisis response system; or v. A behavioral health entity (BHE) licensed with a current twenty-four (24) hour endorsement pursuant to Section 25-27.6-106, C.R.S.

Section 25-27.6-106, C.R.S. is incorporated by reference. The incorporation of Section 25-27.6-106, C.R.S. excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during Ave., Denver, CO 80203.

Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.leg.colorado.gov.

8.019.E NON-COVERED SERVICES

Secure Transportation does not include transportation services provided by law enforcement;

a. Except that any member of a co-responder team may provide Secure Transportation Services if that co-responder:

i. Is not law enforcement or personnel employed by or contracted with a law enforcement agency; and ii. Holds a valid license for Secure Transportation by the county in which the Secure Transportation originates; and iii. Provides Secure Transportation in a vehicle:

With a valid permit issued by the county in which the Secure Transportation originates; and 2) That meets the minimum requirements for Secure Transportation services set forth at 6 CCR 1011-4. 6 C.C.R. 1011-4 is incorporated by reference. The incorporation of 6 C.C.R. 1011-4 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.sos.state.co.us.

8.019.F PRIOR AUTHORIZATION REQUIREMENTS

Prior authorization is not required.

8.020 MOBILE CRISIS RESPONSE

8.020.A DEFINITIONS

Behavioral Health Crisis means a significant disruption in a person’s mental or emotional stability or functioning resulting in an urgent need for immediate assessment and treatment to prevent a further or serious deterioration in the person’s mental or physical health.
Crisis Professional means any person who is receiving or has received crisis professional curriculum training approved by the Behavioral Health Administration (BHA) specific to crisis assessment, management, de-escalation, safety planning and all relevant laws and provisions such that training is complete, and the person can lead a crisis response.
Mobile Crisis Response (MCR) means the community-based brief intervention, stabilization, and de-escalation of a member experiencing a Behavioral Health Crisis.

8.020.B MEMBER ELIGIBILITY

All Health First Colorado members are eligible for MCR services.

8.020.C PROVIDER ELIGIBILITY

A Health First Colorado enrolled provider that is endorsed as a MCR provider by the Behavioral Health Administration (BHA) is eligible to receive reimbursement for MCR covered services.

8.020.D COVERED SERVICES

MCR covered services include:

a. Community-based crisis interventions to members in self-defined Behavioral Health Crises, such interventions include:

i. Screening, ii. Assessment, iii. De-escalation, iv. Safety planning, and v. Coordination with culturally responsive referrals to appropriate resources, including health, social, and other services and supports.

The following requirements must be met for coverage of MCR services:

a. MCR providers must meet a member where they are in the community (most commonly at home or at a location in the community requested by the caller) within one (1) hour of dispatch to urban areas, and within two (2) hours of dispatch to rural and frontier areas.

i. An initial Mobile Crisis Response must be a paired response by any two members of the MCR team.

ii. MCR services may be provided via Telemedicine in accordance with Section 8.095 by any one (1) member of the MCR provider’s team, where appropriate.

iii. The initial Telemedicine face-to-face crisis response must include at least (1) in-person responder from the MCR team.

iv. Every mobile crisis response team must include a Crisis Professional who can lead the crisis assessment and intervention.

v. An MCR team must always include at least one member who is a Crisis Professional and qualified to complete an assessment within their scope of practice under state law.

b. Covered services must be performed during the following episodes of care:

i. The initial face-to-face crisis response;

ii. The initial follow-up consultation(s), which occur(s) until stabilization between twenty-four (24) hours after the initial crisis and for up to five days after; and iii. Secondary follow-up to ensure warm handoff and scheduling appointments to referrals within seven (7) days of referral by the MCR provider.

8.020.E NON-COVERED SERVICES 8.020.E.1 MCR does not include:

a. Services provided in institutions or medical facilities, including but not limited to:

i. Inpatient hospital services.

ii. Inpatient psychiatric hospital services.

iii. Inpatient Substance Use Disorder Services.

iv. Emergency Department services. v.. Psychiatric Residential Treatment Facilities.

vi. Qualified Residential Treatment Programs.

vii. Residential Substance Use Disorder services..

viii. Prisons and Jails.

ix. Other settings that offer crisis services, such as Comprehensive Community Behavioral Health Providers, , or Certified Community Behavioral Health Clinics (CCBHCs).

b. Secure Transportation services as described in Section 8.019.

c. Medical diagnosis, evaluation, medication, and treatment.

d. Higher levels of medical care.

8.020.6 REIMBURSEMENT

Reimbursement is in accordance with the Department’s fee schedule.

8.020.7 PRIOR AUTHORIZATION REQUIREMENTS

Prior authorization is not required.

8.040 RECOVERIES FROM PROVIDERS

In the event that an audit or other competent evidence (e.g. information provided by another government agency) reveals that a Provider is indebted to the State for any reason, the Department shall recover this amount either through a repayment agreement with the Provider, by offsetting the amount owed against current and future claims of the Provider, through litigation, or by any other appropriate action within its legal authority.

8.040.1 ENROLLMENT OF PROVIDERS

Before claims can be accepted for payment for goods and services provided to eligible clients, the provider of goods and services shall be enrolled in the Medical Assistance program and assigned a provider number.

8.040.1.5 NATURE OF DEPARTMENT’S AGREEMENTS WITH HEALTH CARE

PROVIDERS

A. Pursuant to its authority under 25.5-1-104(4), C.R.S. and 25.5-1-201(1)(a), C.R.S., the Department enters into agreements with qualified health care providers for the provision of and payment for medical care, goods, and services to eligible persons. The Department has extended, and continues to extend, an open invitation to all qualified health care providers to enter into such agreements. This regulation clarifies that the Department’s duty to comply with federal law requires that it enter into agreements with qualified health care providers to create a mechanism for payment to those providers, be they individuals or entities, who provide goods to or perform services for the eligible persons served by the Department’s programs.

B. Each qualified provider that enters into a “qualified agreement” shall be deemed to have participated in an open, public invitation (to more than three parties) to provide services to the eligible persons served by the Department’s programs.

C. For the purposes of this regulation, a “qualified agreement” means an agreement for the provision of or payment for medical care, goods, or services, to the eligible persons served by the Department’s programs, by and between the Department and a qualified health care provider and, for these purposes, a “qualified health care provider” means an individual or an entity that:

Has been assigned a Medicaid provider number for the purpose of allowing a payment through the Medicaid Management Information System;
Has been assigned a CHP+ provider number; or 3) Is otherwise approved by the Department to receive payments for the provision of medical care, goods, or services through the Department’s fiscal agent(s).

8.040.2 SUBMISSION OF CLAIMS

Effective July 1, 1994, all Medical Assistance program providers shall be required to transmit in an approved electronic format to the fiscal agent for the Department all claims for goods and services which are benefits of the Medical Assistance program provided to eligible clients. Electronic claims format shall be required unless hard copy claims submittals are specifically authorized by the Department.

A transaction fee shall be required for each electronic claim transmission. This transaction fee shall be collected from the provider against current and future claims of the provider through a reduction in claim reimbursement and shall be so described on the Medicaid Remittance Statement.

Required information concerning the recipient, the service, charges, and provider shall be submitted in the prescribed format. Records verifying the type of service provided, the signed state approved certification statements and agreements which serve as a contractual basis for payment, and required client information or additional documentation which can be matched to the claim for services shall be retained in the provider's file for six years. This documentation shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents.

A. Hard Copy Claims Hard copy (i.e., paper) claim forms shall be submitted only by authorization of the Department. The state approved certification statements contained on the claim form become effective and serve as a contractual basis for payment when the provider signs the form.

B. Automated Medical Payments System/Electronic Transfer of Claims All providers shall be required to transmit claims for goods and services in the approved electronic format to the fiscal agent for the Department. Only those electronic formats which have been approved by the fiscal agent will be accepted for Automated Medical Payments System.

Before a provider can submit claims electronically, either directly to the fiscal agent or through a vendor or billing service, state approved provider certification agreements which contain all state approved certification statements and conditions shall be signed and accepted by both the provider and the Department. The state approved certification statements become effective and serve as a contractual basis for payment once the provider signs the form. A billing service shall also have a state approved billing service agreement signed and accepted by the Department before any claims will be accepted. The content of the agreements shall be determined by the Department.

If a provider chooses to submit claims for payment directly to the fiscal agent, source documents and source records used to create the claims shall be maintained in such a way that all electronic media claims can be readily associated and identified. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for six years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents.

A corporation composed of satellite facilities with a common ownership may be considered as a primary provider and bill as such even though each individual facility has a provider number. However, the submitted claims shall identify the facility providing the services. Original source documents used to create the claims transmission shall be maintained at the facility for six years.

If a provider utilizes a billing service to transmit claims, the provider shall provide source documents and any other data transfer materials necessary to create the electronic claim. The billing service shall retain the source documents and data transfer materials for a six year period except when these items are maintained by the provider. Original source documents and data transfer materials shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents. If the provider furnishes the information to the billing service on a computer disc or some other method of electronic transmission, then the source documents used to create the disc or transmission shall be retained by the provider for six years and made readily available and produced upon request.

If the billing service goes out of business, then upon cessation of business, the billing service shall immediately return all documents to each individual provider.

Upon receipt of the electronic transmission, the fiscal agent will process the claims to the M.M.I.S. If the transmission is rejected, the fiscal agent shall send an electronic acknowledgement of rejection to the sender. Claims denied through the M.M.I.S. shall be described on the Medicaid remittance statement.

Electronic transmission of claims shall be required of any provider or billing service. The Department also reserves the right to reject any electronic claims transmission methods.

Failure of the provider or billing service to maintain and certify appropriate records as required by the state approved provider agreements constitutes breach of the state approved provider agreement, and entitles the Department to recover any payments for goods and services made to the provider and to terminate any state approved provider agreement. Thirty day written notice by registered mail shall be used by either party to terminate a state approved provider agreement unless the Department determines that good cause as defined in 8.076.1.7. exists in which immediate termination is necessary.

Recovery may be accomplished by withholding the amount from future payments or requiring the provider to make payments directly to the Department as described in 8.040.

Electronically submitted claims must have a certification field indicating that the sender has verified that the claim information transmitted is true and correct. A hard copy of this transmittal will be kept on file at the provider's or billing service's place of business. All claim transmissions which require a state authorized attachment for the purposes of reimbursement or certification of service, will be submitted on hard copy (i.e., paper) and maintained with the providers' original source documents for a period of six years. 8.041 Claims Editing 8.041.1 DEFINITIONS Current Procedural Terminology (CPT) means the common medical procedure codes used for the purpose of billing medical services as defined by the American Medical Association (AMA).

Fiscal Agent means a vendor who is contracted by the Department to process and maintain the Medicaid Management Information System (MMIS) for purpose of processing claims.

Healthcare Common Procedural Coding System (HCPCS) means an alpha numeric code set as defined by CMS used for the purpose of billing services that are not identified under CPT.

Medically Unlikely Edits (MUE) means units of service edits. This edit restricts the maximum units of services per claim line that may be billed for a procedure code.

National Correct Coding Initiative (NCCI) means a set of claim edits developed by the Centers of Medicare and Medicaid Services (CMS) to promote NCCI methodologies and control improper coding leading to improper Medicaid payments.

Procedure to Procedure edit means the prevention of certain procedure codes from being billed with other procedure codes for the same patient by the same practitioner on the same date of service.

Remittance Statement means the electronic or hard copy statement sent by the Medicaid fiscal agent to advise a provider of claims reimbursement or claims status.

8.041.2 AUTHORITY 8.041.2.A Pursuant to Colorado Revised Statute §25.5-4-300.7 the Department is authorized to implement and maintain a system for reducing medical services coding errors in Medicaid claims submitted to the state department for reimbursement. The system shall include automatic, prepayment review of Medicaid claims through the use of nationally recognized correct coding methods in MMIS. 8.041.2.B The Department will utilize a claims editing program to automatically review claims prior to payment to identify and correct improper coding for professional and outpatient services claims pursuant to Colorado Revised Statute §25.5-4-422(3). The claims editing program will recommend that the Department approve for payment, deny, or modify providers’ submitted claims.

The claims editing program will utilize a nationally recognized standardized method of processing claims for professional and outpatient services using clinical logic based on the most Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD), American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), and nationally recognized specialty practice guidelines.

8.041.3 NCCI PAYMENT METHODOLOGIES 8.041.3.A All providers shall report services performed on and rendered to clients by submitting claims using the HCPCS/ CPT codes designated by the Department.

The use of these codes will be limited to providers who submit claims that are reimbursed based on the CPT code. Claim forms containing these codes are submitted to the Fiscal Agent for payment. NCCI methodologies include a set of edits, a definition of the type of claims subject to the edits, and rules regarding the application of the edits and provider appeals of denied payments. Claims submitted by providers shall be edited according to the six NCCI methodologies defined within the rule:

NCCI procedure to procedure edits for practitioners and Ambulatory Surgical Centers (ASC) services.
NCCI procedure to procedure edits for out-patient hospital services reimbursed based on CPT codes.
NCCI procedure to procedure edits for Durable Medical Equipment (DME) claims.
MUE units of service edits for practitioner and ASC services.
MUE units of service edits for out-patient hospital services reimbursed based on CPT codes.
MUE units of service edits for provider claims for Durable Medical Equipment (DME). 8.041.3.B The Department shall apply the following types of NCCI edits for services performed by the same provider for the same client on the same date of service.
Procedure-to-procedure edits (also known as Column I/Column II define pairs of HCPCS/ CPT codes) that should not be reported together.
MUEs (also known as units-of-service edits) define for each HCPCS/CPT code the maximum number of units of service allowable for each (e.g., claims for excision of more than one gallbladder or more than one pancreas).
Providers’ services shall be denied by line item for the HCPCS/CPT code that is rejected by one of the NCCI edits in the above methodology.

8.041.4 PROVIDER APPEALS 8.041.4.A Providers may submit an appeal for denied line items due to NCCI edits in accordance with 10 CCR 2505-10 Sections 8.049 and 8.050.

8.041.5 REMITTANCE STATEMENTS 8.041.5.A A system of electronic remittance statements shall be used by the Department’s Fiscal Agent to advise all Medicaid providers of claims reimbursement or claims status unless hard copy remittance statements are specifically authorized by the Department.

8.042 UTILIZATION OF A CASH SYSTEM OF ACCOUNTING

8.042.1 PROGRAMS UTILIZING THE CASH SYSTEM OF ACCOUNTING

Effective Fiscal Year 05-06 and ongoing, The Department shall utilize the cash system of accounting regardless of the source of revenues involved, for the following appropriations:

A. Medical Services Premiums Long Bill group.

B. Medicaid Mental Health Community Programs Long Bill group.

C. Medical Programs administered by the Department of Human Services except for the administration of such programs. This includes the following Long Bill line items:

Child Welfare Services 2. Mental Health Community Programs, Goebel Lawsuit Settlement 3. Residential Treatment for Youth (H.B. 99-1116)
Mental Health Institutes 5. Alcohol and Drug Abuse Division, High Risk Pregnant Women Program 6. Community Services Adult Program Costs and CCMS Replacement – Medicaid Funding 7. Federally – matched Local Program Costs 8. Regional Centers – Medicaid Funding 9. Services for Children and Families – Medicaid Funding 10. Division of Youth Corrections – Medicaid Funding D. Nurse Home Visitor Program Long Bill line item.

E. SB 97-101 Public School Health Services Long Bill line item.

F. University of Colorado Family Medicine Residency Training Programs Long Bill line item.

8.042.2 PROGRAMS UTILIZING THE CASH SYSTEM OF ACCOUNTING

Effective Fiscal Year 07-08 and ongoing, The Department shall utilize the cash system of accounting regardless of the source of revenues involved, for the following appropriations:

A. Services for Old Age Pension State Program Clients.

B. Children’s Basic Health Plan Premium Costs and Dental Benefit Costs.

C. Medicare Modernization Act of 2003 State Contribution Payment.

8.043 TIMELY FILING REQUIREMENTS .01 All claims for services provided to eligible Medicaid recipients must be received by the fiscal agent within 365 days from the date of service or 120 days from the Medicare processing date for all Medicare Crossover claims. .02 Timely Filing Extensions for Circumstances Beyond the Control of the Provider A. Delayed Processing by Third Party Resources Medicaid is always the payer of last resort; however, if the initial timely filing period expires because of delays by the third party insurer in providing third party payment or denial documentation, the claim will be considered timely if it is received within 60 days from the date of the third party payment or denial or within 365 days from the date of service, whichever occurs first. A copy of the third party payment voucher or letter of denial must be attached to the claim form or the claim will be denied.

B. Delayed/Retroactive Recipient Eligibility If the initial timely filing period expires because of delays by the county in establishing recipient eligibility or because recipient eligibility is backdated, the claim will be considered timely; if it is received within the applicable initial timely filing period from the date that the recipient appears on the state eligibility files. Each claim must be accompanied by an authorized notification from the county department of social services which verifies the delayed or retroactiave eligibility, and states the date when such action was entered on the eligibility system or the claim will be denied.

C. In all other instances, including possible exceptions to 8.043.02, A. and B. above, and 8.043.03 following, where extenuating circumstances beyond the provider's control allegedly existed, such circumstances as might have existed must be thoroughly documented and submitted as a reconsideration to the fiscal agent's Medicaid Exceptions Unit. However, employee negligence in carrying out their duties or employer negligence in making sufficient and well-trained employees available or in properly monitoring contractual employees/agents will not be considered extenuating circumstances beyond the control of the provider. .03 Rebills/Adjustments/Reconsiderations Denied and incorrectly paid claims may be resubmitted to the fiscal agent at any time during the initial timely filing period. However, if the initial timely filing period has expired, the fiscal agent must receive the rebill or adjustment/reconsideration request within 60 days from the latest Remittance Statement (RS) run date or the latest other written notification of adverse action. Copies of all Medicaid Remittance Statements and/or other written notifications of adverse action documenting initial and subsequent timely filing within the 60-day limit must be attached to the claim form or the rebill or request for adjustment/reconsideration will be denied. .04 All original claims, rebills of denied claims, requests for adjustment of incorrectly paid claims, or requests for reconsideration of denied or incorrectly paid claims to the fiscal agent's Medicaid Exceptions Unit must be received by the fiscal agent within the applicable timely filing period; and, it is the provider's responsibility to ensure that this receipt occurs.

A claim, whether filed for the first time, rebilled, or submitted for adjustment/reconsideration, is considered to be filed when the fiscal agent documents receipt of that claim. Dated claim signatures, certified mail receipts and postmarks, or internal office logs (computerized or manual), for example, shall not constitute filing for the purpose of meeting the timely filing requirements of this manual and the controlling federal regulations. The date of receipt is the date the fiscal agent receives the claim, as indicated by a date stamp, or an imprinted Transaction Control Number assigned by the automated claims processing system - on the claim.

If an original claim, a rebill of a denied claim, a request for adjustment of an incorrectly paid claim, or a request for reconsideration of a denied or incorrectly paid claim to the fiscal agent's Medicaid Exceptions Unit is not acknowledged in written/printed form within thirty (30) days, it is the responsibility of the provider to inquire concerning its status, or resubmit. The weekly Medicaid Remittance Statement shall be proper and sufficient notification of fiscal agent action resulting from any provider request or submittal. .05 All valid claims must be paid within 12 months from the date of receipt, except in the following circumstances:

A. This time limitation does not apply to retroactive adjustments paid to providers who are reimbursed under a retrospective payment system; that is, claims that are paid on the basis of a provisional payment rate set prospectively for an accounting period, and in which payments may be retrospectively adjusted on the basis of the cost experience during the accounting period.

B. If a claim for payment under Medicare has been filed in a timely manner, payment may be made for a Medicaid claim relating to the same services within 6 months of notice of the disposition of the Medicare claim.

C. The time limitation does not apply to claims from providers under investigation for fraud or abuse.

D. Payment may be made at any time in accordance with a court order, to carry out hearing decisions or agency corrective actions taken to resolve a dispute, or to extend the benefits of a hearing decision, corrective action, or court order to others in the same situation as those directly affected by it, including the resolution of an administrative reconsideration or appeal.

8.045.1 PROHIBITION AGAINST PROVIDER REASSIGNMENT OF CLAIMS TO

BENEFITS

For purposes of this section, the following definitions shall apply:

a. “Organized Health Care Delivery System” is a public or private organization for delivering health services. The system may include, but is not limited to, a clinic or a group practice prepaid capitation plan.

b. “Factor” is an organization; i.e., collection agency or service bureau, which, or an individual who, advances money to a provider for his accounts receivable which the provider has assigned or sold, or otherwise transferred, including transfer through the use of a power of attorney, to this organization or individual. The organization or individual receives an added fee or a deduction of a portion of the face value of the accounts receivable in return for the advanced money. For purposes of this

regulation, the term “factor” does not include business representatives, such as billing agents or accounting firms as described within this section. .11 No payment under the State Medical Assistance program for any care or services furnished to an eligible individual by a health care provider shall be made to anyone other than that provider, except as specified in this section. .12 Payments may be made to other than the provider of service when:

a. That payment is made in accordance with an assignment from the provider to a government agency or an assignment made pursuant to a court order;

b. That payment is made to a business agent (such as a billing service or accounting firm) who renders statements and receives payments in the name of the provider, if the agent's compensation for this service is:

(1) Reasonably related to the cost of processing the billings, (2) Not related on a percentage or other basis to the dollar amounts to be billed or collected, and (3) Not dependent upon the actual collection of payment.

With respect to physicians, dentists or other individual practitioners, payment may be made:

a. To the employer of the physician, dentist, or other practitioner if the practitioner is required as a condition of his employment to turn over his fees to his employer; or b. To a foundation, plan, or similar organization, including a health maintenance organization, which furnishes health care through an organized health care delivery system if there is a contractual arrangement between the organization and the person furnishing the service under which the organization bills or receives payments for such person's services. .14 Payment under the Medical Assistance program for any care or service furnished to an eligible individual by a provider shall not be made to or through a factor, either directly, or by virtue of a power of attorney given by the provider to the factor.

8.049 RECONSIDERATION/APPEAL OF ADVERSE ADMINISTRATIVE ACTION

8.049.01 ROLE OF THE FISCAL AGENT

A. The fiscal agent is authorized by the Colorado Department of Social Services to recognize and apply all applicable State and Federal rules and regulations to process claims to satisfactory claim payment. Adverse administrative action by the fiscal agent through routine fiscal agent operations which results in the reduction or claim denial to a Medicaid provider may be submitted for reconsideration. Providers shall submit rebills and adjustment requests through routine fiscal agent operations until all routine processing procedures have been exhausted.

B. If satisfactory resolution is not obtained through routine fiscal agent operations, the provider may file a written reconsideration with the fiscal agent's Medicaid Exceptions Unit. The provider must provide documentation essential to review the request for reconsideration. Copies of all Medicaid Remittance Statements (RS) and other written notification of adverse action documenting initial and subsequent timely filing, along with a signed copy of the original claim (including original attachments), and a brief explanation of the nature of the reconsideration must be submitted. The Request for Reconsideration must clearly be identified by attaching a designated Request for Reconsideration form to the claim or by identifying the word “Reconsideration” on the face of the claim form. Requests for reconsideration that do not include a completed claim form will be returned to the provider.

C. Requests for reconsideration will be reviewed and the result of the review will, upon completion, be reported on the Medicaid Remittance Statement.

8.049.02 FINAL ADMINISTRATIVE APPEAL

Adverse decisions of the fiscal agent's Medicaid Exceptions Unit or decisions made by state Medicaid in exceptional circumstances may be appealed to the Office of Administrative Courts, as set forth in the PROVIDER APPEALS AND HEARING section of this manual.

8.050 PROVIDER APPEALS

8.050.1 DEFINITIONS

Adverse Action means:

a. The Department or its designees makes a finding of fact or interpretation of rules that results in a determination that goods or services were not medically necessary; results in identification of overpayments; or results in a reduction in, or denial of, other specific payments under the Medical Assistance program.

b. The denial, non-renewal or termination of a Provider agreement.

c. The denial of, or request for additional information regarding an application for Medicaid Certification of a Nursing Facility pursuant to Section 8.430.

d. The suspension of payments due to a determination of a credible allegation of fraud.

Mailed means caused to be directed, transmitted, or made available and includes, but is not limited to:

a. The use of the United States Postal Service;

b. The use of electronic mail (e-mail);

c. Making a notice available for retrieval through the Internet or an internet application, as long as notification of the availability is provided through e-mail;

d. The use of private courier or delivery services; and e. The use of facsimile (fax) machines.

Medical assistance shall have the meaning defined in Section 25.5-1- 103(5), C.R.S.
Provider means any person, public or private institution, agency, or business concern enrolled under the state Medical Assistance program to provide medical care, services, or goods and holding, where applicable, a current valid license or certificate to provide such services or to dispense such goods.

8.050.2 NOTICE OF ADVERSE ACTION 8.050.2.A. A notice of Adverse Action shall be in writing, Mailed to the Provider, and include the following:

A statement of what action the Department intends to take.
The reasons for the intended action and the applicable regulations in support of that action.
Information about appeal rights. 8.050.2.B. A notice of Adverse Action regarding a nursing facility’s rate determination shall include a description of the method of rate calculation, the recommended or proposed audit adjustments with an explanation of adjustments and the final rate established. 8.050.2.C. A notice of Adverse Action regarding a determination of overpayment(s) following a review or an audit of a provider shall include the offer of an informal reconsideration of the review or audit findings and notice that no recovery of the overpayment will be implemented until such informal reconsideration, if requested, has been completed.

8.050.3 PROVIDER APPEALS 8.050.3.A. A Provider, other than a nursing facility whose notice of Adverse Action is regarding a rate determination, may appeal a notice of Adverse Action by filing a written appeal within thirty (30) calendar days from the date on the notice of Adverse Action. The appeal shall be filed with the Office of Administrative Courts, Department of Personnel and Administration 1525 Sherman Street, Fourth Floor, Denver, CO 80203. 8.050.3.B. The appeal shall specify the basis upon which the Provider appeals the Adverse Action. 8.050.3.C. The date of filing the appeal shall be the date the Office of Administrative Courts receives the appeal. Failure to file a timely appeal shall result in dismissal of the appeal. 8.050.3.D. No recovery of an overpayment shall be implemented until the appeal process has been completed.

8.050.4 NURSING FACILITY RATE DETERMINATION APPEALS 8.050.4.A. Mandatory Informal Reconsiderations 1. A nursing facility, whose notice of Adverse Action results from its rate determination, may file a written request for informal reconsideration with the Department within thirty (30) days of the date the rate determination letter is mailed or the date that the nursing facility is notified that an electronic copy of the rate determination letter is available for review, whichever is later. The request shall state, with specificity, the adjustments to the cost report the nursing facility wants reconsidered and the nursing facility's position as to each adjustment.

Requests that do not comply with the requirements of this section shall be considered incomplete and shall be denied.
When the first rate letter that incorporates a nursing facility’s new appraised value is issued or made available electronically to the facility, the nursing facility may file a written request with the Department for informal reconsideration of the appraisal within thirty (30) days of the date on the rate letter or the date that the facility was notified that an electronic copy of the rate letter is available for review, whichever is later. Failure to file an informal reconsideration as set forth in this section shall cause any subsequent reconsideration or appeal of the appraisal at issue to be untimely and the reconsideration or appeal shall be dismissed.
Failure to file a written request for reconsideration as set forth in this

section shall result in a waiver of the right to appeal the Adverse Action.

Any issue not presented for informal reconsideration shall not be considered and shall not be appealable to the Office of Administrative Courts.

At informal reconsideration, the Provider shall not be allowed to present any information that was not submitted during the audit process prior to the issuance of the rate determination. The end of the audit process is defined as the expiration of the proposed adjustment review period as specified in Sections 8.442.3.B and 8.442.3.C. 8.050.4.B. The nursing facility may file an appeal with the Office of Administrative Courts of the Department’s written decision on the informal reconsideration within thirty (30) days of the date of the written decision. The appeal shall conform to the requirements of Section 8.050.3. 8.050.4.C. Should the Department not issue a written decision on the informal reconsideration within forty-five (45) days of the Department’s receipt of the request for informal reconsideration, the nursing facility may file an appeal with the Office of Administrative Courts within thirty (30) days of the 45th day following receipt of the request for informal reconsideration. 8.050.4.D. Notwithstanding the position of the parties, their conduct or statements made during the informal reconsideration process, any subsequent appeal initiated by the nursing facility shall be a de novo proceeding. Neither the Department nor the nursing facility shall be bound by their positions, conduct or statements made as part of the informal reconsideration process. The evidence submitted by the nursing facility and considered at the de novo proceeding, shall be limited to that which was submitted during the audit process prior to the issuance of the rate determination being appealed. No new nursing facility information or documentary evidence shall be admissible at the de novo proceeding. 8.050.4.E. The administrative law judge (ALJ) may not under any circumstances alter the appraisal methodology used by the contract appraiser. The ALJ has no

authority to consider appeals from providers requesting the use of any method for calculation of depreciation other than the cost valuation system used by the contract appraiser. 8.050.4.F. The ALJ may alter the findings of fact, judgments and opinions contained in the appraisal report (e.g. measurements, decisions regarding the depreciation components of effective age and building condition) when supported by the evidence.

8.050.5 EXEMPTIONS FROM MANDATORY INFORMAL RECONSIDERATION

IN NURSING FACILITY RATE DETERMINATION APPEALS 8.050.5.A. The following nursing facility rate issues are exempt from mandatory informal reconsideration.

In the case of Class I and Class II nursing facilities or private for-profit or non-profit nursing facility Class IV Providers, the nursing facility’s right to appeal shall commence on the mailing date of the rate letter setting a rate based on the maximum reasonable cost calculation or on the date the facility array and other data used by the Department in its determination of the maximum reasonable rate is made available to Providers. This appeal period shall then expire thirty (30) days after the commencement date.
In the case of state-administered Class IV intermediate care facilities for individuals with intellectual disabilities which are not subject to maximum reasonable cost calculations, the nursing facility's right to appeal shall commence on the mailing date of the nursing facility's rate letter setting the final rate based on the facility's actual allowable audited costs as reported on the form MED-13. Such appeal period shall then expire thirty (30) days after the commencement date. The Office of Administrative Courts shall not conduct the appeal hearing. The appeal process shall be resolved by both agencies presenting their position to the Governor's office. The Governor's decision shall be binding on both agencies.
An appeal of the imposition of a civil money penalty or the denial of a Medicaid payment for a Medicaid-only certified nursing facility's failure to meet federal requirements for participation in Medicaid, shall follow the formal appeal process set forth in Section 8.050.3. The penalty shall not be enforced or collected until the Department sends a certified letter to the Provider explaining the penalty or the denial of payment. In cases where the Provider appeals the penalty, collection of the penalty shall be suspended until the ALJ adjudicates the appeal.

8.050.6 INFORMAL RECONSIDERATIONS AND APPEALS OF

OVERPAYMENTS RESULTING FROM REVIEW OR AUDIT FINDINGS 8.050.6.A. A Provider whose notice of Adverse Action results from a determination of overpayment(s), may file a written request for informal reconsideration with the Department within thirty (30) calendar days of the date of the notice of Adverse Action.

Requests made by telephone shall not be accepted.
The written request shall include:

a. The specific overpayments the Provider wants reconsidered;

b. The Provider’s position as to each overpayment; and c. Documentation that has not already been provided to the Department that substantiates the Provider’s position as to each overpayment.

If a Provider files a written request for informal reconsideration of an Adverse Action and an appeal of the same Adverse Action before a decision has been rendered on the informal reconsideration, the appeal shall control, and the request for an informal reconsideration shall not be acted upon. 8.050.6.B. Requests that do not comply with the requirements of this section shall be considered incomplete and shall be denied. 8.050.6.C. The Department shall issue a written decision on the informal reconsideration within forty-five (45) calendar days of the date on which the Department received the request for informal reconsideration. The Provider may file a written appeal of the informal reconsideration decision no later than thirty (30) calendar days from the date of the informal reconsideration decision pursuant to Section 8.050.3. 8.050.6.D. If the Department is unable to issue a written decision on the informal reconsideration decision within the time period described at Section 8.050.6.C., then the Department shall notify the Provider of its inability to complete the decision. The Provider may file a written appeal no later than 30 calendar days from the date of the notice stating that the Department is unable to render an informal reconsideration decision pursuant to Section 8.050.3. 8.050.6.E. Notwithstanding the position of the parties, their conduct or statements made during the informal reconsideration process, any subsequent appeal initiated by the Provider shall be a de novo proceeding, and neither the Department nor the Provider shall be bound by their prior positions, conduct or statements. 8.050.6.F. No recovery of an overpayment shall be implemented until the informal reconsideration and appeals process has been completed.

8.050.7 CONDUCT OF HEARINGS 8.050.7.A. Except as otherwise specifically provided in these rules, the provisions of

Section 24-4-105, C.R.S., as amended, shall apply to the conduct of fair hearings. 8.050.7.B. For nursing home appeals regarding appraisals, the ALJ shall not, under any circumstance, alter the appraisal methodology from the most recent Request for Proposal but may alter the finding of fact, judgments and opinions contained in the appraisal report if supported by the evidence.

8.057 APPLICANT OR MEMBER APPEALS

8.057.1 DEFINITIONS

Action means a denial, termination, suspension or reduction of Health First Colorado (Colorado Medicaid), eligibility or covered services. It also means determinations by skilled nursing facilities and nursing facilities to transfer or discharge residents and adverse determinations with regard to a Level II Screen finding for the preadmission screening and annual resident review requirements.
Adverse determination means a determination with regard to a Level II Screen finding for the preadmission screening and annual review requirements that the individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.
Authorized representative means a person or organization designated by the applicant or member to act on their behalf. Such authorization shall be in writing in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy regulations located at 45 C.F.R. parts 160 and 164. A written designated power of attorney may substitute for the HIPAA compliant release.
Date of action means the intended date on which a denial, termination, suspension, reduction, transfer or discharge becomes effective. It also means the date of the preadmission screening and annual resident review determination.
Notice, other than that required to be provided by a nursing facility seeking to transfer or discharge a resident, means a written statement which contains:

a. A statement of what action the Department or its designee intends to take and the effective date of such action;

b. The reasons for the intended action;

c. The specific regulations that support, or the change in federal or state law that requires the action;

d. An explanation of i. The individual’s right to request an evidentiary hearing if one is available; or ii. In cases of an action based on a change in law, the circumstances under which a hearing will be granted.

e. The method by which the individual may obtain a hearing;

f. That the individual may represent themselves or use legal counsel, a relative, a friend, or other representative at the hearing; and g. An explanation of the circumstances under which the Health First Colorado (Colorado Medicaid) eligibility or benefit that is the subject of the appeal is continued if a hearing is requested.

h. For notices concerning a medical assistance program eligibility determination under section 8.100, an explanation of the applicant’s or member’s right to a county or service delivery agency dispute resolution conference.

Notice required to be provided by a nursing facility seeking to transfer or discharge a resident means a written statement which contains, in addition to the requirements above:

a. The reason for transfer or discharge;

b. The effective date of the transfer or discharge;

c. The location to which the resident is to be transferred or discharged;

d. The name, address and telephone number of the State long-term care ombudsman;

e. For nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and f. For nursing facility residents living with a mental illness, the mailing address and telephone number of the agency responsible for the protection and advocacy of individuals living with a mental illness established under the Protection and Advocacy for Mentally Ill Individuals Act.

Request for a hearing means a clear expression by the applicant or member, or their authorized representative that they want an opportunity to present their case to a reviewing authority.
Service delivery agency or designated service agency means a Departmentdesignated, certified medical assistance site contracted with the Department to accept and process medical assistance applications approved by the federal Centers for Medicare and Medicaid Services, as authorized by C.R.S. § 25.5-4- 205. Service delivery agencies utilize the Colorado Benefits Management System (CBMS) to determine eligibility for Child Health Plan Plus (CHP+) and Health First Colorado (Colorado Medicaid) medical assistance programs.

8.057.2 ADVANCE NOTICE 8.057.2.A. Notice shall be mailed at least ten (10) calendar days before the date of action except as permitted in 8.057.2.B and 8.057.2.C. Requirements for the timing of notice before the facility can transfer or discharge a resident shall be governed by 8.057.2.D and 8.057.2.E. 8.057.2.B. Notice for any action other than when a nursing facility seeks to transfer or discharge a resident, may be mailed less than ten (10) calendar days before the date of action if:

The Department or its designee has factual information confirming the death of a member;
The Department or its designee receives a clear written statement signed by a member that a. The member no longer wishes services; or b. The member gives information that requires termination or reduction of services and indicates that they understand that this must be the result of supplying that information;

c. The member has been admitted to an institution where they are ineligible for further services;

d. The member’s whereabouts are unknown and the post office returns agency mail directed to them indicating no forwarding address;

e. The member has been accepted for Health First Colorado (Colorado Medicaid) services by another State, territory or commonwealth;

f. A change in the level of medical care is prescribed by the member’s physician; or g. The notice involves an adverse determination made with regard to the preadmission screening and annual resident review 8.057.2.C. Notice for any action other than when a nursing facility seeks to transfer or discharge a resident, shall be sent five (5) calendar days before the date of the action if:

The Department or its designee has facts indicating that action should be taken because of probable fraud by the member; and 2. The facts have been verified, if possible, through secondary sources. 8.057.2.D. Except as specified in 8.057.2.E, the required notice when a nursing facility seeks to transfer or discharge a resident shall be mailed at least thirty (30) calendar days before the resident is transferred or discharged. 8.057.2.E. The required notice by a nursing facility before transfer or discharge shall be as soon as practicable when:
The safety of individuals in the facility would be endangered;
The health of individuals in the facility would be endangered; or 3. The resident’s health improves sufficiently to allow a more immediate transfer or discharge because the resident no longer needs the services provided by the facility;

8.057.3 OPPORTUNITY FOR HEARING 8.057.3.A An individual shall have an opportunity for a hearing where:

An application for eligibility or a request for benefits or services is denied or is not acted upon with reasonable promptness;
The applicant or member requesting the hearing believes the action is erroneous, including a loss of coverage without notice;
The resident of a nursing facility believes the facility has erroneously determined that they must be discharged; or 4. An individual believes the determination with regard to the preadmission and annual resident review requirements is erroneous. 8.057.3.B. An individual does not have the right to an opportunity for hearing if the sole issue is a federal or state law requiring an automatic change adversely affecting some or all applicants or members. 8.057.3.C. An individual does not have the right to an opportunity for hearing for a preadmission screening and annual resident review Level I Screen finding. 8.057.3.D. A provider of medical assistance or any other provider of goods and services to an applicant or member, shall not have the right to a hearing concerning an action or an adverse determination to an applicant or member. 8.057.3.E. A member of a Managed Care Organization must exhaust the internal appeals process described at 8.209 prior to requesting a fair hearing. 8.057.3.F. Opportunity For County or Service Delivery Agency Dispute Resolution Conference. In addition to the opportunity for a hearing, an applicant or member shall have an opportunity to have their medical assistance program eligibility under section 8.100 resolved through an informal dispute resolution conference.

An informal dispute resolution does not extend the period of time within which a member can timely file a formal appeal pursuant to 8.057.4.B.; nor does a request for an informal dispute resolution conference result in a continuation of benefits. Filing a formal appeal pursuant to 8.057.4. is the only way to receive a continuation of benefits, if applicable.

County and service delivery agencies shall afford applicants and members the opportunity for informal dispute resolutions as follows:

An applicant or member who disagrees with a decision regarding their eligibility may request dispute resolution either in writing or by phone no later than sixty (60) calendar days after the date of the Notice of Action (NOA). If available through the County or service delivery agencies, applicants and members may use email to make a request.
No later than ten (10) calendar days after receipt of the request for dispute resolution the County or service delivery agency, after a review of the case for accuracy and completeness, shall notify the applicant or member, in writing, of the date, time, and location of the conference. The notification shall also include the applicant or member’s rights to a state level appeal and a deadline date for requesting such an appeal.
The County or service delivery agency shall hold the conference no later than twenty-five (25) calendar days from the date the request was received unless both parties agree, in writing, to extend the date of the conference.
The applicant or member shall have the choice to have the dispute conference held in person or by phone.
The dispute resolution conference facilitator shall, within three (3) business days of the date of making an eligibility finding, notify the applicant or member of the finding from the conference via U.S. Mail.
If the finding is that the dispute has been resolved and the applicant or member has already filed an appeal, the County or service delivery agency shall inform the applicant or member of the process for dismissing their appeal.

8.057.4 REQUEST FOR HEARING 8.057.4.A. The request for a hearing shall be made to the Office of Administrative Courts in one or more of the following modalities: in writing, via the Office of Administrative Courts electronic filing system, by telephone, via mail, electronic mail, or in person, and contain:

The member or applicant’s name, address and State Identification Number, if applicable;
The action, denial or failure to act promptly on which the requested appeal is based; and 3. The reason for appealing the action, denial or failure to act promptly. 8.057.4.B. The request for a hearing shall be submitted in the manner described in 8.057.4.A with the Office of Administrative Courts:
No later than sixty (60) calendar days after the date of the Notice of Action. 8.057.4.C. The member or applicant or their authorized representative shall be entitled to examine the complete case file and any other documents to be used at hearing at a reasonable time before the hearing and during the hearing.

Documents and information that are confidential as a matter of law shall be exempt from this requirement unless they are to be offered as evidence during the hearing. 8.057.4.D. If the member or applicant makes an oral request for a hearing to the Department or its designee, the Department or its designee shall either prepare a written request for the individual’s signature or have the individual prepare such a 8.057.4 E. Expedited Hearings 1. An applicant or member may request an expedited hearing if the appeal involves an issue where the application of the standard timeframe for making a decision may seriously jeopardize the applicant or member's life, health or ability to regain, attain, and maintain maximum function.

The process for requesting an expedited hearing shall be by the same method as prescribed in 8.057.4.A, B, C, and D.
Upon receipt of the request for expedited hearing, the Office of Administrative Courts shall contact the Department’s Office of Appeals.
Upon notification by the Office of Administrative Courts, the Department’s Office of Appeals shall determine whether the application of the standard timeframe for making a decision may seriously jeopardize the applicant/member’s life, health or ability to regain, attain, and maintain maximum function.
The Office of Appeals must make the decision whether to grant or deny the request for expedited hearing no later than one (1) day after notification.
Grant of a request. If the Office of Appeals grants a request for expedited hearing, the Office of Appeals must:

a. Give the individual prompt oral notice of this decision; and b. Subsequently send to the individual at their last known address written notice of the decision. This notice may be provided within the written notice of hearing.

Denial of a request. If the Office of Appeals denies a request for expedited hearing, the Office of Appeals must:

a. Give the individual prompt oral notice of the denial that informs the individual of the denial and explains that the Office of Appeals will notify the Office of Administrative Courts to process the request for a non-expedite hearings; and b. Subsequently send to the individual at their last known address and to the Department an equivalent written notice of the decision within three (3) business days after the oral notice.

A decision by the Office of Appeals to deny a request for expedited hearing may not be appealed.
Timeframe for decision.

a. If the Office of Appeals grants a request for expedited hearing, the Office of Appeals shall schedule a hearing, as expeditiously as the applicant/member’s health condition requires, but no later than the end of the day after the decision to grant the hearing was made.

b. If the decision involves a benefit appeal, a decision on the hearing shall be made as expeditiously as the applicant/member’s health condition requires, but no later than three (3) business days after the Office of Appeals receives the request for an expedited appeal.

c. If the decision involves an eligibility issue, pursuant to 8.100, the decision on the hearing shall be made as expeditiously as the individual’s health condition requires, but no later than seven (7) business days after the Office of Appeals receives the request for an expedited appeal.

d. These time limits shall not apply if the Department cannot reach a decision because the applicant/member requests a delay or fails to take a required action, or if there is an administrative or other emergency beyond the Department’s control. The Department must document the reasons for any delay in the record.

Hearing.

a. The scheduled hearing may be held in person, by video conference, or telephone and shall be recorded.

b. The Department’s Executive Director, Medicaid Director, Medical Director or their designees may preside over the hearing.

Hearing Decision.

a. The Department’s Executive Director, Medicaid Director, Medical Director or their designees shall make a decision within the required timeframe.

b. The Department’s Executive Director, Medicaid Director, Medical Director or their designees shall give the individual prompt oral notice of this decision; and c. Subsequently send to the applicant or member at their last known address written notice of the decision.

d. The hearing decision shall constitute a Final Agency Decision for purposes of requesting judicial review, and Section 8.057.11 shall apply.

8.057.5 MAINTAINING, REINSTATING, AND CONTINUING BENEFITS AND

SERVICES 8.057.5.A. Where the member requests a hearing before the date of action, the member’s benefits or services may not be terminated or reduced until a final agency decision is rendered after the hearing unless:

It is determined at the hearing that the sole issue is one of federal or state law or policy; and 2. If it is determined at the hearing that the sole issue is one of federal or state law in accordance with section 8.057.5.A.1., the member must be promptly informed in writing that services are to be terminated or reduced pending the hearing decision. 8.057.5.B. A request for an informal dispute resolution conference concerning eligibility determinations, in accordance with Section 8.057.3.F., does not maintain services or continue benefits. 8.057.5.C. Continued Benefits During an SSA Appeal. If an individual receiving Medicaid based upon disability is determined by SSA not to be disabled, and they are not eligible for Medicaid on some other basis, Medicaid is continued during the sixty (60)-day period within which an SSA appeal may be filed. If the individual does not appeal the SSA decision within the sixty (60)-day period, Medicaid shall be terminated.

If an SSA hearing is requested within the sixty (60)-day period, Medicaid may not be terminated until a final decision is made after the SSA hearing. A final administrative decision occurs when the Medicaid member has no right to further administrative appeal with the SSA. The Department shall provide ten (10)-days notice to the individual that Medicaid shall be terminated after the sixty (60)-day period if the individual fails to appeal the SSA decision. 8.057.5.D. Reinstatement and Continuation of Benefits After the Effective Date of the Action. Where the member requests a hearing not more than ten (10) days after the date of action, the member’s services must be reinstated back to the date of action and continued until a final agency decision is rendered after the hearing, unless it is determined at the hearing that the sole issue is one of federal or state law or policy.

A member’s services must be reinstated and continued until a hearing decision is rendered after a hearing if:

a. Action is taken without the advance notice required in section 8.057.2.A, b. The member requests a hearing within ten (10) days from the date that the individual receives the notice of action. The date on which the notice is received is considered to be five (5) days after the date on the notice, unless the member attests that they did not receive the notice within the five (5) day period by submitting a written statement with their appeal request, filed no later than sixty (60) days from the date of notice in accordance with section 8.057.4.B.1. to the Office of Administrative Courts, and c. The Department determines that the action resulted from other than the application of federal or state law or policy.

8.057.6 DENIAL OR DISMISSAL OF REQUEST FOR HEARING 8.057.6.A. The request for hearing shall be denied or dismissed if:

The applicant or member withdraws the request in one or more of the following modalities: in writing, via the Office of Administrative Courts electronic filing system, by telephone, via mail, electronic mail, or in person; or a. For telephonic hearing withdrawals, the Office of Administrative Courts must record the application or member’s statement.

b. For telephonic, online and other electronic withdrawals, the Office of Administrative Courts must send the affected applicant or member written confirmation, via regular mail or electronic notification.

The applicant or member fails to appear at a scheduled hearing without good cause. Good cause shall mean a sudden severe illness, an accident, or other particular occurrence which, by its emergent nature and drastic effect, prevented appearance at the hearing. 8.057.6.B. The applicant or member shall have ten (10) calendar days from the date of the notice of dismissal of scheduled hearing to explain, in a letter to the Administrative Law Judge, the reason for their failure to appear. If the Administrative Law Judge finds that there was good cause for the nonappearance, the Administrative Law Judge shall schedule another hearing date.

8.057.7 FAIR HEARINGS 8.057.7.A. A hearing shall cover:

Action, denial, or failure to act with reasonable promptness regarding eligibility, benefits, or services;
Decisions regarding changes in the type or amount of benefits or services;
Decision by a nursing facility to transfer or discharge a resident; and 4. Determination with regard to the preadmission screening and annual resident review requirements. 8.057.7.B. Conference telephone hearings may be conducted as an alternative to face-to-face hearings. All applicable provisions of the face-to-face hearing shall apply to telephone hearings. 8.057.7.C. Upon receipt of notice of a Department hearing of an appeal, the county department shall arrange for a suitable hearing room appropriate to accommodate the number of persons, including witnesses, who are expected to be in attendance. 8.057.7.D. Except as otherwise specifically provided in these rules, the provisions of

Section 24-4-105, C.R.S., as amended, shall apply to the conduct of fair hearings. 8.057.7.E. Hearings related to an applicant or member’s disability determination, level of care determination or target group eligibility shall be held within twenty (20) calendar days after the Office of Administrative Courts receives the request for a fair hearing unless the applicant or member demonstrates good cause for postponement of the hearing. Under no circumstances shall the hearing be conducted more than forty-five (45) calendar days after receipt of the request for a fair hearing. 8.057.7.F. In hearings which involve medical issues such as those concerning a diagnosis, an examining physician’s report or a medical review team’s decision, the Administrative Law Judge may order a medical assessment other than that in the record of the Department or its designee making the disability determination if the Administrative Law Judge considers such medical assessment necessary.

The assessment shall be at the expense of the Department or its designee and shall be made part of the record. 8.057.7.G. The hearing shall be private unless the applicant or member requests, on the record, that the hearing be open to the public. 8.057.7.H. If the appellant is not fluent in English or has a language difficulty, the Department will arrange with county assistance to have present at the hearing a qualified interpreter who will be sworn to translate correctly.

8.057.8 INITIAL DECISIONS 8.057.8.A. The Administrative Law Judge shall promptly prepare and issue a written Initial Decision and file it with the Office of Appeals of the Department. Initial decisions shall be based exclusively on evidence introduced at the hearing. 8.057.8.B. The Administrative Law Judge shall issue the Initial Decision following a disability determination hearing, a level of care denial hearing or a target group eligibility hearing within twenty (20) calendar days of the hearing date. 8.057.8.C. The Initial Decision shall be in writing and shall:

Summarize the facts;
Identify the regulations and evidence supporting the decision;
Advise the applicant or member that failure to file exceptions to the provisions of the Initial Decision shall waive the right to seek judicial review of a final agency decision affirming those provisions. 8.057.8.D. The Administrative Law Judge shall be bound by the Department’s interpretation of statutes where the Department has regulations implementing such statutes. 8.057.8.E. The Administrative Law Judge shall have no jurisdiction or authority to determine issues of constitutionality or legality of the Department’s regulations. 8.057.8.F. In hearings concerning disability determinations, the only factual issue to be determined by the Administrative Law Judge is whether the applicant or member meets the Health First Colorado (Colorado Medicaid) definition of disability or blindness set forth in section 8.100.1. The Administrative Law Judge’s determination shall be limited to whether or not the applicant or member met the definition of disability or blindness on the date that the disability determination was completed. 8.057.8.G. In hearings concerning level of care determinations, the only factual issue to be determined by the Administrative Law Judge is whether the applicant or member meets the level of care screen applicable to the program at issue. The Administrative Law Judge’s determination shall be limited to whether or not the applicant or member met the level of care on the date that the level of care determination was completed.

8.057.9 REVIEW BY THE OFFICE OF APPEALS 8.057.9.A. The Department’s Office of Appeals shall promptly serve the Initial Decision upon each party to the fair hearing by first class mail. The Office of Appeals will also mail information regarding the administrative review process and the effective date of the Final Agency Decision, filing exceptions, requesting a transcript, and continuation of benefits. The Department shall be a party, even if the Department has not previously appeared as a party to the appeal. 8.057.9.B. Any party seeking to reverse, modify or remand the Initial Decision shall file exceptions with the Office of Appeals within fifteen (15) calendar days, plus five (5) calendar days for mailing, of the date the Initial Decision is mailed to the parties. 8.057.9.C. Exceptions to Initial Decisions shall be in writing and shall state the specific grounds for reversal, modification, or remand of the Initial Decision. 8.057.9.D. A written transcript of the hearing is required where the party filing the exceptions asserts that the findings of evidentiary fact in the Initial Decision are not supported by the weight of the evidence.

The party requiring a written transcript of the hearing shall request the written transcript from the Office of Administrative Courts prior to the filing of exceptions. If the written transcript is not filed with the exceptions, the exceptions shall state that a written transcript has been requested. The party shall comply with all applicable due dates. Prior to the due date for filing exceptions, the party may request, in writing, an extension of time to file either exceptions or the written transcript.
In cases where the applicant or member (Appellant) requests a written transcript in order to file exceptions based on findings of evidentiary fact, the Department shall pay the transcribing agency for the cost of one original transcript for the Office of Appeals, and one copy for the requesting applicant or member.

a. If the Appellant requests a transcript from the Office of Administrative Courts before expiration of the deadline for filing exceptions or an extension of time granted to the Appellant, the Office of Appeals shall automatically grant an extension of forty-five (45) calendar days from the original due date to file exceptions. The Office of Appeals shall issue written notice confirming the revised due date for filing of Appellant’s exceptions and transcript.

While review of the Initial Decision is pending, the submitted written transcript of the hearing shall be available for examination by any party to the appeal, during regular business hours of the Office of Appeals. 8.057.9.E. The Office of Appeals shall promptly serve a copy of the exceptions on each party by first class mail. Each party may file a written response to an exception filed by another party within ten (10) calendar days, plus five (5) calendar days for mailing from the date the exceptions were mailed to the parties. 8.057.9.F. The parties shall not have the right to oral argument to the Office of Appeals. 8.057.9.G. The Office of Appeals shall compile data on outcomes and conduct an administrative review of all Initial Decisions to ensure they include findings of fact, conclusions of law, and an order granting or denying relief.
Administrative review includes reviewing the Initial Decision for the proper application of federal and state law regulations and policies.

8.057.10 FINAL AGENCY DECISIONS 8.057.10.A. The Final Agency Decision shall be based on the record except that the Office of Appeals may remand for rehearing if a party establishes in its exceptions that material evidence has been discovered which the party could not, with reasonable diligence, have produced at the hearing. 8.057.10.B. Record on appeal. The record shall consist only of:

The written transcript of testimony and exhibits, 2. All papers and requests filed in the proceeding;
The Initial Decision of the Administrative Law Judge; and 4. Any exceptions and requests filed in response to the Initial Decision of the Administrative Law Judge. 8.057.10.C. Access to the record. The applicant or member shall have access to the record at a convenient place and time. 8.057.10.D. Streamlined appeal resolution. Effective June 30, 2026, if no exceptions, requests for transcripts, or requests for extension of time to file exceptions are filed within twenty (20) calendar days after the date on which the Initial Decision is mailed to the parties, the Office of Appeals shall have ten (10) calendar days to complete the administrative review of the Initial Decision pursuant to section 8.057.9.G. and determine if a substantive review of the Initial Decision is necessary.
If the Department elects to perform a substantive review of the Initial Decision pursuant to 8.057.10.D, it must mail notification to the parties of its decision within thirty (30) calendar days of the date on which the Initial Decision is mailed to the parties. The Department shall mail a separate Final Agency Decision.
If the Office of Appeals does not mail a notification to the parties of its decision to perform a substantive review of the Initial Decision within thirty (30) calendar days of the date on which the Initial Decision is mailed to the parties, the Initial Decision shall automatically become the Final Agency Decision. If a party does not agree with the Initial Decision but does not file timely exceptions, the party will not have a right to judicial review pursuant to C.R.S.§ 24-4-105(14)(c). 8.057.10.E. Effect of additional filings after Initial Decision issued, or the Department elects to perform a substantive review if no additional filings after Initial Decision issued. If exceptions, requests for transcripts, or requests for extension of time to file exceptions are filed within twenty (20) calendar days after the date the Initial Decision is mailed to the parties, or the Department has elected to perform a substantive review of the Initial Decision in the absence of such filings pursuant to section 8.057.10.D.1., the Office of Appeals shall mail a separate Final Agency Decision within ninety (90) calendar days, except as stipulated in 8.057.10.F., below, from the date the request for a hearing is received unless an extension has been granted to the applicant or member, in which case the ninety (90) calendar day period shall be increased accordingly.
If a party requests an extension of time to file exceptions and does not file exceptions, the Office of Appeals shall mail the parties a separate Final Agency Decision consistent with 8.057.10.E., above, noting the party’s failure to file exceptions. Failure to file exceptions results in a waiver of judicial review pursuant to C.R.S. § 24-4-105(14)(c), unless that portion of the Final Agency Decision subject to exception is different from the content of the Initial Decision. 8.057.10.F. Expedited appeal resolution. If a request for expedited hearing is granted under section 8.057.4.E., the Office of Appeals shall mail a Final Agency Decision within three (3) calendar days from the date the request for an expedited hearing is received.

8.057.11 NOTIFICATION OF DECISION 8.057.11.A. The applicant or member:

Will be mailed only the written Initial Decision if no exceptions, requests for transcript, and/or requests for extension of time to file exceptions are filed and the Office of Appeals does not issue a separate Final Agency Decision pursuant to 8.057.10.D.1.
Will be mailed a notification of the Department’s decision to perform a substantive review of the Initial Decision if it elects to perform the substantive review pursuant to 8.057.10.D.1.
Will be mailed a separate Final Agency Decision if exceptions, requests for transcripts, and/or an extension of time to file exceptions are filed, pursuant to section 8.057.10.E., or a substantive review is performed pursuant to section 8.057.10.D.1, which will include notification of their right to seek judicial review. 8.057.11.B. For purposes of requesting judicial review, the effective date of the Final Agency Decision is as follows:
If Initial Decision exceptions and/or a motion for extension of time to file exceptions were filed pursuant to section 8.057.9.B. or requests for transcripts were filed pursuant to sections 8.057.9.D.1-2., the effective date is the fifth calendar day after the date the Final Agency Decision is mailed pursuant to section 8.057.10.E. or section 8.057.10.E.1., even if the fifth day falls on Saturday, Sunday, or a legal holiday;
If no Initial Decision exceptions and/or a motion for extension of time to file exceptions were filed pursuant to section 8.057.9.B. or requests for transcripts were filed pursuant to sections 8.057.9.D.1-2., and the Office of Appeals mails its own Final Agency Decision after performing a substantive review under section 8.057.10.D.1., the effective date is the fifth calendar day after the date the Final Agency Decision is mailed to the parties, even if the third day falls on Saturday, Sunday, or a legal holiday; or 3. If no Initial Decision exceptions and/or a motion for extension of time to file exceptions were filed pursuant to section 8.057.9.B., or requests for transcripts were filed pursuant to sections 8.057.9.D.1-2., and the Office of Appeals does not mail a notification to the parties that it is performing a substantive review under section 8.057.10.D.1., the Initial Decision converts automatically to a Final Agency Decision pursuant section 8.057.10.D.2 and the effective date is the thirty-fifth calendar day after the Initial Decision was mailed to the parties, even if the thirty-fifth day falls on Saturday, Sunday, or a legal holiday.

8.057.12 CORRECTIVE ACTION 8.057.12.A. If the Final Agency Decision is favorable to the applicant or member, corrective action shall be taken, within three (3) working days after the effective date of the Final Agency Decision, retroactive to the date the incorrect action was taken.

8.057.13 RECONSIDERATION OF FINAL AGENCY DECISION 8.057.13.A. A party may file a motion for reconsideration of a Final Agency Decision with the Office of Appeals:

Upon a showing of good cause for failure to file exceptions to the Initial Decision within the allowed twenty (20) calendar day period—good cause shall mean circumstances beyond the control of the member, including but not limited to medical emergencies or hospitalization, a member who has a disability or other medical condition(s) requiring additional time and/or assistance, or a statement that the party did not receive the Initial Decision prior to the deadline for exceptions; or 2. Upon a showing that the Final Agency Decision is based upon a clear or plain error of fact or law. 8.057.13.B. The motion for reconsideration shall be filed, in writing, with the Office of Appeals within twenty (20) calendar days of the date that the Initial Decision becomes a Final Agency Decision under section 8.057.10.D.2, or the date that the Final Agency Decision is mailed to the parties under sections 8.057.10.D.1. or 8.057.10.E. The motion shall state the specific grounds for reconsideration. 8.057.13.C. The Office of Appeals shall promptly serve a copy of the motion for reconsideration on each party by first class mail. Each party may file a written response to a motion for reconsideration filed by another party within fifteen (15) calendar days from the date the motion was mailed to the parties. 8.057.13.D. The Office of Appeals shall promptly serve a copy of its decision on the motion for reconsideration on all parties by first class mail.

8.057.14 INFORMAL APPLICANT OR MEMBER CONFERENCE IN DISABILITY

DETERMINATIONS 8.057.14.A. Prior to the issuance of an action regarding an applicant or member’s disability determination, the Department or the entity designated to conduct the disability determination shall provide the applicant or member with the opportunity for an informal conference, in person or by telephone, at which time the applicant or member may provide new or additional information relevant to the applicant or member’s claim of disability or blindness. 8.057.14.B. If the Department or designated entity issues an action, the appeal procedures set forth in section 8.057, Applicant or Member Appeals, shall apply to disability determinations.

8.057.15 ALTERNATIVES TO INSTITUTIONAL CARE 8.057.15.A Members who are determined to be likely to require a level of care available in an institution shall have the right to request a hearing where:

The member is not given the choice of home and community-based services as an alternative to the institutional care or 2. The member is denied the service of their choice or available provider of their choice.

8.058 REQUEST FOR PRIOR AUTHORIZATION 8.058.1 Certain services, supplies, equipment, and drug items are available as a benefit of the Medical Assistance program only with prior authorization from the Department or its designee. With respect to benefits not specifically dealt with elsewhere in the Volume VIII staff manual, prior authorization shall be requested by submission of a Request for Prior Authorization form, or in the case of dental services, submission of a Dental Claim form. 8.058.2 Upon receipt of a request for prior authorization which is inadequate or incomplete, the Department or its designee shall contact the requesting provider by phone or mail, as appropriate, within 10 working days to request the missing information. 8.058.3 Based upon medical information included on the appropriate request form, the Department or its designee shall approve or deny all requests for prior authorization within l0 working days following receipt of a complete and adequate 8.058.4 The provision of care, drugs, services, or equipment during an emergency situation is exempt from the regular prior authorization system. In such cases, benefits which would have been authorized in the absence of the emergency may be authorized retroactively. An emergency is defined as any condition in which care, drugs, services, or equipment must be immediately dispensed due to a life threatening condition or a condition requiring immediate medical intervention. The treating physician shall determine the existence of an emergency, and shall reduce the request to writing, including a description of the emergency. Such description shall serve as justification of the emergency benefits, and shall be submitted with a Form 10013 within 60 days following the emergency situation. The Department shall review the emergency request in order to determine the need for continuing or ongoing benefits arising from the emergency.

8.061 USE OF OTHER RESOURCES IN THE PROVISION OF MEDICAL

ASSISTANCE BENEFITS 1 Individuals are expected to utilize, to the extent possible, all those resources which are available to them through Social Security, Medicare or other private or public medical care programs which provide benefits to such individuals. 2 Benefits provided under the Medical Assistance Program (Medicaid) will not duplicate those available to the client from private insurance policies. (See

Section 26-4- 106(4), C.R.S.) 3 Clients who are eligible for medical care or benefits through the Veterans Administration. Military Dependency (CHAMPUS), United States Public Health Service, or other health programs are expected to make maximum use of these services before Medical Assistance benefits are utilized. 4 If a client has primary health coverage through a third party (i.e., a commercial or individual policy, an HMO, PPO, automobile or worker's compensation policy), the client must utilize that primary third party coverage prior to utilizing Medicaid 5 If a client fails to comply with the primary health coverage requirements (including not using the primary coverage's provider network, not obtaining a referral or other cost containment provisions), the client will be liable to the provider for the health services and Medicaid will not be liable. 6 If a provider knowingly provides health services to a Medicaid client who is not enrolled into a client's primary health coverage, neither the client nor Medicaid will be liable for the costs of services. 7 If written or oral communication regarding the health coverage requirements is not provided to the client by the liable third party or the provider of service, then the client will not be liable for the service. The client will only be liable if written documentation exists that the client was provided with instructions regarding the plan requirements. The client will not be liable to the provider for the cost of health services if the client is unable to comply with the requirements of the primary health coverage due to an emergency medical condition. (See Section 26-4-403(1)(III)(A). 8 Emergency medical condition means the sudden, and at the time, unexpected onset of a health condition that required immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. Benefits cannot be denied for conditions which a prudent lay person would perceive as emergency medical conditions as specified by the Division of Insurance Regulation 4-2-17, Section 6.G. (Vol. 8.

Sec. 8.205 C,). 9 A client may enter into an agreement with a third party or provider whereby the client agrees to be personally liable for payment of services not covered by the third party or Medicaid. This agreement must set forth the specific services provided by the third party or provider, the approximate cost of services provided and the method of payment by the client. The agreement must be signed and dated by both the client and the third party or provider in advance of the services being rendered. (See Section 26-4-403 (1)(III)(B). 10 A client who becomes liable for medical services under this rule has the right to the formal adjudication process described at Section 8.058 of this staff manual, also known as the Fair Hearing process at which an Administrative Law Judge (ALJ) presides. An appeal to the ALJ shall be in writing.

8.061.2 RESPONSIBILITY FOR SECURING MEDICAL RESOURCE

INFORMATION 21 The county department is required to secure information concerning the health insurance or other medical coverage of an individual at the time that individual applies or is predetermined eligible for public assistance. Such information relates to the name(s) and State ID. number(s) of the individual(s) covered by the medical coverage, the name of the insurance company, policy number, policy holder, the effective dates of the policy coverage, the address where the medical claim forms must be submitted, and any other information determined necessary for third party liability purposes. This information is to be entered on the State prescribed Client Health Resource Information Form (MS-10). The completed form will be given to the State Department (or its fiscal agent). The information so supplied will be entered into a computerized file and will serve as the basis for claims payment or denial. 22 The county must enter the required medical resource code for a client on either the AP-800 Financial and Medical Eligibility Reporting Form, PCS 100 or FCS 700, Family and Children Services/Child Welfare Medical Forms. This medical resource indicator will be available on the eligibility verification. Medical providers will be required to bill the resource listed (if applicable) before submitting the claim to the Medical Assistance Program for payment. 23 The individual providers, e.g., hospitals, physicians, home health agencies, etc., are required to make inquiry regarding other medical resources a client has at the time medical services are furnished. If the eligibility verification indicates that a resource appropriate to the medical service provided exists, that resource must pay or deny the claim before the Medical Assistance Program can be billed. It is the responsibility of providers to obtain any necessary assignment of benefits from the client.

8.061.3 RIGHT OF RECOVERY IN THIRD PARTY LIABILITY CASES

Section 26-4-403(3), as amended, establishes the State Department's right to recover the cost of medical care provided to an eligible Medicaid client when a third party is liable. 31 Examples of situations in which third party may be liable are: work-related injury covered by worker's compensation, automobile accidents, accident or personal injury claims.

County department staff shall report any and all possible cases of this type involving a Medicaid client to the State Department Specific information regarding the case should be provided whenever known. This includes date and nature of the accident, injuries sustained, name and address of potentially liable third party, name and address of client's attorney.

8.061.40 AGREEMENTS AND PROCEDURES UTILIZING OTHER AGENCY -

RESOURCES

The State Department of Health Care Policy & Financing has working agreements with various agencies which provide medical care under other programs to individuals. To the extent possible, Medical Assistance Program benefits are to be coordinated with the activities and efforts made by other agencies. This includes details on how referrals are made and utilization of other agency benefits, etc.

8.062 SOCIAL SECURITY MEDICARE BENEFITS

8.062.10 SOCIAL SECURITY “MEDICARE” HOSPITAL INSURANCE BENEFITS

(HIB)

(PART “A”) 11 Individuals who receive financial benefits under OASDI or Railroad Retirement and are 65 years of age and over are automatically enrolled for HIB. All other persons must complete an application form for HIB. 12 Certain of the benefits provided under HIB have deductible provisions, coinsurance, or both. The State Department shall reimburse deductible and cost sharing amounts for skilled nursing homes at the Medicare or Medicaid maximum allowable reimbursement limits, whichever is the lesser. The State Department's reimbursement for hospital inpatient and hospital outpatient deductible and cost sharing shall not exceed Medicare reimbursement to the hospital.

8.062.20 SOCIAL SECURITY “MEDICARE” SUPPLEMENTARY MEDICAL

INSURANCE BENEFITS (SMIB) (PART “B”) 21 The State Department shall pay the monthly SMIB premium for all recipients of the Medical Assistance Program who are found eligible for participation by Social Security. These eligibles include:

A. People 65 and over who have Medicare Part “A”.

B. All other people 65 and over who are U.S. citizens, or aliens lawfully admitted to the U.S. and residing here for at least five years.

C. People under 65 who have been receiving monthly Social Security disability benefits under Title II for 24 months.

D. People under 65 who are eligible for Medicare Part “A” because they have chronic renal disease.

In addition to the charge for premium payment, individuals who have SMIB coverage are charged a yearly deductible, plus 20% of the Medicare maximum allowable reimbursement for services. The state department shall reimburse the deductible and cost sharing amounts for non-institutional services up to the Medicare or Medicaid maximum allowable limit, whichever is lower. 22 The county department is responsible for notification to the State Department, using the appropriate “Notice of Action” form, of individuals who are newly eligible or no longer eligible, and who are covered under SMIB.

8.062.30 METHOD OF ADMINISTRATION

Administrative arrangements have been made between the State Department and the Medicare fiscal intermediaries for payment of the deductibles and co-insurance payments to vendors.

8.062.40 REFUSAL TO APPLY FOR TITLE XVIII BENEFITS

In some instances, an individual who refuses to sign a Medicare Application can be determined to be incompetent and an application can be signed in his behalf by another person. The following is in accordance with a guidance statement from the Social Security Administration for such cases:

If a recipient is incompetent, the application for Medicare benefits (Form SSA-18) can be signed by someone else in his behalf. Such person can be the recipient's legal guadian, a relative, an interested friend, an authorized official of an institution where the individual may reside, or an authorized official of the county department (such as the director, a supervisor, or a caseworker, etc.). Where such an application is made for Medicare benefits only (as opposed to monthly money payments for Social Security Retirement or Survivor's benefits, etc.), there does not necessarily have to be a physician's statement concerning incompetency. The person making such an application must, however, enter a statement on the form, describing the recipient's condition to the extent necessary to leave no reasonable doubt regarding such condition. Only where doubt exists as to incompetency, need a doctor's statement be attached as to the person's incompetency for Medicare application.

8.062.50 USE OF CERTIFIED FACILITIES

When a recipient is hospitalized in a licensed hospital or utilized a licensed facility which is not certified, or accredited, as a participant in the Title XVIII Medicare Program, benefits under Title XVIII are unavailable for the care of the recipient. In such situation, the Medical Assistance Program will provide the recipient with emergency services only.

Whenever feasible, the county department shall encourage recipients to utilize certified facilities.

8.063 MEDICAL ASSISTANCE ESTATE RECOVERY 11 The state department may seek to recover medical assistance expenditures correctly paid from the estates of deceased individuals as follows:

A. Recoveries of payments are made for all medical assistance paid on behalf of an individual who was institutionalized at the time he/she received medical assistance B. Recoveries of payments are made for nursing facility services, home and community-based services, and related hospital and prescription drug services paid on behalf of an individual who was 55 years of age or older at the time he/she received medical assistance. The state department does not make the optional recoveries described under federal law in 42 U.S.C. § 1396p(b)(1)(B)(ii) in the case of an individual described in this subsection. 12 The state department may limit estate recovery to recoveries that are costeffective. The term “cost effective” means that the amount of medical assistance expenditures likely to be recovered is greater than the likely cost to the state of the recovery. 13 The state department may file a lien on the real property of an institutionalized person for the amount of medical assistance correctly paid on behalf of the person, only if:

A. the department determines that the medical assistance recipient cannot reasonably be expected to be discharged from the institution and to return home; and B. there is no spouse of the recipient lawfully residing in the home; and C. there is no child of the recipient under age 21 or blind or disabled dependent of the recipient lawfully residing in the home; and D. there is no sibling of the recipient who has an equity interest in the home and who was lawfully residing in the home for at least one year immediately prior to the date the recipient was admitted to the institution;

E. later recovery from the estate is likely to be cost-effective.

Medical assistance payments made on behalf of an institutionalized recipient during the time that all lien criteria are not met will be subject to a lien at such time that all lien criteria are met. 14 The state department shall determine whether a medical assistance recipient reasonably can be expected to be discharged from the institution and to return home. This determination shall be made by the Utilization Review Contractor after notice and opportunity for a hearing. The determination that the recipient is not likely to return home will be used to decide if a lien will be filed. This determination will not change an exempt home into a countable resource for eligibility purposes.

The notice to the recipient shall include the following:

A. A statement of the action that the Utilization Review Contractor intends to take, the reasons for the intended action, and the specific regulations that support the action.

B. An explanation of the term “lien”, and that imposing a lien does not mean that the individual will lose ownership of the home.

C. A statement that the determination will not result in a loss of eligibility for medical assistance benefits.

D. The process by which a recipient may request a hearing to appeal the decision of the Utilization Review Contractor.

The decision may be appealed through the procedures in the RECIPIENT APPEALS PROTOCOLS/PROCESS Section of this staff manual.

The state department shall dissolve any lien on a recipient's home if the recipient is discharged from the institution and returns to the home subject to the lien. 15 The state department shall not recover medical assistance expenditures correctly paid from the estate of a medical assistance recipient if:

A. There is a surviving spouse of the recipient; or B. There is a child of the recipient under age 21 or a blind or disabled dependent of the recipient. 8.063.16 In addition to the prohibitions of 8.063.15, the state department shall not recover medical assistance expenditures correctly paid from the sale of the recipient's home, whether or not the home was subject to a lien, if:

A. there is a sibling of the recipient who was lawfully residing in the home for at least one year immediately prior to the date the recipient was admitted to the institution and who has continuously lived in the home since that date; or B. there is a son or daughter of the recipient who was lawfully residing in the home for at least two years immediately prior to the date the recipient was admitted to the institution and who has continuously lived in the home since that date, and who provided care to the recipient which permitted the recipient to reside at home rather than in an institution.

If either of the two conditions above exist, the state department may recover medical assistance expenditures correctly paid from assets in the estate other than the sale of the recipient's home. 17 The state department shall file liens and recover expenditures for medical assistance provided on or after July 1, 1992. 18 The state department may compromise, settle, or waive recovery of medical assistance expenditures if it determines good cause to do so. The department shall determine that good cause exists if:

A. it concludes that without receipt of the proceeds of the estate, the heirs would become eligible for assistance payments and/or medical assistance programs; or B. it concludes that allowing the heirs to receive the inheritance from the estate will enable these individuals to discontinue eligibility for assistance payments and/or medical assistance programs; or C. it concludes that the home is part of a business, including a working farm or ranch, and recovery of medical assistance expenditures will result in the heirs to the estate losing their means of livelihood. 19 The state department may agree to a payment plan for repayment of any debt owed the state under the Medical Assistance Estate Recovery Program.

8.064 DATA PROVISION AND CLAIMS REQUIREMENTS

8.064.1 DATA PROVISION FROM THIRD PARTIES 8.064.1.A. All third parties, as a condition of doing business in the state, shall provide on a monthly basis, and within 60 days of request, to the Department or its Business Associate or designee, including Medicaid MCO plans, an electronic file from the third party’s database containing eligibility records of all persons covered by the third party containing the minimum necessary data elements to enable the Department or its Business Associate or designee to achieve a satisfactory data match. The Department or its Business Associate or designee has the right, in their sole discretion, to request additional data from any third party if the file provided does not result in a satisfactory data match that enables the Department or its Business Associate to determine which persons are dually eligible for medical assistance and the coverage provided by the third party necessary to prepare HIPAA compliant bills and for the purpose of cost avoidance. Such request will be cumulative and the third party will be required to submit monthly eligibility records with all requested data elements. 8.064.1.B Third parties are encouraged to work with the Department or its Business Associate or designee to enter into Data Use Agreements on a case by case

basis. Execution of a Data Use Agreement with the Department or its Business Associate shall satisfy the Minimum Necessary requirement. 8.064.1.C. “Satisfactory Data Match” means obtaining results from the data match that enable the Department to achieve cost avoidance and that will provide medical providers with adequate information to bill the third party and have their claims adjudicated without request for further information from the third party and that enables the Department or its Business Associate or designee to bill previously paid claims to the third party resulting in proper adjudication without requests for further information from the third party to proceed with adjudication. 8.064.1.D. “Third Party” means a health insurer, self-insured plan, group health plan as defined in 29 U.S.C. Sec 1167(1), service benefit plan, managed care organization, pharmacy benefit manager, or other party, that is by statute, contract, or agreement legally responsible for payment of a claim for a health care item or service, such as third party administrators. 8.064.1.E. “Minimum Necessary” is defined as those data elements necessary to achieve a satisfactory match, and includes, but is not limited to the following:

First name, Middle initial, and Last name;
Date of Birth;
Sex code (M or F);
Social Security number or policy number if a crosswalk to actual social security numbers is provided contemporaneously, or the last 4 digits of the SSN;
Policy and Group number;
Group Name/Employer Name;
Begin and end dates of coverage;
Coverage types provided to each member and dependent;
Pharmacy Indicator and PBM information including a crosswalk to PBMs if multiple PBMs;
Subscriber Full address;
Dependent(s) First name, Middle Initial, and Last name;
Dependent(s) DOB;
Dependent(s) SSN or last 4 digits of SSN;
Dependent(s) Sex Code. 8.064.1.F. “Business Associate” shall have the same meaning as provided in 45 CFR 160.103. 8.064.1.G. Third parties shall accept and respond to inquiries and contact, either in writing or telephonically for verification purposes or otherwise, regarding members and coverage from the Department or its Business Associate or its designee including the provision of applicable NPI numbers.

8.064.2 CLAIMS REQUIREMENT 8.064.2.A. Third parties shall accept the Department’s right of recovery and assignment of benefits from any individual or entity to the extent that such item or service is covered by the third party. 8.064.2.B. Claims shall not be denied for lack of preauthorization. 8.064.2.C. Claims shall not be denied for the type of format of the claim form. 8.064.2.D. Claims shall not be denied for a failure to present proper documentation at the point-of-sale that is the basis for the claim if the claim is presented within three years of the date that the item or service is furnished, and any action by the Department to enforce its right is commenced within six years after the Department’s submission of the claim. 8.064.2.E. Third parties are required to accept and adjudicate claims submitted by the Department or its Business Associate and it is the duty of the third party to inform its clients that they intend to accept and adjudicate claims with or without specific authorization from its clients.

8.065 RECOVERY OF MEDICAL ASSISTANCE OVERPAYMENTS 8.065.1 For purposes of Section 8.065, an “overpayment” includes any medical assistance payments, including capitation payments, paid on behalf of a recipient who was not lawfully entitled to receive the benefits for which the payments were made. The County Department of Social Services shall recover all overpayments except that no recovery shall be made where the overpayment occurred through no fault of the recipient.

8.065.2 RECOVERY PROCESS 21 When it is determined that an overpayment has occurred, the county department shall within 90 days:

A. Document the facts and circumstances which produced the overpayment and retain this documentation until the overpayment is paid in full or otherwise resolved.

B. Initiate timely and adequate notice as set forth in Section 8.057, ADVANCE NOTICE, of this Staff Manual. Such notice shall include applicable rules concerning the overpayment and recovery sought, and shall request the client to voluntarily repay the amount overpaid.

C. Pursue all legal remedies in order to recover the overpayment following the 10-day advance notice period and appeal, if any, pursuant to 8.058, RECIPIENT APPEALS PROTOCOLS/PROCESS of this Staff Manual.

Legal remedies include, but are not limited to, judgments, garnishments, claims on estates, interception of other grants in aid, and the State Income Tax Refund Intercept process. 22 In accordance with Sections 26-2-133 et seq., C.R.S., the state and county departments may recover overpayments of medical service benefits through the offset (intercept) of a taxpayer's state income tax refund. This method may be used to recover overpayments which have been:

A. determined by final agency action, or B. ordered by a court as restitution, or C. reduced to judgment. 23 Prior to certifying the taxpayer's name and other information to the Department of Revenue, the county department shall notify the taxpayer, in writing at his/her last-known address, that the State intends to use the tax refund offset to recover the overpayment. The pre-offset notice shall include the name of the county department claiming the overpayment, a reference to Medicaid as the source of the overpayment, and the current balance owed. 24 The taxpayer is entitled to object to the offset by filing a request for a county evidentiary conference or state hearing within 30 days from the date that the county department mails its pre-offset notice to the taxpayer. In all other respects, the procedures applicable to such hearings shall be those which are stated in this Staff Manual (Section 8.057). At the hearing on the offset, the county department or Administrative Law Judge shall not consider whether an overpayment has occurred, but may consider the following issues if raised by the taxpayer in his/her request for a hearing:

A. Whether the taxpayer was properly notified of the overpayment.

B. Whether the taxpayer is the person who owes the overpayment.

C. If the amount of the overpayment has been paid or, D. If the offset amount is incorrect, or E. If the debt created by the overpayment has been discharged through bankruptcy.

8.066 HEALTH INSURANCE BUY-IN

The purpose of the Department of Health Care Policy & Financing (Department)'s Health Insurance Buy-In (HIBI) program is to reduce, or shift, Medicaid liability by paying the cost of private health insurance premiums and out-of-pocket expenses for Medicaid clients, when it is cost-effective for Medicaid to do so. The health insurance premiums, deductibles, coinsurance, or other cost-sharing obligation for services, of Medicaid clients who are enrolled in a group or individual health insurance plan, will be paid by the Department, when it is cost-effective to do so. Payment of said services shall be treated as payment for medical assistance. This program is in addition to a client's regular Medicaid benefits.

1 ELIGIBILITY/CONDITIONS FOR ENROLLMENT 11 In order to be eligible to participate in the HIBI program, the following criteria must be met:

A. Client must be eligible for Medicaid during the time period for which premium or cost-sharing payment is requested.

B. Client must be covered by, or have access to, a cost-effective group or individual health insurance plan.

C. Client must comply with the requirements of their health insurance plan.

D. Client must provide documentation required by the Department, sufficient to verify eligibility, continuing coverage, and to permit accurate reimbursement. 12 Once shown to be cost-effective, enrollment in a group or individual health insurance plan shall be required of clients as a condition of obtaining or retaining Medicaid. A client who is a policyholder shall be required to enroll his or her dependents in the insurance plan, if the dependents are Medicaid-eligible and also eligible to enroll in the cost-effective health insurance plan. However, Medicaid for such dependents shall not be discontinued if a policyholder fails to enroll the Medicaid-eligible dependent.

8.066.2 COST-EFFECTIVENESS 21 The determination of cost-effectiveness shall be in accordance with applicable state and federal guidelines. 22 A Medicaid client's enrollment in a group or individual health plan is cost-effective when the amount paid for premiums and other cost-sharing obligations plus the State's administrative costs are less than Medicaid's expenditure for an equivalent set of services for the average person in the same category of service. 23 If a plan is determined not to be cost-effective using average Medicaid costs in the above process, the specific client's known historical medical costs may be substituted for the average Medicaid costs in the above formula. 24 If a Medicaid client has access to more than one health insurance plan, a costeffectiveness evaluation shall be performed on each. The client shall be informed as to which plan(s), if any, are likely to be cost-effective to Medicaid. The Medicaid client shall be required to enroll in the health plan that indicates the greatest cost savings to Medicaid. If multiple health plans are equally costeffective, the client may choose which plan to enroll in. 25 Written notification shall be mailed to the Medicaid client upon approval for participation in HIBI. The notification will include the effective date, participation requirements, and applicable instructions. 26 The enrollment in, or continuation of, a health insurance plan determined not to be cost-effective shall be the client's decision. The client shall be required to notify the county of any plan change or termination. The disposition of such noncost-effective health insurance plan shall not affect a client's Medicaid eligibility.

8.066.3 PAYMENT OF PREMIUMS 31 Premiums and cost-sharing will be paid by the Department, from the date the Department receives a premium claim or an approved referral.

A. Up to three (3) months of premium back-payments will only be considered in the following circumstances:

(1) Consolidated Omnibus Budget Reconciliation Act (COBRA) invoice, which may cover one to three months.

(2) The first invoice of any new plan, which may cover more than one month.

(3) Reinstatement of an insurance plan in arrears, if shown to be costeffective to Medicaid.

(4) In certain cases, if it is cost-effective to Medicaid, and good cause is shown. The term “good cause” is defined as conditions outside the control of the individual such as, but not limited to, sudden illness, fire, theft, or acts of God.

B. For pregnant women, premiums will be paid by the Department through the end of the month following the birth of the baby. 32 Premium payment will be made to an insurance carrier, employer, COBRA administrator, or directly to the client or policyholder, if circumstances warrant. 33 Only the portion of the premium that covers the Medicaid client will be paid (i.e., the amount the policyholder would save if he/she were to drop the Medicaid client from coverage). This amount shall be obtained from the premium cost breakdown supplied by the employer or insurance company. 34 The portion of the premium covering plan members who are not Medicaid-eligible will be paid if paying the full premium amount is necessary to obtain coverage for the Medicaid-eligible client(s). 35 If payment is made in error, the Department has the right to recover the funds paid in error. If a Medicaid client fails to return monies received, participation in the HIBI program may terminate, and the client's county technician may be notified of undeclared income, which may jeopardize Medicaid eligibility.

8.066.4 CRITERIA FOR EXCLUSION 41 Criteria for exclusion from the HIBI program are as follows:

A. Medicaid payment of the client's health insurance premium is not found to be cost-effective.

B. Client is no longer eligible for Medicaid.

C. Eligibility for, or access to, the health insurance plan has ended.

D. Payment of the Medicaid client's health insurance premium cannot be made because the insurance coverage is a court-ordered obligation.

E. Health Insurance is provided at no cost to either the client or policyholder.

F. Policyholder intends to continue premium payment and does not want to participate in HIBI.

G. Client has not provided documentation required by the Department.

H. Client does not comply with the requirements of their health insurance plan. 42 Written notification of denial or discontinuation shall be mailed to the Medicaid client upon determination that the Medicaid client is not eligible for participation in the HIBI program. The notification will include the effective date and reason for denial or discontinuation.

5 USE OF/NON-MEDICAID PROVIDERS

The Medicaid client can continue to use his/her own medical provider that participates in the cost-effective health insurance plan. If the provider is not an approved Medicaid provider, the cost of deductibles, coinsurance, and other cost-sharing amounts will be paid by the Department, if it would still be cost-effective to do so.

6 CLIENT APPEAL RIGHTS

If a Medicaid client is denied or discontinued from participation in the HIBI program, he/she may appeal the decision to the Department of Health Care Policy and Financing.

The aggrieved Medicaid client shall file his or her written appeal within sixty (60) days of the mailing date of the adverse action to the HIBI program, the Department of Health Care Policy & Financing. The written appeal will be reviewed by the HIBI officer and manager. A written response to the appeal will be sent to the appellant within 60 calendar days of receipt of the written appeal. A cost-effectiveness evaluation may be resubmitted to the Department with additional information for consideration. Denial or discontinuation at one point in time does not preclude future participation.

8.070 MISUTILIZATION, FRAUD, OR ABUSE

8.070.01 ACTIONS CONCERNING INDIVIDUALS SUSPECTED OF

FRAUDULENT ACTS

It is the duty of the county department to take action against any person suspected of obtaining Medicaid benefits to which he is not entitled or in a greater amount than that to which he is entitled. *Much of Section 8.070 was eliminated and Section 8.076 was created and adopted by the Medical Services Board on December 8, 2000.

8.075 CLIENT OVERUTILIZATION PROGRAM 8.075.1 Authority is given in 42 CFR 456.3 and 431.54(e) to establish a process that safeguards against unnecessary or inappropriate utilization of care and services. This program allows for the development and review of client utilization profiles, provider service profiles and exception criteria. It identifies excessive patterns in order to rectify overutilization practices of clients, providers and institutions. 8.075.2 The Client Overutilization Program restricts Medicaid clients to one designated pharmacy, primary care physician (PCP) or managed care organization (MCO) when there is documented evidence of abuse or overutilization of benefits.

8.075.3 DEFINITIONS

Client Overutilization Program means a process used to restrict a Medicaid client to a single physician or managed care organization and a single pharmacy to control excessive Medicaid benefits usage.

Overutilization means the improper or excessive utilization of medical care and services that are not medically necessary. 8.075.4 Clients whose utilization of Medicaid benefits without medical necessity has exceeded any one of the following parameters during a quarter shall be subject to placement in the program:

Use of three or more drugs in the same therapeutic category;.
Use of three or more pharmacies;
Use of sixteen or more prescriptions; or 4. By referral, review or other analysis that indicates possible overutilization. 8.075.4.A. Once the Department identifies a client that falls under 8.075.4, a postpayment review of documented information may be initiated, which includes but is not limited to:
Medicaid Management Information System reports;
Billing invoices;
Investigative reports;
Medical record reviews. 8.075.4.B. The Department shall inform the client in writing of program placement.

The client will be notified of client's appeal rights granted in accordance with 8.057. The client will not be placed in the Overutilization Program until the appeal has been heard and a decision rendered or if no appeal, the appeal timeline has passed. The client has 10 days from the date the notification is mailed to appeal the decision. 8.075.4.C. The client will work in conjunction with the Department to select one physician or managed care organization and one pharmacy in which to receive their care. Clients shall be in the Client Overutilization Program for at least 12 consecutive months. 8.075.4.D. If a client becomes ineligible for Medicaid benefits during the restricted period, restrictions shall automatically commence for 12 consecutive months from the month eligibility is reestablished unless determined otherwise by the Department. 8.075.4.E. The following shall apply when the client has been assigned to the selected physician/MCO and pharmacy:

The client shall receive notification that identifies the program restrictions and providers. It is the responsibility of the client to request services only from the providers identified on the card. Emergency services are available to the client without the need to prior authorize the services.
The client shall have the right to a second surgical opinion should surgery be deemed necessary by the designated physician. 8.075.4.F. The designated provider shall serve as the case manager for the client.

The physician shall authorize and monitor services rendered to the client by any other provider. 8.075.4.G. A change in designated providers may be granted if any of the following occur:

The provider moves, retires, dies, discontinues Medicaid participation of refuses to continue providing care to the client; or 2. The client moves from the physician's service area. 8.075.4.H. Restrictions will be rescinded upon the written recommendations of the client's designated provider and the Department. The Department will notify the client in writing of the decision to rescind restrictions. If, after the case review the decision is not to rescind the restrictions the client shall be afforded the opportunity to appeal in accordance with 8057.

8.075.5 CLIENT REFUSAL TO COOPERATE 8.075.5.A. If the client refuses to cooperate with the Department and does not appeal the decision to be placed in the program, the Department shall proceed with program placement. The Department shall notify the client of the providers and the effective date of implementation.

8.076 PROGRAM INTEGRITY

8.076.1 DEFINITIONS

Abuse means Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medical Assistance program, an Overpayment by the Medical Assistance program, in reimbursement for goods or services that are not medically necessary, as defined at Section 8.076.1.8., or that fail to meet professionally recognized standards for health care. These practices may include, but are not limited to:

a. Billing for goods or services without valid documentation to support the claims submitted for reimbursement.

b. Unbundling charges on claims for goods or services by separating components of a group of procedures that are required to be billed together (or bundled), and billing each component separately.

c. Submitting a fee-for-service claim or claims for goods or services before they have been provided.

d. Signing prior authorizations or physician's orders for goods or services that are inappropriate or not medically necessary for the client.

e. Presenting or causing to be presented for payment any false or fraudulent claim for goods or services.

f. Submitting or causing to be submitted false information for the

purpose of obtaining greater compensation than that to which the provider is legally entitled.

g. Submitting or causing to be submitted false information for the

purpose of meeting prior authorization requirements.

h. Failing to retain or disclose or make available to the Department or its authorized agent(s) records of goods or services provided to eligible clients and related records of payments when requested.

i. Engaging in a course of conduct or performing an act deemed improper or continuing such conduct following notification that said conduct should cease.

j. Visiting a facility, such as a nursing home, and billing for individual visits without rendering any specific service to individual clients.

k. Overutilizing by inducing, furnishing, or otherwise causing a client to receive goods or services not otherwise required or requested by the client or prescribing Provider.

l. Violating any applicable regulation listed at Section 8.000, et seq. or failing to comply with any guidance provided by the Department, including but not limited to provider bulletins and billing manuals.

m. Submitting a false or fraudulent application for provider enrollment.

n. Violating any laws or regulations pertaining to federal or state health care programs or failing to meet professionally recognized standards for health care.

o. Conviction of a criminal offense relating to:

i) Performance of the Provider Agreement with the State;

ii) Negligent practice resulting in the death or injury to patients;

iii) Patient abuse;

iv) Fraudulent billing practices;

v) Misuse or misapplication of program funds;

vi) The unlawful manufacture, distribution, prescription or dispensing of controlled substances; or vii) Actions that indicates a Provider may pose a risk to the health, safety, or well-being of a client.

p. Failure to meet standards required by state or federal law for participation such as licensure or certification requirements.

q. Failure to correct deficiencies in provider operations in accordance with an accepted plan of correction or written response after receiving written notice of these deficiencies from the Department, its designees, or other state agencies.

r. Formal reprimand or censure by an association of the Provider’s peers or the appropriate state or federal regulatory or licensing body for unethical, illegal, or improper practices.

s. Suspension, exclusion, or termination from participation in another governmental medical program for fraudulent or abusive practices.

t. Failure to repay or make arrangements to repay Overpayments or payments made in error.

u. Use of another Provider’s provider identification number for the

purpose of obtaining reimbursement.

v. Use of client identification numbers to submit claims for reimbursement for goods or services that were not rendered or delivered.

w. Alteration of any source documentation performed to support claims billed or creation of new source documentation to support claims billed when the alteration or creation occurs after a request for documentation is received by the Provider from the Department or its agent. Alteration does not include a late entry that is signed and dated when documented or transcriptions made to facilitate a Department review.

x. Upcoding services by submitting claims for a higher level of goods or services than what was provided or medically necessary.

Conviction or Convicted means that:

a. A judgment of conviction has been entered against an individual or an entity by a federal, state, or local court, regardless of whether there is a post-trial motion or an appeal pending;

b. A federal, state, or local court has made a finding of guilt against an individual or entity;

c. A federal, state, or local court has accepted a plea of guilty or nolo contendere by an individual or entity; or d. An individual or entity has entered into participation in a first offender, deferred adjudication, or other program or arrangement where judgment of conviction has been withheld.

Excluded means a Provider that has been barred from participating in any health care program by the Office of Inspector General for the United States Department of Health and Human Services (OIG).
False Representation means an inaccurate statement that is relevant to a claim for reimbursement or Prior Authorization Request and is made by a Provider who has actual knowledge of the truth or false nature of the statement, or by a Provider acting in deliberate ignorance of or with reckless disregard for the truth of the statement. A Provider acts with deliberate ignorance of or with reckless disregard for the truth if the Provider fails to maintain records required by the Department or if the Provider fails to become familiar with rules, manuals, and bulletins issued by the Department, board or the Department's fiscal agent.
Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to her/himself or some other person. It includes any act that constitutes fraud under any federal or state law.
Furnished means goods or services provided directly by, or under the direct supervision of, or ordered by, a practitioner or other individual (either as an employee or in his or her own capacity), a Provider, or other supplier of goods or services.
Good cause, for the purpose of withholding payments to a provider or denying, terminating, or not renewing a Provider agreement means:

a. The Provider has failed to comply substantially with rules, manuals, and bulletins issued by the Department, board, or the Department’s fiscal agent.

b. The Provider has not complied with applicable federal and state statutes and regulations.

c. The Provider, either by omission or commission, is endangering or has endangered the health, safety, or well-being of a program services client or cients.

d. The owner, operator, partner, or other participating employee of the Provider has previously owned, operated, or otherwise participated in and received direct or indirect payment from the Medical Assistance Program and has a documented pattern of program abuse, substandard care, endangerment of the health or well-being of clients, or non-compliance with program requirements.

e. The Provider's license or certification has expired, been revoked, suspended, surrendered while a formal disciplinary proceeding was pending before a state licensing authority, or for any other reason is invalid at the time goods are provided or services are rendered for which claims are submitted for reimbursement.

f. The Provider has been excluded, suspended, or terminated from any Medical Assistance program of another state or has been excluded, suspended, terminated or had had its billing privileges revoked under the Medicare program, or has been excluded by the OIG unless a waiver is granted by the OIG.

g. The Provider has failed to fully and accurately make any disclosures required by federal and state statutes or regulations.

h. Any Provider, or person with an ownership or controlling interest in the Provider, or who is a Provider's agent or managing employee, has been convicted of a criminal offense outlined in Section 8.076.1.1.o.

i. The Provider has demonstrated a pattern of Abuse.

j. The Provider has engaged in False Representation and/or Fraud in submitting Medical Assistance program claims.

k. The Provider has billed or sought collection through a third party from a client or the estate of a client, his or her family, friend, or other representative, for any amount for covered goods or services, excluding any required copayment, coinsurance, or other client cost-sharing amounts, and failed, once notified by the Department, to correct the billing or collection action.

l. The Provider has failed to return money paid by clients for covered goods or services rendered during any period of client eligibility.

This includes failing to pay back clients for goods or services for which they were charged when their eligibility was determined retroactively and there is evidence of notification of retroactive eligibility for the client, regardless of whether payment for the covered goods or services were received.

m. The Provider owes the Department an outstanding balance and has failed to enter into a payment plan with the Department or the provider has failed to comply with a payment plan it had previously entered into.

n. The Provider has failed to provide a written response within thirty (30) days of the Department’s request or the Provider has provided a written response but failed to meet the requirements set out in the Department’s request as described in Section 8.076.6.

o. The Provider has failed to provide information related to the False Claims Act and whistleblower protections described in Section 8.076.7, within thirty (30) days of the Department’s request.

Medical necessity means a Medical Assistance program good or service:

a. Will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, condition, injury, or disability. This may include a course of treatment that includes mere observation or no treatment at all;

b. Is provided in accordance with generally accepted professional standards for health care in the United States;

c. Is clinically appropriate in terms of type, frequency, extent, site, and duration;

d. Is not primarily for the economic benefit of the provider or primarily for the convenience of the client, caretaker, or provider;

e. Is delivered in the most appropriate setting(s) required by the client's condition;

f. Is not experimental or investigational; and g. Is not more costly than other equally effective treatment options.

Overpayment means the amount paid to a Provider which is in excess of the amount that is allowable for goods or services furnished and which is required by Title XIX of the Social Security Act to be refunded. An Overpayment may include, but is not limited to, improper payments made as the result of fraud, waste, and abuse.
Provider means any person, public or private institution, agency, or business concern enrolled under the state Medical Assistance program to provide medical care, services, or goods and holding, where applicable, a current valid license or certificate to provide such services or to dispense such goods.

8.076.2 COMPLIANCE MONITORING 8.076.2.A. All Providers shall comply with the efforts of the Department, the U.S.

Department of Health and Human Services (HHS), any investigative entity, the Medicaid Fraud Control Unit (MFCU), or their designees to monitor Provider compliance with federal and state Medical Assistance program statutes, regulations and guidance in order to detect and correct noncompliance and prevent fraud, waste and abuse. 8.076.2.B. Compliance monitoring includes, but is not limited to:

Conducting prospective, concurrent, and/or post-payment reviews of claims.
Verifying Provider adherence to professional licensing and certification 3. Reviewing goods provided and services rendered for fraud, waste and abuse.
Reviewing compliance with rules, manuals, and bulletins issued by the Department, board, or the Department’s fiscal agent.
Reviewing compliance with nationally recognized billing standards and those established by professional organizations including, but not limited to, Current Procedural Terminology (CPT), Current Dental Terminology (CDT), and Healthcare Common Procedure Coding System (HCPCS).
Reviewing adherence to the terms of the Provider Participation Agreement. 8.076.2.C. Compliance monitoring activities may include, but are not limited to:
Site reviews.
Desk audits.
Medical records reviews.
Claims reviews.
Data mining. 8.076.2.D. The Department, HHS, investigative entities, the MFCU, or their designees has the right to audit and confirm any information submitted by the Provider to the Medical Assistance program. The Provider shall furnish information about submitted claims, claim documentation records, and original source documentation including, but not limited to, provider and patient signatures; medical, accounting, or financial records; or any other relevant information upon request. 8.076.2.E. A written request to review records shall be provided to the Provider. This request shall include clearly defined due dates for submitting requested records, and the procedures for requesting an extension of time to submit the requested records. This request shall include the option of providing paper copies of records, electronic copies of records in a format that is compatible with the Department’s or its designee’s systems, or an inspection or reproduction of the records by the Department or its designees at the Provider’s site. Medical records requested for review shall be provided to the Department at the expense of the Provider. The Provider shall submit or produce the requested materials within forty-five (45) calendar days unless:
The review is based on quality of care concerns, in which case the materials shall be submitted within fourteen (14) calendar days of the request;
The request is made during the course of a civil or criminal investigation, in which case the records shall be submitted immediately upon request; or 3. The request is made during the course of an external audit with the state or federal government, in which case the records shall be submitted within the timeframe the external auditors request. 8.076.2.F. Records received by the Department after the forty-five (45) calendar day deadline may be considered in the review at the Department’s discretion. The written request for an extension to submit records must be received by the Department within fifteen (15) calendar days from the date of the Department’s request. Telephone requests shall not be accepted. The request shall specify the additional time requested and the circumstances present that require an extension of time. 8.076.2.G. Any claims submitted for which documentation is not received within the time limits specified in this section shall be considered an Overpayment subject to recovery regardless of whether goods or services have been provided. This subsection does not apply to audits conducted by the recovery audit contractor. 8.076.2.H. A Provider subject to a review or audit may request an interview in person or by telephone with the Department or its designees before the final written post-review correspondence is released. The request for an interview must be in writing, specify whether an in person or telephone interview is being requested, and must be received by the Department within ten (10) calendar days from the date of the Department’s request for records. During this interview, the Provider may discuss the preliminary findings of the review or audit, what documentation the Provider may use to refute the findings, and the next steps in the review or audit process. The request for an interview described in this subsection does not apply to audits conducted by the recovery audit contractor. 8.076.2.I. For all post-payment reviews, the Provider shall receive a letter identifying the Overpayment demand or notice of no repayments. This notice shall include the procedures for requesting an informal reconsideration or an appeal. The notice requirements described in this subsection do not apply to audits conducted by the recovery audit contractor. 8.076.2.J. The staff of the Department, HHS, investigative entities, the MFCU, or their designees may photocopy or otherwise duplicate any paper or electronic document, chart, policy, or other record relating to medical care or services provided, charges to or payments made by clients, or goods or services provided for which a claim is submitted. The use of duplicating equipment on the Provider’s premises shall be allowed to the extent that such use results in minimal disruption of the Provider’s business. If such use of duplicating equipment will cause more than minimal disruption of business, the Provider shall notify the Department in writing or by telephone, and the Department shall attempt to resolve the issue with the Provider or make other arrangements. 8.076.2.K. Providers who maintain records to substantiate their claims for reimbursement in another entity’s records including, but not limited to, a nursing facility, adult day care center, or hospital, are still subject to the requirements set forth at Section 8.076.2.E. 8.076.2.L. The Department may delegate compliance monitoring activities to its designees. 8.076.2.M. Nothing in Section 8.076 shall be construed as limiting the right of the Department to conduct quality improvement activities in accordance with the provisions of Section 8.079. 8.076.2.N. Nothing in Section 8.076 shall be construed as limiting the right of the Department to conduct emergency site visits when the Department has concerns about client safety, quality of care, fraud, abuse, or Provider financial failure.

8.076.3 RECOVERY OF OVERPAYMENTS 8.076.3.A. Overpayments are subject to recovery by the Department or its designees. 8.076.3.B. Any identified Overpayment shall be recoverable from the Provider following exhaustion of any informal reconsideration and appeal pursuant to 8.050.

Overpayments and/or other indebtedness to the state are recoverable through a repayment agreement with the Provider, by offsetting the amount owed against current and future claims of the Provider, through litigation, or by any other appropriate action within the Department's legal

authority.

The offset rate shall be 100% of the total amount owed to be withheld from subsequent payments until the entire amount owed is recovered. The Overpayment offset rate may be reduced if the Provider shows good cause that withholding payment at the established rate will result in undue hardship. 3 In cases where sufficient records are not available to the reviewer or auditor, the recovery may be determined through a sampling of records so long as the sampling and any extrapolation are reasonably valid from a statistical standpoint and is in accordance with generally accepted auditing standards. 8.076.3.C. Self-Disclosure of Provider Identified Overpayments 1. If a Provider has received an Overpayment, the Provider is required to report and return the Overpayment within sixty (60) days of identification.
Identification of an Overpayment occurs when the Provider has determined that it has received an Overpayment and quantified the amount of the Overpayment.
Reporting an Overpayment must be made in writing and at a minimum contain the following information:

a) Provider National Provider Identification (NPI);

b) Provider Medicaid Identification Number;

c) Provider contact information (name, phone number, address and email address);

d) Claims affected for each service location; and e) Basis for the Overpayment determination.

Failure to report and return the Overpayment within sixty (60) days of identification shall result in the Department recovering the Overpayment plus statutory interest in accordance with Section 8.076.3.C.
Self-disclosure of Provider-identified Overpayments are not an Adverse Action as defined in Section 8.050, and are not subject to an appeal.

8.076.4 SUSPENSION OF PAYMENTS IN CASES OF A CREDIBLE

ALLEGATION OF FRAUD 8.076.4.A. Payments to a Provider will be suspended, in whole or in part, upon a determination of a credible allegation of fraud for which an investigation is pending unless there is good cause to not suspend payments or to suspend payment only in part.

An allegation of fraud is considered credible if the allegation has evidence of reliability after a review of the allegation, facts and evidence.
A determination that there is good cause to not suspend payments or to suspend payment only in part will be made in accordance with the provisions in 42 C.F.R. § 455.23(e)-(f). 8.076.4.B. A Provider shall be notified of a suspension of payments, in whole or in

part, by a notice of Adverse Action. 8.076.4.C. A Provider shall be granted appeal rights in accordance with Section 8.050. 8.076.4.D. Payments may be suspended without first notifying the Provider of the intention to withhold such payments. Notice of suspension of payments shall be sent to the Provider within the following timeframes:

Within five (5) calendar days of taking such action.
Within thirty (30) days if requested by law enforcement in writing to delay sending the notice. Requests for delay notice may be renewed in writing twice, not to exceed ninety (90) days. 8.076.4.E. The notice shall include:
A statement that payments are being suspended in accordance with this provision and 42 C.F.R. § 455.23;
The general allegations as to the nature of the suspension of payments action;
A statement that the suspension of payments is for a temporary period, and the circumstances under which suspension of payments will be terminated;
Which type or types of claims are subject to the suspension of payments, when appropriate;
A statement that the Provider may submit written evidence showing why the suspension of payments should not be implemented for consideration by the Department; and 6. The right to appeal as described in Section 8.050. 8.076.4.F. A suspension of payment action under Section 8.076.4 shall cease if the Department or prosecuting authorities determine that there is insufficient evidence of fraud or false representation by the Provider or if legal proceedings related to the alleged fraud are complete.

8.076.5 DENIAL, TERMINATION AND/OR NONRENEWAL OF PROVIDER

AGREEMENTS 8.076.5.A. The Department may deny an application for a Provider agreement, terminate or not renew a Provider agreement for Good Cause, as defined at

Section 8.076.1.7. 8.076.5.B. A potential Provider shall be notified of the Department's decision to deny an application for a Provider agreement by a notice of Adverse Action. 8.076.5.C. A Provider shall be notified of the Department's decision to terminate or not renew a Provider agreement by a notice of Adverse Action. Termination and/or nonrenewal shall not be effective sooner than thirty (30) calendar days from the date of the notice except as provided at Section 8.076.5.D, where notice will be provided within five (5) calendar days of taking such action. 8.076.5.D. Provider agreements may be terminated without prior notice if:

The Provider has been convicted of fraud or convicted of a crime related to the Provider’s involvement in Medicare, Medicaid, or any other federally funded program;
The Provider has been found to have made a false representation;
The termination is imperatively necessary for the preservation of the public health, safety, or welfare and observance of the requirements of notice would be contrary to the public interest. Within five (5) business days of the emergency termination, the Provider shall receive a notice of Adverse Action;
The Provider has been excluded by the OIG, or Medicare has terminated its Provider agreement or revoked the Provider’s billing privileges. 8.076.5.E. Providers who had their Provider agreement terminated for Good Cause under this Section must apply for reinstatement in the Medical Assistance program prior to filing an application for enrollment. In order to apply for reinstatement, the Provider-applicant must send a written request to the Department that includes information that provides reasonable assurances that the actions that were the basis for termination have not reoccurred and will not recur in the future. After reviewing the written request, the Department will notify the provider of whether the provider is eligible for reinstatement or if the reinstatement has been denied, If the reinstatement has been denied the provider has the right to appeal in accordance with Section 8.050.

8.076.6 REQUEST FOR WRITTEN RESPONSE 8.076.6.A. The Department may request a written response from any Provider who fails to comply with the rules, manuals, bulletins, other guidance issued by the Department, state board or the Department’s fiscal agent, or from any Provider whose activities endanger the health, safety, or welfare of clients. 1 The request by the Department will be made in writing and contain specific information on the Provider’s failed compliance. 2 The Provider must provide a written response within thirty (30) calendar days of the request addressing each identified area of failed compliance and either describe how the Provider will come into and ensure future compliance, or provide an explanation and specific reason why the Provider disagrees with the Department’s finding of failed compliance.

The Department will review the written response to determine if it addresses the identified areas of failed compliance or provides an acceptable explanation of why the Department’s findings were incorrect.

The Department will notify the Provider of its determination within thirty (30) calendar days of the receipt of the response. 8.076.6.B Once the Department has requested a written response, the Department may take the following actions until it determines that the Provider has come into compliance:

Conduct a prospective review to ensure compliance with rules in accordance with Section 8.076.2.
Prohibit the provider from accepting new referrals or receiving reimbursement for services provided under new referrals for Medicaid 8.076.7 FALSE CLAIMS ACT AND WHISTLEBLOWER PROTECTIONS COMPLIANCE 8.076.7.A. If an entity is reimbursed at least $5,000,000 per year, as a condition of reimbursement the entity must maintain documentation:
Establishing written policies for all employees of the entity (including management), and of any contractor or agent of the entity, that provide detailed information about the False Claims Act established 31 U.S.C. §§ 3729-3733; administrative remedies for false claims and statements as provided in 31 U.S.C. §§ 3801-3812; state laws pertaining to civil or criminal penalties for false claims and statements; and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse;
Detailing provisions regarding the entity’s policies and procedures for detecting and preventing fraud, waste, and abuse; and 3. Of the employee handbook for the entity, including a specific discussion of the laws described in subparagraph (1), the rights of employees to be protected as whistleblowers, and the entity’s policies and procedures for detecting and preventing fraud, waste and abuse. 8.076.7.B. In order to ensure compliance with the provisions of Section 8.076.7.A, the entity must comply with written requests for this information within thirty (30) calendar days.

8.079 QUALITY IMPROVEMENT

8.079.1 DEFINITIONS

Incentive payment means an annual payment made to PIHP contractors based on performance measures agreed upon by the Department and the contracted entity. The criteria for the incentive payment must meet all state and federal statutes and regulations.

Managed Care Entity means, for purposes of Section 8.079, any person, public or private institution, agency or business concern with which the Department does business pursuant to a capitated reimbursement contract.

Prepaid inpatient health plan (PIHP) means an entity that- (1) Provides medical services to enrollees under contract with the State agency, and on the basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates; (2)

Provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract.

Provider means a Provider, as defined in 8.050.1.4.

8.079.2 EXTERNAL QUALITY REVIEW (EQR)

Providers and Managed Care Entities shall comply with annual EQR activities. EQR may include, but is not limited to the following activities:

Performance improvement projects.
Performance improvement project validation.
Performance improvement measurement.
Performance improvement measurement validation.
Consumer satisfaction survey.
Medical record review.
Review of individual cases.
PCPP credentialing and recredentialing.

8.079.3 MONITORING AND REVIEW 8.079.3.A. All Providers and Managed Care Entities shall comply with the efforts of the Department, its designees, any investigative entity, or the Medicaid Fraud Control Unit to monitor performance through site visits, reviews, desk audits, emergency site visits, profiling, compliance reporting requirements and other quality and program integrity review activities. Monitoring activities shall be conducted for the purpose of determining compliance with state and federal requirements, contracts or Provider agreements, Medicaid service provision and billing procedures, and/or Medicaid Bulletins and Provider Manuals.

Managed Care Entities - The Managed Care Entity shall be subject to annual site visits to determine compliance with established standards. The annual site visit process shall consist of a desk audit component and an onsite visit. The Managed Care Entities and/or its subcontractors shall, upon request, provide and make available staff to assist in the audit or inspection efforts and provide adequate space on the premises to reasonably accommodate review personnel.
Providers – Providers shall be subject to the compliance monitoring provisions of 8.076.2.
The Department reserves the right to deem other State agencies or private accreditation organizations approved reviews to constitute compliance with specific contractual obligations or regulatory 4. The Department may delegate monitoring activities.
The Department may conduct emergency site visits when the Department has concerns about patient safety, quality of medical care, fraud, abuse, or Provider financial failure.

8.079.4 QUALITY BASED INCENTIVE PAYMENTS FOR PIHP CONTRACTS

Performance measures eligible for incentive payment may include but are not limited to measures of quality and effectiveness of care, including process and outcomes; client satisfaction; use of services; and care outcomes; with the intent to provide incentive for delivering the highest quality care with the best outcomes at the best value for Colorado Medicaid clients enrolled in PIHP-contracted managed care plans. Measures shall be credible, comparable and actionable for the purpose of the incentive program. 8.079.4.A Such performance measures may include but are not limited to:

Healthcare Effectiveness Data and Information Set (HEDIS) measures;
Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures;
In-patient hospitalizations for ambulatory sensitive conditions such as: urinary tract infections, immunization preventable disease in pediatric clients, asthma, etc.
Hospital readmissions within 7, 30 and 90 days post-discharge;
Behavioral Health Organizations’ penetration rates for both children and adults by region;
Statewide Behavioral Health Organization measures;
Other measures related to quality of care, use of services and care outcomes. 8.079.4.B. Additionally, incentive payments may be made to PIHPs to provide for an increase in the fee paid to the contractor in an reasonable amount calculated to cover the costs of collecting, maintaining and coordinating medical records of recipients among rendering providers through an electronic medical records health information exchange system, provided that the system meets all applicable state and federal statutes and regulations, and is used to measure and enhance the quality of care and care outcomes in accordance with the criteria listed in this rule for the Medicaid clients served. 8.079.4.C. In order to be eligible for any incentive payments, PIHP contractors must meet minimum performance measure criteria determined by the Department.

Minimum performance criteria shall include minimum national percentile benchmarks for specific measures, and/or alternate minimum standards for non- HEDIS measures, as determined by the Department and agreed upon by the contractor at the outset of the contract period. 8.079.4.D. Performance measures and minimum performance criteria shall be agreed upon at the outset of the contract period and may vary from PIHP agreement to PIHP agreement at the discretion of the Department to reflect differences in contract type or model (e.g., BHO vs. Health Plan, network vs. group/staff system, risk vs. non-risk), as well as targeted performance improvement or maintenance objectives. 8.079.4.E. Provision of any incentive payment is contingent upon the continuing availability of state funds for the purpose thereof. 8.080 MEDICAID ELIGIBILITY QUALITY CONTROL [moved to 10 CCR 2505-5, Executive Director of Health Care Policy and Financing Rules, Section 1.020.10.1 (2022)]

8.090 MEDICAID CLAIMS PROCESSING AND THIRD PARTY LIABILITY QUALITY

CONTROL

8.091 PURPOSE 10 Medicaid Quality Control is a unit within the Medical Assistance Division of the Colorado Department of Social Services. This unit is independent of and functionally different (as described below) from the Quality Control Unit described in Colorado State Department of Social Services Staff Manual 3 Section 3.870.11 et seq. 11 Medicaid Quality Control is a federally required ongoing review conducted by the Division of Medical Assistance to determine the extent to which third party liability or claims processed by the fiscal agent contain errors. 12 The Medicaid Quality Control system is a method of State administration that is intended to reduce the incidence of claims processing and third party liability errors. This is accomplished by means of three processes.

A. A continuous review of the Medicaid claims processed for a statistically reliable statewide sample of cases;

B. The periodic assembly and analysis of findings to determine the incidence of errors; and C. The taking of corrective action to reduce the level of error, and, if necessary, bring such error rate within established tolerance.

8.090.2 METHOD 20 The Medicaid Quality Control Review covers:

A. The manner in which county departments identified and then documented recipient's third party medical insurance benefits and coverage;

B. Accuracy of information provided by client;

C. Accuracy of fiscal agent action with respect to claims processing and third party liability for paid claims.

D. Medically necessary transportation authorized by the State or county departments.

E. Medical certification for recipients in long term care facilities. 21 Errors are of two types:

A. Third party liability errors - when there is a third party(ies) which is available to pay for medical services for eligible recipients, but the party(ies) was not known or fully utilized prior to claims payments.

B. Claims processing errors - when claims were paid which did not contain all necessary information, which did not meet the service or payment amount restrictions, or which did not reflect liability for payment correctly. 22 Third party liability errors are reported to the county departments by the Quality Control Unit via the Third Party Recovery Unit, Division of Medical Assistance, Colorado State Department of Social Services with requests for the county's report of corrective action. 23 Claims processing errors are reported to the appropriate section within the Medical Assistance Division and/or fiscal agent with requests for corrective action. 24 At periodic intervals, the findings of Medicaid Quality Control are assembled, tabulated, and summarized for use by the State Department of Social Services to meet federal reporting requirements. 8.095 Telemedicine 8.095.1.A DEFINITIONS 1. Electronic Consultation (eConsult) means an asynchronous dialogue initiated by a Treating Practitioner seeking a Consulting Practitioner’s expert opinion without a face-to-face member encounter with the Consulting Practitioner.

Electronic Consultation Platform (eConsult Platform) means a web-based and application-based electronic system authorized by the Department that allows for an asynchronous exchange between a Treating Practitioner and a Consulting Practitioner to securely share health information and discuss member care. An eConsult Platform may be either:

a. State Platform: A platform contracted with the Department as the state’s eConsult Platform.

b. Approved Platform: Any platform other than the State Platform that meets the criteria identified by the Department.

Electronic Health Entity (eHealth Entity) means a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty. eHealth entities:

a. Cannot be Primary Care Medical Providers;

b. Can be either in-state or out-of-state.

Facilitated Visit means a Telemedicine visit where the rendering provider is at a distant site and the member is physically present with a support staff team member who can assist the provider with in-person activities.
HIPAA means the federal “Health Insurance Portability and Accountability Act of 1996”, PUB. L. 104-191, as amended.
Primary Care Medical Provider (PCMP) means an individual physician, advanced practice nurse or physician assistant, who contracts with a Regional Accountable Entity (RAE) in the Accountable Care Collaborative (ACC), with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology.
Consulting Practitioner means a provider who has education, training, or qualifications in a specialty field other than primary care.
Telemedicine means the delivery of medical and health-care services and any diagnosis, consultation, or treatment using interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission).
Treating Practitioner means a member’s treating physician or other qualified health care practitioner who is a primary care provider contracted with a Regional Accountable Entity to participate in the Accountable Care Collaborative as a Network Provider. Beginning July 1, 2025, a Treating Practitioner may also be a member’s treating provider who has education, training, or qualification in a specialty field other than primary care and is a medical doctor (MD), doctor of osteopathy (DO), nurse practitioner (NP), or physician assistant (PA).

8.095.2 CLIENT ELIGIBILITY 8.095.2.A. All Colorado Medicaid clients are eligible for medical and behavioral services delivered by telemedicine.

8.095.3 PROVIDER ELIGIBILITY 8.095.3.A. Any licensed provider enrolled with Colorado Medicaid is eligible to provide telemedicine services within the scope of the provider’s practice. 8.095.3.B. Providers that meet the definition of an eHealth Entity shall enroll as the eHealth specialty.

8.095.4 COVERED SERVICES 8.095.4.A. Covered Telemedicine services must:

Meet the same standard of care as in-person care;
Be compliant with state and federal regulations regarding care coordination;
Be services the Department has approved for delivery through Telemedicine;
Be within the provider’s scope of practice and for procedure codes the provider is already eligible to bill;
Be provided only where contact with the provider was initiated by the member for the services rendered; and 6. Be provided only after the member’s consent, either verbal or written, to receive telemedicine services is documented. 8.095.4.B. eHealth Entities shall only provide:
Covered Telemedicine services, including Facilitated Visits. 8.095.4.C. Beginning February 1, 2024, a Treating Practitioner may request an eConsult with a Consulting Practitioner. eConsult services must:
Be requested by the Treating Practitioner through an eConsult Platform;
Be responded to by the Consulting Practitioner through an eConsult Platform;

a. The Consulting Practitioner may send the eConsult to another Consulting Practitioner in a different specialty practice through an eConsult Platform, when clinically appropriate.

b. For eConsults between specialty providers, the Consulting Practitioner must be in a different specialty field than the Treating Practitioner who requested the eConsult.

The Consulting Practitioner must, when clinically appropriate, provide clinical guidance pertaining to the eConsult electronically to the requesting Treating Practitioner through an eConsult Platform; and, 4. All dialogue between the Treating Practitioner and the Consulting Practitioner pertaining to an eConsult must be through an eConsult Platform.

8.095.5 PRIOR AUTHORIZATION REQUIREMENTS 8.095.5.A. The use of Telemedicine does not change prior authorization requirements for the underlying services provided.

8.095.6 RECORDKEEPING. 8.095.6.A. eHealth Entities must maintain a Release of Information in compliance with current HIPAA standards to facilitate communication with the member’s P C M P.

8.095.7 REIMBURSEMENT 8.095.7.A Pursuant to C.R.S. § 25.5-5-320(2) (2022), the reimbursement rate for a Telemedicine service shall, as a minimum, be set at the same rate as the Colorado Medicaid rate for a comparable in-person service. 8.095.7.B. eConsults 1. eConsults are reimbursed after the eConsult is closed by the requesting Treating Practitioner and the following conditions are met:

a. The eConsult is conducted instead of face-to-face in-person visit referral to a Consulting Practitioner;

b. The eConsult is provided to the Treating Practitioner by the Consulting Practitioner through an eConsult Platform, with clinical guidance where appropriate; and, c. The eConsult is closed after the Treating Practitioner reviews the care plan provided by the Consulting Practitioner.

Treating Practitioners may directly submit a procedure code specific feefor-service claim for reimbursement.
Consulting Practitioners who utilize an Approved Platform may directly submit a procedure code specific fee-for-service claim for reimbursement for all closed eConsults that meet the criteria in Section 8.095.7.B.1.
Consulting Practitioners who utilize the State Platform must only be reimbursed through the State Platform for all closed eConsults that meet the criteria in Section 8.095.7.B.1.
eConsults must be delivered through an eConsult Platform to be eligible for reimbursement.

8.095.8 NON-COVERED SERVICES 8.095.8.A Services not otherwise covered by Colorado Medicaid are not covered when delivered through Telemedicine. 8.095.8.B eConsults that are not delivered, and responded to, through an eConsult Platform.

8.096 TELEHEALTH REMOTE MONITORING (REMOTE PATIENT MONITORING)

8.096.1.A DEFINITIONS

Telehealth Remote Monitoring means the ongoing remote assessment and monitoring of clinical data through technological equipment in order to detect changes in a member’s clinical status, which allows health care providers to intervene before a health condition exacerbates and requires emergency intervention or inpatient hospitalization.

8.096.2 MEMBER ELIGIBILITY 8.096.2.A. A member is eligible if the member’s health care provider determines that Remote Patient Monitoring (RPM) is medically necessary based on the member’s medical condition or status and that RPM would likely prevent the member’s admission or readmission to a hospital, Emergency Department, nursing facility, or other clinical setting and have one of the following conditions:

Diabetes;
COPD;
Heart Failure;
Asthma;
Pneumonia; or 6. Members who are pregnant and carrying a high-risk pregnancy. 8.096.2.B. The member is cognitively and physically capable of operating the telehealth remote monitoring device or equipment or the member has a caregiver who is able and willing to assist with the telehealth remote monitoring device or equipment. 8.096.2.C. The member resides in a setting that is suitable for telehealth remote monitoring and does not have health care staff on site.

8.096.3 PROVIDER ELIGIBILITY 8.096.3.A. Remote Patient Monitoring services must be rendered and supervised in accordance with the scope of practice for the enrolled provider. 8.096.3.B. Remote Patient Monitoring must be performed by one of the following licensed health care professionals:

Physician (MD/DO);
Podiatrist;
Advanced Practice Registered Nurse (APRN);
Physician Assistant (PA);
Respiratory Therapist;
Pharmacist; or 7. Licensed health care professional working under the supervision of a medical director. 8.096.3.C. Rural Health Clinics (refer to section 8.740.7.E) for reimbursement RHC 8.740.7.E 8.096.4 COVERED SERVICES 8.096.4.A. Covered Remote Patient Monitoring services include the ongoing remote assessment and monitoring of clinical data through technological equipment in order to detect changes in a member’s clinical status. 8.096.4.B. Criteria for the technological equipment required for Remote Patient Monitoring is as follows:
FDA-certified or UL listed, and used according to the manufacturer’s instructions;
Maintained in good repair and free from safety hazards;
Sanitized before utilization in the member’s home per the manufacturer’s instructions;
HIPAA requires healthcare software to meet the security standards related to patient health information. All healthcare software companies and service providers must follow HIPAA requirements to protect patient data confidentiality, integrity, and availability.
Equipment must be capable of automatically uploading data without the member needing to manually self-report or self-record the data.

8.096.5 PRIOR AUTHORIZATION REQUIREMENTS 8.096.5.A. Remote Patient Monitoring does not require prior authorization.

Editor's Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first

section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule’s current version page. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.100 MEDICAL ASSISTANCE - SECTION 8.100 Eligibility, Provider Screening, NPI {#sec-10-ccr-2505-10-8.100 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.100}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE - SECTION 8.100 ELIGIBILITY, PROVIDER SCREENING, NPI 10 CCR 2505-10 8.100 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

8.100 MEDICAL ASSISTANCE ELIGIBILITY 8.100.1 Definitions 300% Institutionalized Special Income Group is a Medical Assistance category that provides Long-Term Care Services to aged or disabled individuals. 1619b is section 1619b of the Social Security Act which allows individuals who are eligible for Supplemental Security Income (SSI) to continue to be eligible for Medical Assistance coverage after they return to work.

AB - Aid to the Blind is a program which provides financial assistance to low-income blind persons.

ABD - Aged, Blind and Disabled Medical Assistance is a group of Medical Assistance categories for individuals that have been deemed to be aged, blind, or disabled by the Social Security Administration or the Department.

Achieving a Better Life Experience (ABLE) accounts – Special savings accounts that are set up by (or for) certain individuals with disabilities in a qualified ABLE program that are exempt for eligibility. They can be established by any state’s qualified ABLE Program. Colorado’s ABLE program is administered by the Department of Higher Education.

Adjusted Gross Income (AGI)-means “ gross income”, as defined in federal tax rules, minus certain adjustments prescribed in the federal tax rules to derive the “Adjusted Gross Income” line on the tax return. These adjustments from gross income are taken before the taxpayer takes his or her Schedule A deductions or Standard Deduction.

Adult MAGI Medical Assistance Group provides Medical Assistance to eligible adults from the age of 19 through the end of the month that the individual turns 65, who do not receive or who are ineligible for Medicare.

AND - Aid to Needy Disabled is a program which provides financial assistance to lowincome persons over age 18 who have a total disability which is expected to last six months or longer and prevents them from working.

AFDC - Aid to Families with Dependent Children is the Title IV federal assistance program in effect from 1935 to 1997 which was administered by the United States Department of Health and Human Services. This program provided financial assistance to children whose families had low or no income.

AP-5615 is the form used to determine the patient payment for clients in nursing facilities receiving Long Term Care.

Alien is a person who was not born in the United States and who is not a naturalized citizen.

Ambulatory Services is any medical care delivered on an outpatient basis.

Annuity is an investment vehicle whereby an individual establishes a right to receive fixed periodic payments, either for life or a term of years.

Applicant is an individual who is seeking an eligibility determination for Medical Assistance through the submission of an application.

Application Date is the date the application is received and date-stamped by the eligibility site or the date the application was received and date-stamped by an Application Assistance site or Presumptive Eligibility site. In the absence of a datestamp, the application date is the date that the application was signed by the client.

Application for Public Assistance is the designated application used to determine eligibility for financial assistance. It can also be used to determine eligibility for Medical Blindness is defined in this volume as the total lack of vision or vision in the better eye of 20/200 or less with the use of a correcting lens and/or tunnel vision to the extent that the field of vision is no greater than 20 degrees.

Burial Spaces are burial plots, gravesites, crypts, mausoleums, urns, niches and other customary and traditional repositories for the deceased's bodily remains provided such spaces are owned by the individual or are held for his or her use, including necessary and reasonable improvements or additions to or upon such burial spaces such as: vaults, headstones, markers, plaques, or burial containers and arrangements for opening and closing the gravesite for burial of the deceased.

Burial Trusts are irrevocable pre-need funeral agreements with a funeral director or other entity to meet the expenses associated with burial for Medical Assistance applicants/recipients. The agreement can include burial spaces as well as the services of the funeral director.

Caretaker Relative is a person who is related to the dependent child or any adult with whom the dependent child is living and who assumes responsibility for the dependent child’s care.

Case Management Services are services provided by community mental health centers, clinics, community centered boards, and EPSDT case managers to assist in providing services to Medical Assistance clients in gaining access to needed medical, social, educational and other services.

Cash Surrender Value is the amount the insurer will pay to the owner upon cancellation of the policy before the death of the insured or before maturity of the policy.

Categorically Eligible means persons who are eligible for Medical Assistance due to their eligibility for one or more Federal categories of public assistance.

CBMS - Colorado Benefits Management System is the computer system that determines an applicant’s eligibility for public assistance in the state of Colorado.

CDHS -Colorado Department of Human Services is the state department responsible for administering the social service and financial assistance programs for Colorado.

Children MAGI Medical Assistance group provides Medical Assistance coverage to tax dependents or otherwise eligible applicants through the end of the month that the individual turns 19 years old.

Child Support Services is a CDHS program that assures that all children receive financial and medical support from each parent. This is accomplished by locating each parent, establishing paternity and support obligations, and enforcing those obligations.

Citizen is a person who was born in the United States or who has been naturalized.

Client is a person who is eligible for the Medical Assistance Program. “Client” is used interchangeably with “recipient” when the person is eligible for the program.

CMS - Centers for Medicare and Medicaid Services is the Federal agency within the US Department of Health and Human Services that partners with the states to administer Medicaid and CHP+ via State Plans in effect for each State. Colorado is in Region VIII.

CHP+ - Child Health Plan Plus is low-cost health insurance for Colorado's uninsured children and pregnant women. CHP+ is public health insurance for children and pregnant women who earn too much to qualify for The Medical Assistance Program, but cannot afford private health insurance.

COLA - Cost of Living Adjustment is an annual increase in the dollar value of benefits made automatically by the United States Department of Health and Human Services or the state in OASDI, SSI and OAP cases to account for rises in the cost of living due to inflation.

Colorado State Plan is a written statement which describes the purpose, nature, and scope of the Colorado’s Medical Assistance Program. The Plan is submitted to the CMS and assures that the program is administered consistently within specific requirements set forth in both the Social Security Act and the Code of Federal Regulations (CFR) in order for a state to be eligible for Federal Financial Participation (FFP).

Common Law Marriage is legally recognized as a marriage in the State of Colorado under certain circumstances even though no legally recognized marriage ceremony is performed or civil marriage contract is executed. Individuals declaring or publicly holding themselves out as a married couple through verbal or written methods may be recognized as legally married under state law. C.R.S. § 14-2-104(3).

Community Centered Boards are private non-profit organizations designated in statute as the single entry point into the long-term service and support system for persons with developmental disabilities.

Community Spouse is the spouse of an institutionalized spouse.

Community Spouse Resource Allowance is the amount of resources that the Medical Assistance regulations permit the spouse staying at home to retain.

Complete Application means an application in which all questions have been answered, which is signed, and for which all required verifications have been submitted.

The Department is defined in this volume as the Colorado Department of Health Care Policy and Financing which is responsible for administering the Colorado Medical Assistance Program and Child Health Plan Plus programs as well as other State-funded health care programs.

Dependent Child is a child who lives with a parent, legal guardian, caretaker relative or foster parent and is under the age of 18, or, is age 18 and a full-time student, and expected to graduate by age 19.

Dependent Relative for purposes of this rule is defined as one who is claimed as a dependent by an applicant for federal income tax purposes.

Difficulty of Care Payments is a payment to an applicant or member as compensation for providing live-in home care to an individual who qualifies for foster care or Home and Community Based Services (HCBS) waiver program and lives in the home of the care recipient. This additional care must be required due to a physical, mental, or emotional handicap.

Disability means the inability to do any substantial gainful activity (or, in the case of a child, having marked and severe functional limitations) by reason of a medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of l2 months or more.

Dual Eligible clients are Medicare beneficiaries who are also eligible for Medical Earned Income is defined for purposes of this volume as any compensation from participation in a business, including wages, salary, tips, commissions and bonuses.

Earned Income Disregards are the allowable deductions and exclusions subtracted from the gross earnings. Income disregards vary in amount and type, depending on the category of assistance.

Electronic Data Source is an interface established with a federal or state agency, commercial entity, or other data sources obtained through data sharing agreements to verify data used in determining eligibility. The active interfaces are identified in the Department’s verification plan submitted to CMS.

Eligibility Site is defined in this volume as a location outside of the Department that has been deemed by the Department as eligible to accept applications and determine eligibility for applicants.

Employed means that an individual has earned income and is working part time, full time or is self-employed, and has proof of employment. Volunteer or in-kind work is not considered employment.

EPSDT- Early Periodic Screening, Diagnosis and Treatment is the child health component of the Medical Assistance Program. It is required in every state and is designed to improve the health of low-income children by financing appropriate, medically necessary services and providing outreach and case management services for all eligible individuals.

Equity Value is the fair market value of land or other asset less any encumbrances.

Ex Parte Review is an administrative review of eligibility during a redetermination period in lieu of performing a redetermination from the client. This administrative review is performed by verifying current information obtained from another current aid program.

Face Value of a Life Insurance Policy is the basic death benefit of the policy exclusive of dividend additions or additional amounts payable because of accidental death or other special provisions.

Fair Market Value is the average price a similar property will sell for on the open market to a private individual in the particular geographic area involved. Also, the price at which the property would change hands between a willing buyer and a willing seller, neither being under any pressure to buy or to sell and both having reasonable knowledge of relevant facts.

FBR - The Federal Benefit Rate is the monthly Supplemental Security Income payment amount for a single individual or a couple. The FBR is used by the Aged, Blind and Disabled Medical Assistance Programs as the eligibility income limits.

FFP - Federal Financial Participation as defined in this volume is the amount or percentage of funds provided by the Federal Government to administer the Colorado FPL - Federal Poverty Level is a simplified version of the federal poverty thresholds used to determine financial eligibility for assistance programs. The thresholds are issued each year in the Federal Register by the Department of Health and Human Services (HHS).

Good Cause is the client’s justification for needing additional time due to extenuating circumstances, usually used when extending deadlines for submittal of required Good Cause for Child Support is the specific process and criteria that can be applied when a client is refusing to cooperate in the establishment of paternity or establishment and enforcement of a child support order due to extenuating circumstances.

HCBS are Home and Community Based Services are also referred to as “waiver programs”. HCBS provides services beyond those covered by the Medical Assistance Program that enable individuals to remain in a community setting rather than being admitted to a Long-Term Care institution.

In-Kind Income is income a person receives in a form other than money. It may be received in exchange for work or service (earned income) or a non-cash gift or contribution (unearned income).

Inpatient is an individual who has been admitted to a medical institution on recommendation of a physician or dentist and who receives room, board and professional services for 24 hours or longer, or is expected to receive these services for 24 hours or longer.

Institution is an establishment that furnishes, in single or multiple facilities, food, shelter and some treatment or services to four or more persons unrelated to the proprietor.

Institutionalization is the commitment of a patient to a health care facility for treatment.

Institutionalized Individual is a person who is institutionalized in a medical facility, a Long-Term Care institution, or applying for or receiving Home and Community Based Services (HCBS) or the Program of All Inclusive Care for the Elderly (PACE).

Institutionalized Spouse is a Medicaid eligible client who begins a stay in a medical institution or nursing facility on or after September 30, 1989, or is first enrolled as a Medical Assistance client in the Program of All Inclusive Care for the Elderly (PACE) on or after October 10, 1997, or receives Home and Community Based Services (HCBS) on or after July 1, 1999; and is married to a spouse who is not in a medical institution or nursing facility. An institutionalized spouse does not include any such individual who is not likely to be in a medical institution or nursing facility or to receive HCBS or PACE for at least 30 consecutive days. Irrevocable means that the contract, trust, or other arrangement cannot be terminated, and that the funds cannot be used for any purpose other than outlined in the document.

Insurance Affordability Program (IAP) refers to Medicaid, Child Health Plan Plus (CHP+), and premium and cost-sharing assistance for purchasing private health insurance through state insurance marketplace.

Legal Immigrant is an individual who is not a citizen or national and has been permitted to remain in the United States by the United States Citizenship and Immigration Services (USCIS) either temporarily or as an actual or prospective permanent resident or whose extended physical presence in the United States is known to and allowed by USCIS.

Legal Immigrant Prenatal is a medical program that provides medical coverage for pregnant legal immigrants who have been legal immigrants for less than five years.

Limited Disability for the Medicaid Buy-In Program for Working Adults with Disabilities means that an individual has a disability that would meet the definition of disability under SSA without regard to Substantial Gainful Activity (SGA).

Long-Term Care is Medical Assistance services that provides nursing-home care, homehealth care, personal or adult day care for individuals aged at least 65 years or with a chronic or disabling condition.

Long-Term Care Institution means class I nursing facilities, intermediate care facilities for intellectual and developmental disabilities (ICF/IDD) and swing bed facilities. Long- Term Care institutions can include hospitals.

Long-Term Services and Supports Level of Care Eligibility Determination is the determination using the state prescribed assessment instrument that an individual does or does not meet institutional level of care.

Long-Term Services and Supports Level of Care Eligibility Determination Screen is a comprehensive evaluation with an individual seeking services and appropriate collaterals (such as family members, friends, and/or caregivers) to determine the individual’s eligibility for long-term services and supports based on their need for institutional level of care as determined using the state prescribed assessment instrument.

Managed care system is a system for providing health care services which integrates both the delivery and the financing of health care services in an attempt to provide access to medical services while containing the cost and use of medical care.

Medical Assistance is defined as all medical programs administered by the Department of Health Care Policy and Financing. Medical Assistance/Medicaid is the joint state/federal health benefits program for individuals and families with low income and resources. It is an entitlement program that is jointly funded by the states and federal government and administered by the state. This program provides for payment of all or

part of the cost of care for medical services.

Medical Assistance Required Household is defined for purposes of this volume as all parents or caretaker relatives, spouses, and dependent children residing in the same home.

Minimal Verification is defined in this volume as the minimum amount of information needed to process an application for benefits. No other verification can be requested from clients unless the information provided is questionable or inconsistent.

Minimum Essential Coverage is the type of coverage one must maintain to be in compliance with the Affordable Care Act in order to avoid paying a penalty for being uninsured. Minimum essential coverage may include but not limited to: Medicaid; CHP+; private health plans through Connect for Health Colorado; Medicare; job-based insurance, and certain other coverage.

MMMNA - Minimum Monthly Maintenance Needs Allowance is the calculation used to determine the amount of institutionalized spouse’s income that the community spouse is allowed to retain to meet their monthly living needs.

MAGI - Modified Adjusted Gross Income refers to the methodology by which income and household composition are determined for the MAGI Medical Assistance groups under the Affordable Care Act. These MAGI groups include Parents and Caretaker Relatives, Pregnant Women, Children, and Adults. For a more complete description of the MAGI categories and pursuant rules, please refer to section 8.100.4.

MIA - Monthly Income Allowance is the amount of institutionalized spouse’s income that the community spouse is allowed to retain to meet their monthly living needs.

MSP - Medicare Savings Program is a Medical Assistance Program to assist in the payment of Medicare premium, coinsurance and deductible amounts. There are four groups that are eligible for payment or part-payment of Medicare premiums, coinsurance and deductibles: Qualified Medicare Beneficiaries (QMBs), Specified Low- Income Medicare Beneficiaries (SLIMBs), Qualified Disabled and Working Individuals (QDWIs), and Qualifying Individuals – 1 (QI-1s).

Non-Filer is an individual who neither files a tax return nor is claimed as a tax dependent. For a more complete description of how household composition is determined for the MAGI Medical Assistance groups, please refer to the MAGI household composition section at 8.100.4.E.

Nursing Facility is a facility or distinct part of a facility which is maintained primarily for the care and treatment of inpatients under the direction of a physician. The patients in such a facility require supportive, therapeutic, or compensating services and the availability of a licensed nurse for observation or treatment on a twenty-four-hour basis.

OAP - Old Age Pension is a financial assistance program for low income adults age 60 or older.

OASDI - Old Age, Survivors and Disability Insurance is the official term Social Security uses for Social Security Act Title II benefits including retirement, survivors, and disability.

This does not include SSI payments.

Outpatient is a patient who is not hospitalized overnight but who visits a hospital, clinic, or associated facility for diagnosis or treatment. Is a patient who does not require admittance to a facility to receive medical services.

PACE - Program of All-inclusive Care for the Elderly is a unique, capitated managed care benefit for the frail elderly provided by a not-for-profit or public entity. The PACE program features a comprehensive medical and social service delivery system using an interdisciplinary team approach in an adult day health center that is supplemented by inhome and referral services in accordance with participants' needs.

Parent and Caretaker Relative is a MAGI Medical Assistance group that provides Medical Assistance to adults who are parents or Caretaker Relatives of dependent children.

Patient is an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health, or lessening of illness, disability, or pain.

PEAK – the Colorado Program Eligibility and Application Kit is a web-based portal used to apply for public assistance benefits in the State of Colorado, including Medical PNA - Personal Needs Allowance means moneys received by any person admitted to a nursing care facility or Long-Term Care Institution which are received by said person to purchase necessary clothing, incidentals, or other personal needs items which are not reimbursed by a Federal or state program.

Pregnant Women is a MAGI Medical Assistance group that provides Medical Assistance coverage to pregnant women whose MAGI-based income calculation is less than 195% FPL, including women who are in their 12 months post-partum.

Premium means the monthly amount an individual pays to participate in a Medicaid Buy-In Program.

Provider is any person, public or private institution, agency, or business concern enrolled under the state Medical Assistance program to provide medical care, services, or goods and holding a current valid license or certificate to provide such services or to dispense such goods.

Psychiatric Facility is a facility that is licensed as a residential care facility or hospital and that provides inpatient psychiatric services for individuals under the direction of a licensed physician.

Public Institution means an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

Qualified Hospital Presumptive Eligibility Sites are hospitals that have voluntarily elected to serve as Presumptive Eligibility sites. Qualified Hospital Presumptive Eligibility Sites agree to make determinations in accordance with State policies and assist individuals with completing Medical Assistance applications and understanding documentation requirements.

Questionable is defined as inconsistent or contradictory tangible information, statements, documents, or file records.

Reasonable Compatibility refers to an allowable difference or discrepancy between the income an applicant self attests and the amount of income reported by an electronic data source. For a more complete description of how reasonable compatibility is used to determine an applicant’s financial eligibility for Medical Assistance, please refer to the MAGI Income section at 8.100.4.C Reasonable Explanation refers to the opportunity afforded an applicant to explain a discrepancy between self-attested income and income as reported by an electronic data source, when the difference is above the threshold percentage for reasonable compatibility.

Recipient is any person who has been determined eligible to receive benefits.

Resident is any individual who is living within the state and considers the state as their place of residence. Residents include any unemancipated child whose parent or other person exercising custody lives within the state.

RRB - Railroad Retirement Benefits is a benefit program under Federal law 45 U.S.C. § 231 et seq that became effective in 1935. It provides retirement benefits to retired railroad workers and families from a special fund, which is separate from the Social Security fund.

Secondary School is a school or educational program that provides instruction or training towards a high school diploma or an equivalent degree such as a High School Equivalency Diploma (HSED).

SGA – Substantial Gainful Activity is defined by the Social Security Administration. SGA is the term used to describe a level of work activity and earnings. Work is “substantial” if it involves performance of significant physical or mental activities or a combination of both, which are productive in nature. For work activity to be substantial, it does not need to be performed on a full-time basis. Work activity performed on a part-time basis may also be substantial gainful activity. “Gainful” work activity is work performed for pay or profit; or work of a nature generally performed for pay or profit; or work intended for profit, whether or not a profit is realized.

Single Entry Point Agency means the organization selected to provide case management functions for persons in need of Long-Term Care services within a Single Entry Point District.

Single Streamlined Application or “SSAp” is the general application for health assistance benefits through which applicants will be screened for Medical Assistance programs including Medicaid, CHP+, or premium and cost-sharing assistance for purchasing private health insurance through a state insurance marketplace.

SISC- Supplemental Income Status Codes are system codes used to distinguish the different types of state supplementary benefits (such as OAP) a recipient may receive.

Supplemental Income Status Codes determine the FFP for benefits paid on behalf of groups covered under the Medical Assistance program.

SSA - Social Security Administration is an agency of the United States federal government that administers Social Security, a social insurance program consisting of retirement, disability, and survivors' benefits.

SSI - Supplemental Security Income is a Federal income supplement program funded by general tax revenues (not Social Security taxes) that provides income to aged, blind or disabled individuals with little or no income and resources.

SSI Eligible means an individual who is eligible to receive Supplemental Security Income under Title XVI of the Social Security Act, and may or may not be receiving the monetary payment.

TANF - Temporary Assistance to Needy Families is the Federal assistance program which provides supportive services and federal benefits to families with little or no income or resources. It is the Block Grant that was established under the Personal Responsibility and Work Opportunity Reconciliation Act in Title IV of the Social Security Act.

Tax Dependent is anyone expected to be claimed as a dependent by a Tax-Filer.

Ta x-Filer is an individual, head of household or married couple who is required to and who files a personal income tax return.

Third Party is an individual, institution, corporation, or public or private agency which is or may be liable to pay all or any part of the medical cost of an injury, a disease, or the disability of an applicant for or recipient of Medical Assistance.

Title XIX is the portion of the federal Social Security Act which authorizes a joint federal/state Medicaid program. Title XIX contains federal regulations governing the Medicaid program.

TMA - Transitional Medical Assistance is a Medical Assistance category for families that lost Medical Assistance coverage due to increased earned income or loss of earned income disregards.

Unearned Income is the gross amount received in cash or kind that is not earned from employment or self-employment.

VA - Veterans Affairs is The Department of Veterans Affairs which provides patient care and Federal benefits to veterans and their dependents. 8.100.2 Legal Basis Constitution of Colorado, Article XXIV, Old Age Pensions, section 7, established a health and medical care fund for persons who qualify to receive old age pensions.

Colorado Revised Statutes, Title 25.5, Article 4, Colorado Medical Assistance Act,

section 102, provides for a program of Medical Assistance for individuals and families, whose income and resources are insufficient to meet the costs of necessary medical care and services, to be administered in cooperation with the federal government.

The Social Security Act, Title XIX, Grants to States for Medical Assistance Programs, and the consequent Federal regulations, Title 42, CFR (Code of Federal Regulations),

Chapter IV, Subchapter C, set forth the conditions for states to obtain Federal Financial Participation in Medical Assistance expenditures.

Under the Colorado Medical Assistance Program, the Medicaid program provides coverage of certain groups specified in Title XIX of the Social Security Act. The OAP State Only Medical Assistance Program provides coverage to certain old age pension clients entitled to health and medical care under the Colorado Constitution.

The Department of Health Care Policy and Financing is the single State agency designated to administer the Colorado Medical Assistance Program under Title XIX of the Social Security Act and Colorado statutes. The Office of Medical Assistance of the Department is delegated the duties and responsibilities for administration of the Colorado Medical Assistance Program. 8.100.3. Medical Assistance General Eligibility Requirements 8.100.3.A. Application Requirements 1. The eligibility site shall advise individuals concerning the benefits of the Medical Assistance Program and determine or redetermine eligibility for Medical Assistance in accordance with rules and regulations of the Department. A person who is applying for the Medical Assistance Program or a client who is determined ineligible for the Medical Assistance Program in one category shall be evaluated under all other categories of eligibility. There is no time limit for Medical Assistance coverage as long as the client remains categorically eligible.

If the applicant applied for Medical Assistance on the Single Streamlined Application and was found ineligible, this application shall be reviewed for all other Medical Assistance eligibility programs, the Child Health Plan Plus (CHP+) program and premium and cost-sharing assistance for purchasing private health insurance through the state insurance marketplace.

a. The application data and verifications shall be automatically transferred to the state insurance marketplace through a system interface when applicants are found ineligible for Medical Assistance eligibility programs.

If an individual is pending for a Non-MAGI Medical Assistance eligibility program but has been found financially ineligible for MAGI Medical Assistance eligibility programs, the application data and verifications shall be transferred to the state insurance marketplace.

Persons applying for assistance need complete only one application form to apply for both Medical Assistance and Financial Assistance under the Federal or State Financial Assistance Programs administered in the county. The application will be the Application for Public Assistance.
If an applicant is found to be ineligible for a particular program, the Application for Public Assistance shall be reviewed and processed for other financial programs the household has requested on the Application for Public Assistance and all other Medical Assistance Programs. Referrals to other community agencies and organizations shall be made for the applicant whenever available or requested.
The applicant must sign the application form, give declaration in lieu of a signature by telephone, or may opt to use an electronic signature in order to receive Medical Assistance.
A family member, adult in the applicant’s Medical Assistance Required Household or authorized representative may submit an application and request assistance on behalf of an applicant.
If the applicant is not able to participate in the completion of the application forms because they are a minor (as defined in C.R.S. § 13-22-101) or due to physical or mental incapacity, the spouse, other relative, friend, or representative acting responsibly on behalf of the applicant may complete the forms. When no such person is available to assist in these situations, the eligibility site shall assist the applicant in the completion of the necessary forms. This type of situation should be identified clearly in the case record.
For the purpose of Medical Assistance, when an applicant is incompetent or incapacitated and unable to sign an application, or in case of death of the applicant, the application shall be signed, under penalty of perjury, by someone acting responsibly on behalf of the applicant either:

a. A parent, or other specified relative, or legally appointed guardian or conservator, or b. For a person in a medical institution for whom none of the above in 8.a. are available, an authorized official of the institution may sign the 9. Application interviews or requested visits to the eligibility site for Medical Assistance shall not be required. All correspondence may occur by mail, email or telephone.

During normal business hours, eligibility sites shall not restrict the hours in which applicants may file an application. The eligibility site must afford any individual wishing to do so the opportunity to apply for Medical Assistance without delay.
The applicant has the right to withdraw his or her application at any time. 8.100.3.B. Residency Requirements 1. Individuals shall make application in the county in which they live. Individuals who reside in a county but who do not reside in a permanent dwelling nor have a fixed mailing address shall be considered eligible for the Medical Assistance Program, provided all other eligibility requirements are met. In no instance shall there be a durational residency requirement imposed upon the applicant, nor shall there be a requirement for the applicant to reside in a permanent dwelling or have a fixed mailing address. If an individual without a permanent dwelling or fixed mailing address is hospitalized, the county where the hospital is located shall be responsible for processing the application to completion. If the individual moves prior to completion of the eligibility determination the origination eligibility site completes the determination and transfers the case as applicable.

a. For applicants in Long Term Care institutions - The county of domicile for all Long Term Care clients is the county in which they are physically located and receiving services.

A resident of Colorado is defined as a person that is living within the state of Colorado and considers Colorado to be their place of residence at the time of application. For institutionalized individuals who are incapable of indicating intent as to their state of residence, the state of residence shall be where the institution is located unless that state determines that the individual is a resident of another state, by applying the following criteria:

a. for any institutionalized individual who is under age 21 or who is age 21 or older and incapable of indicating intent before age 21, the state of residence is that of the individual's parent(s) or legally appointed guardian at the time of placement;

b. for any institutionalized individual who became incapable of indicating intent at or after age 21, (1) the state of residence is the state in which the person was living when he or she became incapable of indicating intent, or (2) if this cannot be determined, the state of residence is the state in which the person was living when he or she was first determined to be incapable of indicating intent;

c. upon placement in another state, the new state is the state of residence unless the current state of residence is involved in the placement. If a current state arranged for an individual to be placed in an institution located in another state, the current state shall be the individual's state of residence, irrespective of the individual's indicated intent or ability to indicate intent;

d. in the case of conflicting opinions between states, the state of residence is the state where the individual is physically located.

For purposes of this section on establishing an individual's state of residence, an individual is considered incapable of indicating intent if:

a. the person has an I.Q. of 49 or less or has a mental age of 7 or less, based on standardized tests as specified in the persons in medical facilities section of this volume;

b. the person is judged legally incompetent; or c. medical documentation, or other documentation acceptable to the eligibility site, supports a finding that the person is incapable of indicating intent.

Residence shall be retained until abandoned. A person temporarily absent from the state, inside or outside the United States, retains Colorado residence.

Temporarily absent means that at the time he/she leaves, the person intends to return.

A non-resident shall mean a person who considers his/her place of residence to be other than Colorado. Any person who enters the state to receive Medical Assistance or for any other reason is a non-resident, so long as they consider their permanent place of residence to be outside of the state of Colorado. 8.100.3.C. Transferring Requirements 1. When a family or individual moves from one county to another within Colorado, the client shall report the change of address to the eligibility site responsible for the current active Medical Assistance Program case(s). If a household applies in the county in which they live and then moves out of that county during the application determination process, the originating eligibility site shall complete the processing of that application before transferring the case. The originating eligibility site shall electronically transfer the case to the new county of residence in CBMS.
The originating eligibility site must notify the receiving eligibility site of the client's transfer of Medical Assistance. The originating eligibility site may notify the receiving eligibility site by telephone that a client has moved to the receiving county. If the family or individual wishes to apply for other types of assistance, they shall submit a new application to the receiving eligibility site.
If the household is transferring the current Medical Assistance case, the receiving eligibility site cannot mandate a new application, verification, or an office visit to authorize the transfer. The receiving eligibility site can request copies of specific case documents to be forwarded from the originating eligibility site to verify the data contained in CBMS.
If the originating eligibility site closes a case for the discontinuation reason of “unable to locate,” the applicant shall reapply at the receiving eligibility site for the 5. If a case is closed for any other discontinuation reason than “unable to locate” and the client provides appropriate information to overturn the discontinuation with the originating eligibility site, then, upon transfer, the receiving eligibility site shall reopen the case with case comments in CBMS. These actions shall be performed according to timeframes defined by the Department.
When a recipient moves from his/her home to a nursing facility in another county or when a recipient moves from one nursing facility to another in a different county:

a. the initiating eligibility site will transfer the case electronically in the eligibility system to the eligibility site in which the nursing facility is located when the individual is determined eligible; and b. The following items shall be furnished by the initiating eligibility site to the new eligibility site in hard copy format or via electronic transmission:

i) 5615 that was sent to the nursing facility indicating the case transfer; and ii) Identification and citizenship documents; and iii) Long-Term Services and Supports Level of Care Eligibility Determination 7. When transferring a case, the initiating eligibility site will send an AP-5615 form to the nursing facility administrator of the new nursing facility showing the date of case closure and the current patient payment at the time of transfer. Should the Medical Assistance Program reimbursement be interrupted, the receiving eligibility site will have the responsibility to process the application and back date the Medical Assistance eligibility date to cover the period of ineligibility. 8.100.3.D. Processing Requirements 1. The eligibility site shall process a Single Streamlined Application for Medical Assistance Program benefits within the following deadlines:

a. 90 days for persons who apply for the Medical Assistance Program and a disability determination is required.

b. 45 days for all other Medical Assistance Program applicants.

c. The above deadlines cover the period from the date of receipt of a complete application to the date the eligibility site mails a notice of its decision to the applicant.

d. In unusual circumstances, documented in the case record and in CBMS case comments, the eligibility site may delay its decision on the application beyond the applicable deadline at its discretion. Examples of such unusual circumstances are a delay or failure by the applicant or an examining physician to take a required action such as submitting required documentation, or an administrative or other emergency beyond the agency's control.

e. Due to the Coronavirus COVID-19 Public Health Emergency, required through the Federal CARES Act for the Maintenance of Effort (MOE), the Department will continue eligibility for all Medical Assistance categories, regardless of changes made for a redetermination or additional documentation for current Medicaid enrollees. The Department will allow these individuals to continue eligibility through the period of the COVID-19 pandemic federal emergency declaration. Once the federal emergency declaration has concluded, the Department will process eligibility redeterminations and /or changes for all members whose eligibility was maintained during the emergency declaration. Effective May 11, 2023 the coronavirus COVID-19 pandemic federal emergency has been declared to end. To ensure the Department Maintains access to State and Federal funding provided by the Federal ‘Families First Coronavirus Response Act”

Pub.L. 116-127, and the Federal “Consolidated Appropriations Act, 2023”, the Department will process eligibility redeterminations and take appropriate action for all members whose eligibility was maintained during the emergency declaration. By May 2024 all members whose eligibility has been maintained due to the Public Health Emergency will have completed the renewal process. A member’s eligibility may no longer be maintained after May 31, 2023 if they have completed the renewal process and/or a change is reported, and they are found ineligible.

Members whose eligibility has been maintained during the Public Health Emergency and whose renewal is not due yet will remain in their current category until their renewal due month, regardless if there is a change reported that makes them ineligible.

Upon request, applicants will be given an extension of time within the application processing timeframe to submit requested verification. Applicants may request an extension of time beyond the application processing timeframe to obtain necessary verification. The extension may be granted at the eligibility site's discretion. The amount of time given should be determined on a case-by-case

basis and should be based on the amount of time the individual needs to obtain the required documentation.

The eligibility site shall not use the above timeframes as a waiting period before determining eligibility or as a reason for denying eligibility.
For clients who apply for the Medical Assistance Program and a disability determination is required, the eligibility site shall send a notice informing the applicant of the reason for a delay beyond the applicable deadline, and of the applicant's right to appeal if dissatisfied with the delay. The eligibility site shall send this notice no later than 91 days following the application for the Medical Assistance Program.
For information regarding continuation of benefits during the pendency of an appeal to the Social Security Administration (SSA) based upon termination of disability benefits see section 8.057.5.C.
Eligibility sites at which an individual is able to apply for Medical Assistance benefits shall also provide the applicant the opportunity to register to vote.

a. The eligibility site shall provide to the applicant the prescribed voter registration application.

b. The eligibility site shall not:

i) Seek to influence the applicant's political preference or party registration;

ii) Display any political preference or party allegiance;

iii) Make any statement to the applicant or take any action, the

purpose or effect of which is to discourage the applicant from registering to vote; and iv) Make any statement to an applicant which is to lead the applicant to believe that a decision to register or not to register has any bearing on the availability of services or benefits.

c. The eligibility site shall ensure the confidentiality of individuals registering and declining to register to vote.

d. Records concerning registration and declination to register to vote shall be maintained for two years by the eligibility site. These records shall not be

part of the public assistance case record.

e. A completed voter registration application shall be transmitted to the county clerk and recorder for the county in which the eligibility site is located not later than ten (10) days after the date of acceptance; except that if a registration application is accepted within five (5) days before the last day for registration to vote in an election, the application shall be transmitted to the county clerk and recorder for the county not later than five (5) days after the date of acceptance.

Individuals who transfer from one Colorado county to another shall be provided the same opportunity to register to vote in the new county of residence. The new county of residence shall follow the above procedure. The new county of residence shall notify its county clerk and recorder of the client's change in address within five (5) days of receiving the information from the client. 8.100.3.E. Retroactive Medical Assistance Coverage 1. An applicant for Medical Assistance shall be provided such assistance any time during the three months preceding the date of application, or as of the date the person became eligible for Medical Assistance, whichever is later. That person shall have received medical services at any time during that period and met all applicable eligibility requirements.
An explanation of the conditions for retroactive Medical Assistance shall be given to all applicants. Those applicants who within the three months period prior to the date of application or as of the date the person became eligible for Medical Assistance, whichever is later, have received medical services which would be a benefit under the Colorado State Plan, can request retroactive coverage on the application form. The determination of eligibility for retroactive Medical Assistance shall be made as part of the application process. An applicant does not have to be eligible in the month of application to be eligible for retroactive Medical Assistance. The applicant or client may verbally request retroactive coverage at any time following the completion of an application. Verification required to determine Medical Assistance Program eligibility for the retroactive period shall be secured by the eligibility site to determine retroactive eligibility. Proof of the declared medical service shall not be required. 8.100.3.F. Groups Assisted Under the Program 1. The Medical Assistance Program provides benefits to the following persons who meet the federal definition of categorically needy at the time they apply for benefits:

a. Parents and Caretaker Relatives, Pregnant Women, Children, Adults, and Family Planning Medical Assistance as defined under the Modified Adjusted Gross Income (MAGI)Medical Assistance section 8.100.4.

b. Persons who meet legal immigrant requirements as outlined in this volume, who were or would have been eligible for SSI but for their alien status, if such persons meet the resource, income and disability requirements for SSI eligibility.

c. Persons who are receiving financial assistance; and who are eligible for a SISC Code of A or B. See section 8.100.3.M for more information on SISC Codes.

d. Persons who are eligible for financial assistance under Old Age Pension (OAP) and SSI, but are not receiving the money payment.

e. Persons who would be eligible for financial assistance from OAP or SSI, except for the receipt of Social Security Cost of Living Adjustment (COLA) increases, or other retirement, survivors, or disability benefit increases to their own or a spouse's income. This group also includes persons who lost OAP or SSI due to the receipt of Social Security Benefits and who would still be eligible for the Medical Assistance Program except for the cost of living adjustments (COLA's) received. These populations are referenced as Pickle and Disabled Widow(er)s.

f. Persons who are blind, disabled, or aged individuals residing in the medical institution or Long Term Care Institution whose income does not exceed 300% of SSI.

g. Persons who are blind, disabled or aged receiving HCBS whose income does not exceed 300% of the SSI benefit level and who, except for the level of their income, would be eligible for an SSI payment.

h. A disabled adult child who is at least 18 years of age and who was receiving SSI as a disabled child prior to the age of 22, and for whom SSI was discontinued on or after May 1, 1987, due to having received of OASDI drawn from a parent(s) Social Security Number, and who would continue to be eligible for SSI if the above OASDI and all subsequent cost of living adjustments were disregarded. This population is referenced as Disabled Adult Child (DAC).

i. Children age 18 and under who would otherwise require institutionalization in an Long Term Care Institution, Nursing Facility (NF), or a hospital but for which it is appropriate to provide care outside of an institution as described in 1902(e)(3) of the Act Public Law No. 97-248 (Section 134).

j. Persons receiving OAP-A, OAP-B, and OAP Refugees who do not meet SSI eligibility criteria but do meet the state eligibility criteria for the OAP State Only Medical Assistance Program. These persons qualify for a SISC Code C.

k. Persons who apply for and meet the criteria for one of the categorical Medical Assistance programs, but do not meet the criteria of citizenship shall receive Medical Assistance benefits for emergencies only.

l. Persons with a disability or limited disability who are at least 16, with income less than or equal to 450% of FPL after income disregards, regardless of resources, and who are employed.

m. Children with a disability who are age 18 and under, with household income less than or equal to 300% of FPL after income disregards, regardless of resources.

n. Effective March 2020 due to the Coronavirus COVID-19 Public Health Emergency, an applicant who is not eligible for Medical Assistance but has been impacted through exposure to or potential infection of COVID-19 may be eligible to receive services for COVID-19 testing, treatment, or care for complications related to COVID-19. To qualify for this limited benefit, the applicant must satisfy residency and immigration-or citizenship and not be enrolled in other health insurance. With the expiration of the Covid-19 Public Health Emergency declaration effective May 11, 2023 the limited COVID-19 benefit group will end. Federal financial participation (FFP) is not available for services after the last day of the PHE. The Department will use state-only funds to continue to provide coverage for individuals who were enrolled in the limited Covid-19 benefit group on May 11, 2023 until May 31,2023. After May 11, 2023 individuals will no longer be enrolled in the limited Covid-19 benefit group. 8.100.3.G. General and Citizenship Eligibility Requirements 1. To be eligible to receive Medical Assistance, an eligible person shall:

a. Be a resident of Colorado;

b. Meet the following requirements while being an inmate, in-patient or resident of a public institution:

i) The following individuals, if eligible, may be enrolled for Medical 1. Patients in a public medical institution 2. Residents of a Long-Term Care Institution 3. Prior inmates who have been paroled 4. Residents of a publicly operated community residence which serves no more than 16 residents 5. Individuals participating in community corrections programs or residents in community corrections facilities (“halfway houses”) who have freedom of movement and association which includes individuals who:

a) are not precluded from working outside the facility in employment available to individuals who are not under justice system supervision;

b) can use community resources (e.g., libraries, grocery stores, recreation, and education) at will;

c) can seek health care treatment in the broader community to the same or similar extent as other Medicaid enrollees in the state; and/or d) are residing at their home, such as house arrest, or another location.

ii) Inmates who are incarcerated in a correctional institution such as a city, county, state or federal prison may be enrolled, if eligible, with benefits limited to:

a) an in-patient stay of 24 hours or longer in a medical institution; and b) 90 days prior to release, Reentry Demonstration Initiative Services authorized by the 1115 Demonstration Waiver titled Colorado Expanding the Substance Use Disorder (SUD)

Continuum of Care and described in Attachment G to the Center for Medicare & Medicaid Services’ (“CMS”)

Demonstration Approval dated October 14, 2025. Reentry Demonstration Initiative Services are only available while approved by CMS. CMS’s Demonstration Approval dated October 14, 2025 is hereby incorporated by reference.

c. Not be a patient in an institution for tuberculosis or mental disease, unless the person is under 21 years of age or has attained 65 years of age and is eligible for the Medical Assistance Program and is receiving active treatment as an inpatient in a psychiatric facility eligible for Medical Assistance reimbursement. See Section 8.100.4.H for special provisions extending Medical Assistance coverage for certain patients who attain age 21 while receiving such inpatient psychiatric services;

d. Meet all financial eligibility requirements of the Medical Assistance Program for which application is being made;

e. Meet the definition of disability or blindness, when applicable. Those definitions appear in this volume at Section 8.100.1 under Definitions;

f. Meet all other requirements of the Medical Assistance Program for which application is being made; and g. Fall into one of the following categories:

i) Be a citizen or national of the United States, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, American Samoa or Swain’s Island; or ii) Be a lawfully admitted non-citizen who entered the United States prior to August 22, 1996; or iii) Be a non-citizen who entered the United States on or after August 22, 1996 and is applying for Medical Assistance benefits to begin no earlier than five years after the non-citizen’s date of entry into the United States who falls into one of the following categories:

lawfully admitted for permanent residence under the Immigration and Nationality Act (hereafter referred to as the “INA”); or 2) paroled into the United States for at least one year under 8 U.S.C. § 1182(d)(5); or 3) granted conditional entry under section 203(a)(7) of the INA, as in effect prior to April 1, 1980; or 4) determined by the eligibility site, in accordance with guidelines issued by the U.S. Attorney General, to be a spouse, child, parent of a child, or child of a parent who, in circumstances specifically described in 8 U.S.C. § 1641(c), has been battered or subjected to extreme cruelty which necessitates the provision of Medical Assistance (Medicaid).

iv) Be a non-citizen who arrived in the United States on any date, who falls into one of the following categories:

lawfully residing in Colorado and is an honorably discharged military veteran (also includes spouse, unremarried surviving spouse and unmarried, dependent children); or 2) lawfully residing in Colorado and is on active duty (excluding training) in the U.S. Armed Forces (also includes spouse, unremarried surviving spouse and unmarried, dependent children); or 3) granted asylum under section 208 of the INA; or 4) refugee under section 207 of the INA; or 5) deportation withheld under section 243(h) (as in effect prior to September 30, 1996) or section 241(b)(3) (as amended by P.L. 104-208) of the INA; or 6) Cuban or Haitian entrant, as defined in section 501(e) of the Refugee Education Assistance Act of 1980; or 7) an individual who (1) was born in Canada and possesses at least 50 percent American Indian blood, or is a member of an Indian tribe as defined in 25 U.S.C. § 5304(e) (2016); or 8) admitted to the United States as an Amerasian immigrant pursuant to section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988 (as amended by P.L. 100-461); or 9) lawfully admitted permanent resident who is a Hmong or Highland Lao veteran of the Vietnam conflict; or 10) a victim of a severe form of trafficking in persons, as defined in section 103 of the Victims of Trafficking and Violence Protection Act of 2000, Pub. L.106-386 (as amended by 22 U.S.C. § 7105(b) (2016)); or 11) an alien who arrived in the United States on or after December 26, 2007 who is an Iraqi special immigrant under

section 101(a)(27) of the INA; or 12) an alien who arrived in the United States on or after December 26, 2007 who is an Afghan special immigrant under section 101(a)(27) of the INA; or 13) Compact of Free Association (COFA) migrants, including citizens of Micronesia, the Marshall Islands, and Palau, pursuant to section 208 of the Consolidated Appropriations Act of 2021 (in effect December 27, 2020).

v) The incorporations by reference (as indicated within) throughout this Section 8.100.3.G.1. exclude later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for inspection during regular business hours at 303 E. 17th Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request.

Incorporated materials may also be obtained from the original issuers at www.ecfr.gov or www.medicaid.gov or www.dhs.gov, respectively.

vi) Be a lawfully admitted non-citizen who is a pregnant woman or a child under the age of 19 years in the United States who falls into one of the categories listed in Section 8.100.3.G.1.g.iii or into one of the following categories listed below. These individuals are exempt from the 5-year waiting period:

granted temporary resident status in accordance with 8 U.S.C. § 1160 or 1255a; or 2) granted Temporary Protected Status (TPS) in accordance with 8 U.S.C § 1254a and pending applicants for TPS granted employment authorization; or 3) granted employment authorization under 8 CFR 274a.12(c)

(July 1, 2015, which is hereby incorporated by reference; or 4) Family Unity beneficiary in accordance with section 301 of Pub. L. 101-649, as amended; or 5) Deferred Enforced Departure (DED), pursuant to a decision made by the President; or 6) granted Deferred Action status (excluding Deferred Action for Childhood Arrivals (DACA)) as described in the Secretary of Homeland Security’s June 15, 2012 memorandum, which is hereby incorporated by reference; or 7) granted an administrative stay of removal under 8 CFR 241.6 (2016), which is hereby incorporated by reference; or 8) beneficiary of approved visa petition who has a pending application for adjustment of status; or 9) pending an application for asylum under 8 U.S.C. § 1158, or for withholding of removal under 8 U.S.C. § 1231, or under the Convention Against Torture whoa) has been granted employment authorization; or b) is under the age of 14 and has had an application pending for at least 180 days; or 10) granted withholding of removal under the Convention Against Torture; or 11) a child who has a pending application for Special Immigrant Juvenile status under 8 U.S.C. § 1101(a)(27)(J); or 12) citizens of Micronesia, the Marshall Islands, and Palau; or 13) is lawfully present American Samoa under the immigration of laws of American Samoa; or 14) a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. § 1101(a)(15) or under 8 U.S.C. 1101(a)(17); or 15) A non-citizen who has been paroled into the United States for less than one year under 8 U.S.C. § 1182(d)(5), except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings.

vii) Be an Afghan Humanitarian Parolee who falls into one of the following categories listed below, as defined in Section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act of 2021 (HR 5305). These individuals are exempt from the 5-year waiting period until March 31, 2023, or through the termination of their parole period, whichever is later:

paroled into the United States between July 31, 2021 – September 30, 2022; or 2) paroled into the United States after September 30, 2022, a) is the spouse or child of an individual in subparagraph 1 as defined under section 101(b) of the Immigration and Nationality Act (8 U.S.C. § 4 1101(b)); or b) is the parent or legal guardian of an individual in subparagraph 1 who is determined to be an unaccompanied child under 6 U.S.C. § 279(g)(2).

viii) Exception: Individuals who meet the criteria for one of the following Medical Assistance programs but are not citizens or qualified noncitizens according to criteria set forth in Section 8.100.3.G.1.g, shall be eligible to receive Medical Assistance benefits for programs included under C.R.S. 25.5-5-201.

Children who are under the age of 19, or who turn 19 in the same month eligibility is determined, including those who are pregnant, or who are within the first 12 months of their postpartum period, can be assessed for eligibility in the following Medical Assistance Categories, regardless of immigration status:

a) MAGI Children, MAGI Pregnant, Psych <21, Transitional Medical Assistance, 4 Month Extended Medical Assistance, MAGI Prenatal Presumptive Eligibility, and MAGI Child Presumptive Eligibility b) Medical Buy-In Program for Working Adults with Disabilities (including with Home and Community Based Services), Medicaid Buy-In Program for Children with Disabilities, and Long-Term Care waivers except Program of All Inclusive Care for the Elderly (PACE)

Effective July 1, 2026, the Department will assess the total number of enrolled children described in 8.100.3.G.1.viii.1.

An enrollment cap must be initiated if one of the following conditions occurs:

a) Enrollment exceeds 25,000 children; or b) Total spending for Medical Assistance in a fiscal quarter is over the allocated state budget by more than 5%.

If the enrollment cap is initiated, it will take effect on the first day of the month, following 60 calendar days after the Department determines that one of the conditions described above is met. The cap will remain in place until the Department determines that the conditions described above are no longer met. During this time, children described in 8.100.3.G.1.viii.1 will be assessed for eligibility under all other Medical Assistance programs, or (if ineligible) transferred to the state insurance marketplace.

Individuals aged 19 or older, who are either pregnant or are within the first 12 months of their postpartum period, can be assessed for eligibility in the following Medical Assistance categories, regardless of immigration status:

a) MAGI Pregnant, Psych <21, Transitional Medical Assistance, 4 Month Extended Medical Assistance, and MAGI Prenatal Presumptive Eligibility b) Medical Buy-In Program for Working Adults with Disabilities (including with Home and Community Based Services), and Long-Term Care waivers except Program of All Inclusive Care for the Elderly (PACE)

Persons requesting limited emergency medical care only and/or reproductive care shall not be excluded on the basis of immigration status.

For non-qualified non-citizens receiving Medical Assistance emergency only benefits, the following medical conditions will be covered:

An emergency medical condition (including labor and delivery) which manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

a) placing the patient's health in serious jeopardy;

b) serious impairment of bodily function; or c) serious dysfunction of any bodily organ or part.

These persons need not select a primary care physician as they are eligible only for emergency medical services and/or reproductive health care services. Applicants are not required to obtain a written statement by their physician for their application to be complete and processed. For emergency care, a physician must certify and declare the presence of an emergency medical condition when services are provided and shall indicate that services were for a medical emergency on the claim form. This will suffice as the physician statement for an emergency medical condition when services were provided. Medical Assistance coverage for emergency medical care only is limited to care and services that are necessary to treat immediate emergency medical conditions.

Coverage does not include prenatal care or follow-up care. Medical Assistance benefits for reproductive health care services are limited to care and services that provide reproductive health and/or family planning services only. Once a member has been determined eligible for either of these emergency and/or reproductive health services, the member will not be required to submit a new application before 12 months for any other emergency and/or reproductive health services. Members will have the option to advise the Department, at any time, that they no longer need the services. Members receiving emergency and/or limited reproductive health services will receive a renewal at 12 months to redetermine their eligibility.

The rules on confidentiality indicated under C.R.S. § 24-74- 103 prevent the Department or eligibility site from reporting to the USCIS persons who have applied for or are receiving 2. For determinations of eligibility for Medical Assistance, legal immigration status must be verified. This requirement applies to a non-citizen individual who meets the criteria of any category defined at Section 8.100.3.G(1)(g)(ii), (iii), (iv), (vi), or (vii) and has declared that he or she has a legal immigration status.

a. The Verify Lawful Presence (VLP) interface will be used to verify immigration status. The VLP interface connects to the Systematic Alien Verification for Entitlements (SAVE) Program to verify legal immigration status.

i) If an automated response from VLP confirms that the information submitted is consistent with VLP data for immigration status verification requirements, no further action is required for the individual and no additional documentation of immigration status is required.

ii) If the VLP cannot automatically confirm the information submitted, the individual will be contacted with a request for additional documents and/or information needed to verify their legal immigration status through the VLP interface. If a response from the VLP interface confirms that the additional documents and/or information received from the individual verifies their legal immigration status, no further action is required for the individual and no additional documentation of immigration status is required.

Reasonable Opportunity Period a. If the verification through the electronic interface is unsuccessful then the applicant will be provided a reasonable opportunity period, of 90 days, to submit documents indicating a legal immigration status, as listed in

Section 8.100.3.G.1.g. The reasonable opportunity period will begin as of the date of the Notice of Action. The required documentation must be received within the reasonable opportunity period. b If the applicant does not provide the necessary documents within the reasonable opportunity period, then the applicant’s Medical Assistance application shall be terminated.

c. The reasonable opportunity period applies to MAGI, Adult and Buy-In Programs.

i) For the purpose of this section only, MAGI Programs for persons covered pursuant to Sections 8.100.4.G or 8.100.4.I include the Commonly Used Program Name Rule Citation Children’s Medical Assistance 8.100.4.G.2 Parent and Caretaker Relative Medical 8.100.4.G.3 Adult Medical Assistance 8.100.4.G.4 Pregnant Women Medical Assistance 8.100.4.G.5 Legal Immigrant Prenatal Medical 8.100.4.G.6 Transitional Medical Assistance 8.100.4.I.1ii) For the purpose of this section only, Adult and Buy-In Programs for persons covered pursuant to Sections 8.100.3.F, 8.100.6.P, 8.100.6.Q, or 8.715 include the following:

Commonly Used Program Name Rule Citation Old Age Pension A (OAP-A) 8.100.3.F.1.c Old Age Pension B (OAP-B) 8.100.3.F.1.c Qualified Disabled Widow/Widower 8.100.3.F.1.e Pickle 8.100.3.F.1.e Long-Term Care 8.100.3.F.1.fh Medicaid Buy-In Program for Working Adults with 8.100.6.P Medicaid Buy-In Program for Children with 8.100.6.Q Breast and Cervical Cancer Program (BCCP) 8.715 8.100.3.H. Citizenship and Identity Documentation Requirements 1. For determinations of initial eligibility and redeterminations of eligibility for Medical Assistance made on or after July 1, 2006, citizenship or nationality and identity status must be verified unless such satisfactory documentary evidence has already been provided, as described in 8.100.3.H.4.b. This requirement applies to an individual who declares or who has previously declared that he or she is a citizen or national of the United States.

a. The following electronic interfaces shall be accepted as proof of citizenship and/or identity as listed and should be used prior to requesting documentary evidence from applicants/clients:

i) SSA Interface is an acceptable interface to verify citizenship and identity. An automated response from SSA that confirms that the data submitted is consistent with SSA data, including citizenship or nationality, meets citizenship and identity verification requirements. No further action is required for the individual and no additional documentation of either citizenship or identity is required.

ii) Department of Motor Vehicles (DMV) Interface is an acceptable interface to verify identity. An automated response from DMV confirms that the data submitted is consistent with DMV data for identity verification requirements. No further action is required for the individual and no additional documentation of identity is required.

b. This requirement does not apply to the following groups:

i) Individuals who are entitled to or who are enrolled in any part of Medicare.

ii) Individuals who receive Supplemental Security Income (SSI).

iii) Individuals who receive child welfare services under Title IV-B of the Social Security Act on the basis of being a child in foster care.

iv) Individuals who receive adoption or foster care assistance under Title IV-E of the Social Security Act.

v) Individuals who receive Social Security Disability Insurance (SSDI).

vi) Children born to a woman who has applied for, has been determined eligible, and is receiving Medical Assistance on the date of the child's birth, as described in 8.100.4.G.5. This includes instances where the labor and delivery services were provided before the date of application and were covered by the Medical Assistance Program as an emergency service based on retroactive eligibility.

A child meeting the criteria described in 8.100.3.H.1.b.vi shall be deemed to have provided satisfactory documentary evidence of citizenship or nationality and shall not be required to provide further documentary evidence at any time in the future, regardless of any subsequent changes in the child’s eligibility for Medical Assistance.
Special Provisions for Retroactive Reversal of a Previous Denial a) If a child described at 8.100.3.H.1.b.vi was previously determined to be ineligible for Medical Assistance solely for failure to meet the citizenship and identity documentation requirements, the denial shall be reversed. Eligibility shall be effective retroactively to the date of the child’s birth provided all of the following criteria are met:

(1) The child was determined to be ineligible for Medical Assistance during the period between July 1, 2006 and October 1, 2009 solely for failure to meet the citizenship and identity documentation requirements as they existed during that period;

(2) The child would have been determined to be eligible for Medical Assistance had 8.100.3.H.1.b.vi and/or 8.100.3.H.1.b.vi.2.a been in effect during the period from July 1, 2006 through October 1, 2009; and (3) The child’s parent, caretaker relative, or legally appointed guardian or conservator requests that the denial of eligibility for Medical Assistance be reversed. The request may be verbal or in writing.

b) A child for whom denial of eligibility for Medical Assistance has been retroactively reversed shall be subject to the eligibility redetermination provisions described at 8.100.3.P.1. Such redetermination shall occur twelve months from the retroactive eligibility date determined when the denial was reversed pursuant to this subsection 1.

c) A child granted retroactive eligibility for Medical Assistance shall be subject to the requirements described at 8.100.4.G.2. for continued eligibility.

vii) Individuals receiving Medical Assistance during a period of presumptive eligibility.

viii) Individuals qualifying for Medical Assistance under 8.100.3.G.g.viii.

Satisfactory documentary evidence of citizenship or nationality includes the a. Stand-alone documents for evidence of citizenship and identity. The following evidence shall be accepted as satisfactory documentary evidence of both identity and citizenship:

i) A U.S. passport issued by the U.S. Department of State that:

includes the applicant or recipient, and 2) was issued without limitation. A passport issued with a limitation may be used as proof of identity, as outlined in 8.100.3.H.3.

ii) A Certificate of Naturalization (DHS Forms N-550 or N-570) issued by the Department of Homeland Security (DHS) for naturalized citizens.

iii) A Certificate of U.S. Citizenship (DHS Forms N-560 or N-561) issued by the Department of Homeland Security for individuals who derive citizenship through a parent.

iv) A document issued by a federally recognized Indian tribe, evidencing membership or enrollment in, or affiliation with, such tribe (such as a tribal enrollment card or certificate of degree of Indian blood).

Special Provisions for Retroactive Reversal of a Previous Denial a) For a member of a federally recognized Indian tribe who was determined to be ineligible for Medical Assistance solely for failure to meet the citizenship and identity documentation requirements, the denial of eligibility shall be reversed and eligibility shall be effective as of the date on which the individual was determined to be ineligible provided all of the following criteria are met:

(1) The individual was determined to be ineligible for Medical Assistance on or after July 1, 2006 solely on the basis of not meeting the citizenship and identity documentation requirements as they existed during that period;

(2) The individual would have been determined to be eligible for Medical Assistance had 8.100.3.H.2.a.iv) been in effect on or after July 1, 2006; and (3) The individual or a legally appointed guardian or conservator of the individual requests that the denial of eligibility for Medical Assistance be reversed. The request may be verbal or in writing.

b) A member of a federally recognized Indian tribe for whom denial of eligibility for Medical Assistance has been retroactively reversed shall be subject to the eligibility redetermination provisions described at 8.100.3.P.1. Such redetermination shall occur twelve months from the retroactive eligibility date determined when the denial was reversed as provided in this subsection 2.

b. Evidence of citizenship. If evidence from the list in 8.100.3.H.2.a. is not provided, an applicant or recipient shall provide satisfactory documentary evidence of citizenship from the list specified in this section to establish citizenship AND satisfactory documentary evidence from the documents listed in section 8.100.3.H. 3. to establish identity. Evidence of citizenship includes:

i) A U.S. public birth certificate.

The birth certificate shall show birth in any one of the a) One of the 50 States, b) The District of Columbia, c) Puerto Rico (if born on or after January 13, 1941), d) Guam (if born on or after April 10, 1899), e) The Virgin Islands of the U.S. (if born on or after January 17, 1917), f) American Samoa, g) Swain's Island, or h) The Northern Mariana Islands (NMI) (if born after November 4, 1986 (NMI local time)).
The birth record document shall have been issued by the State, Commonwealth, Territory or local jurisdiction.
The birth record document shall have been recorded before the person was 5 years of age. A delayed birth record document that is recorded at or after 5 years of age is considered fourth level evidence of citizenship, as described in 8.100.3.H.2.d.

ii) A Certification of Report of Birth (DS-1350) issued by the U.S.

Department of State to U.S. citizens who were born outside the U.S. and acquired U.S. citizenship at birth.

iii) A Report of Birth Abroad of a U.S. Citizen (Form FS-240) issued by the U.S. Department of State consular office overseas for children under age 18 at the time of issuance. Children born outside the U.S. to U.S. military personnel usually have one of these.

iv) A Certification of birth issued by the U.S. Department of State (Form FS-545 or DS-1350) before November 1,1990.

v) A U.S. Citizen I.D. card issued by the U.S. Immigration and Naturalization Services (INS):

Form I-179 issued from 1960 until 1973, or 2) Form I-197 issued from 1973 until April 7, 1983.

vi) A Northern Mariana Identification Card (I-873) issued by INS to a collectively naturalized citizen of the U.S. who was born in the NMI before November 4, 1986.

vii) An American Indian Card (I-872) issued by the Department of Homeland Security with the classification code “KIC.”

viii) A final adoption decree that:

shows the child's name and U.S. place of birth, or 2) a statement from a State approved adoption agency that shows the child's name and U.S. place of birth. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate.

ix) Evidence of U.S. Civil Service employment before June 1, 1976.

The document shall show employment by the U.S. government before June 1, 1976.

x) U.S. Military Record that shows a U.S. place of birth such as a DD- 214 or similar official document showing a U.S. place of birth.

xi) Data verification with the Systematic Alien Verification for Entitlements (SAVE) Program for naturalized citizens.

xii) Child Citizenship Act. Adopted or biological children born outside the United States may establish citizenship obtained automatically under section 320 of the Immigration and Nationality Act (8 USC § 1431), as amended by the Child Citizenship Act of 2000 (Pub. L. 106-395, enacted on October 30, 2000). section 320 of the Immigration and Nationality Act (8 USC § 1431), as amended by the Child Citizenship Act of 2000 (Pub. L. 106-395, enacted on October 30, 2000) is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspections from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203- 1818. Any material that has been incorporated by reference in this

rule may be examined at any state publications repository library.

Documentary evidence must be provided at any time on or after February 27, 2001, if the following conditions have been met:

At least one parent of the child is a United States citizen by either birth or naturalization (as verified under the requirements of this part);
The child is under the age of 18;
The child is residing in the United States in the legal and physical custody of the U.S. citizen parent;
The child was admitted to the United States for lawful permanent residence (as verified through the Systematic Alien Verification for Entitlements (SAVE) Program); and 5) If adopted, the child satisfies the requirements of section 101(b)(1) of the Immigration and Nationality Act (8 USC § 1101(b)(1)) pertaining to international adoptions (admission for lawful permanent residence as IR-3 (child adopted outside the United States), or as IR-4 (child coming to the United States to be adopted) with final adoption having subsequently occurred. 8 USC § 1101(b)(1) is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspections from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203-1818. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library.

xiii) Extract of a hospital record on hospital letterhead.

The record shall have been established at the time of the person's birth;
The record shall have been created at least 5 years before the initial application date; and 3) The record shall indicate a U.S. place of birth;
For children under 16 the document shall have been created 5) Souvenir “birth certificates” issued by a hospital are not acceptable.

xiv) Life, health, or other insurance record.

The record shall show a U.S. place of birth; and 2) The record shall have been created at least 5 years before the initial application date.
For children under 16 the document must have been created xv) Religious record.
The record shall have been recorded in the U.S. within 3 months of the date of the individual's birth;
The record shall show that the birth occurred in the U.S.;
The record shall show either the date of birth or the individual's age at the time the record was made; and 4) The record shall be an official record recorded with the religious organization.

xvi) Early school record that meets the following criteria:

The school record shows the name of the child;
The school record shows the child's date of admission to the school;
The school record shows the child's date of birth;
The school record shows a U.S. place of birth for the child;
The school record shows the name(s) and place(s) of birth of the applicant's parents.

xvii) Federal or State census record showing U.S. citizenship or a U.S. place of birth and the applicant's age. xviii) One of the following documents that shows a U.S. place of birth and was created at least 5 years before the application for The Medical Assistance Program. For children under 16 the document must have been created near the time of birth or at least 5 years before the date of application.

Seneca Indian tribal census record;
Bureau of Indian Affairs tribal census records of the Navajo Indians;
U.S. State Vital Statistics official notification of birth registration;
A delayed U.S. public birth record that is recorded more than 5 years after the person's birth;
Statement signed by the physician or midwife who was in attendance at the time of birth; or 6) The Roll of Alaska Natives maintained by the Bureau of Indian Affairs.

xix) Institutional admission papers from a nursing facility, skilled care facility or other institution created at least 5 years before the initial application date that indicate a U.S. place of birth.

xx) Medical (clinic, doctor, or hospital) record.

The record shall have been created at least 5 years before the initial application date; and 2) The record shall indicate a U.S. place of birth.
An immunization record is not considered a medical record for purposes of establishing U.S. citizenship.
For children under 16 the document shall have been created xxi) Written affidavit. Affidavits shall only be used in rare circumstances.

They may be used by U.S. citizens or nationals born inside or outside the U.S. If documentation is by affidavit, the following rules apply:

There shall be at least two affidavits by two individuals who have personal knowledge of the event(s) establishing the applicant's or recipient's claim of citizenship (the two affidavits could be combined in a joint affidavit);
At least one of the individuals making the affidavit cannot be related to the applicant or recipient. Neither of the two individuals can be the applicant or recipient;
In order for the affidavit to be acceptable the persons making them shall provide proof of their own U.S. citizenship and identity.
If the individual(s) making the affidavit has (have) information which explains why documentary evidence establishing the applicant's claim of citizenship does not exist or cannot be readily obtained, the affidavit shall contain this information as well;
The applicant/recipient or other knowledgeable individual (guardian or representative) shall provide a separate affidavit explaining why the evidence does not exist or cannot be obtained; and 6) The affidavits shall be signed under penalty of perjury pursuant to 18 U.S.C. §1641 and Title 18 of the Criminal Code article 8 part 5 and need not be notarized.

c. Evidence of citizenship for collectively naturalized individuals. If a document shows the individual was born in Puerto Rico, the Virgin Islands of the U.S., or the Northern Mariana Islands before these areas became

part of the U.S., the individual may be a collectively naturalized citizen. A second document from 8.100.3.H.3. to establish identity shall also be presented.

i) Puerto Rico:

Evidence of birth in Puerto Rico on or after April 11, 1899 and the applicant's statement that he or she was residing in the U.S., a U.S. possession or Puerto Rico on January 13, 1941; OR 2) Evidence that the applicant was a Puerto Rican citizen and the applicant's statement that he or she was residing in Puerto Rico on March 1, 1917 and that he or she did not take an oath of allegiance to Spain.

ii) US Virgin Islands:

Evidence of birth in the U.S. Virgin Islands, and the applicant's statement of residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927;

OR 2) The applicant's statement indicating residence in the U.S.

Virgin Islands as a Danish citizen on January 17, 1917 and residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927, and that he or she did not make a declaration to maintain Danish citizenship; OR 3) Evidence of birth in the U.S. Virgin Islands and the applicant's statement indicating residence in the U.S., a U.S. possession or Territory or the Canal Zone on June 28, 1932.

iii) Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI)):

Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the U.S., or a U.S. Territory or possession on November 3, 1986 (NMI local time) and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time); OR 2) Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981 (NMI local time), voter registration prior to January 1, 1975 and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time); OR 3) Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time).
If a person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile, and the individual is not a U.S. citizen.

d) Referrals for Colorado Birth Certificates i) An applicant or client who was born in the State of Colorado who does not possess a Colorado birth certificate shall receive a referral to the Department of Public Health and Environment by the county department to obtain a birth certificate at no charge, pursuant to C.R.S. § 25-2-117(2)(a)(I)(C).

ii) The referral shall be provided on county department letterhead and shall include the following:

The name and address of the applicant or client;
A statement that the county department requests that the Department of Public Health and Environment waive the birth certificate fee, pursuant to C.R.S. § 25-2- 117(2)(a)(I)(C); and 3) The name and contact telephone number for the county caseworker responsible for the referral.

iii) An applicant or client who has been referred to the Department of Public Health and Environment to obtain a birth certificate shall not be required to present a birth certificate to satisfy the citizenship documentation requirement at 8.100.3.H.2. The applicant or client shall have the right to use any of the documents listed under 8.100.3.H.2. to satisfy the citizenship documentation requirement.

The following documents shall be accepted as proof of identity and shall accompany a document establishing citizenship from the groups of documentary evidence outlined in 8.100.3.H.2.b. through d.

a) A driver's license issued by a State or Territory either with a photograph of the individual or other identifying information such as name, age, sex, race, height, weight, or eye color;

b) School identification card with a photograph of the individual;

c) U.S. military card or draft record;

d) Identification card issued by the Federal, State, or local government with the same information included on driver's licenses;

e) Military dependent's identification card;

f) U.S. Coast Guard Merchant Mariner card;

g) Certificate of Degree of Indian Blood, or other U.S. American Indian/Alaska Native Tribal document with a photograph or other personal identifying information relating to the individual. The document is acceptable if it carries a photograph of the individual or has other personal identifying information relating to the individual such as age, weight, height, race, sex, and eye color; or h) Three or more documents that together reasonably corroborate the identity of an individual provided such documents have not been used to establish the individual's citizenship and the individual submitted evidence of citizenship listed under 8.100.3.H.2.b. or 8.100.3.H.2.c. The following requirements must be met:

i) No other evidence of identity is available to the individual;

ii) The documents must at a minimum contain the individual's name, plus any additional information establishing the individual's identity; and iii) All documents used must contain consistent identifying information.

iv) These documents include, but are not limited to, employer identification cards, high school and college diplomas from accredited institutions (including general education and high school equivalency diplomas), marriage certificates, divorce decrees, and property deeds/titles.

i) Special identity rules for children. For children under 16, the following records are acceptable:

i) Clinic, doctor, or hospital records; or ii) School records.

The school record may include nursery or daycare records and report cards; and 2) The school, nursery, or daycare record must be verified with the issuing school, nursery, or daycare.
If clinic, doctor, hospital, or school records are not available, an affidavit may be used if it meets the following requirements:

a) It shall be signed under penalty of perjury by a parent or guardian;

b) It shall state the date and place of birth of the child;

c) It cannot be used if an affidavit for citizenship was provided.

d) The affidavit is not required to be notarized.

e) An affidavit may be accepted on behalf of a child under the age of 18 in instances when school ID cards and drivers' licenses are not available to the individual until that age.

j) Special identity rules for disabled individuals in institutional care facilities.

i) An affidavit may be used for disabled individuals in institutional care facilities if the following requirements are met:

It shall be signed under penalty of perjury by a residential care facility director or administrator on behalf of an institutionalized individual in the facility; and 2) No other evidence of identity is available to the individual.
The affidavit is not required to be notarized.

k) Expired identity documents.

i) Identity documents do not need to be current to be acceptable. An expired identity document shall be accepted as long as there is no reason to believe that the document does not match the l) Referrals for Colorado Identification Cards i) An applicant or client who does not possess a Colorado driver’s license or identification card shall be referred to the Department of Revenue Division of Motor Vehicles by the county department to obtain an identification card at no charge, pursuant to C.R.S. § 42- 2- 306(1)(a)(II).

ii) The referral shall be provided on county department letterhead and shall include the following:

The name and address of the applicant or client;
A statement that the county department requests that the Department of Revenue Division of Motor Vehicles waive the identification card fee, pursuant to C.R.S § 42-2- 306(1)(a)(II).; and 3) The name and contact telephone number for the county caseworker responsible for the referral.

iii) An applicant or client who has been referred to the Division of Motor Vehicles to obtain an identification card shall not be required to present a Colorado identification card to satisfy the identity documentation requirement at 8.100.3.H.3. The applicant or client shall have the right to use any of the documents listed under 8.100.3.H.3. to satisfy the identity documentation requirement.

Documentation Requirements a. Citizenship and identity documents may be submitted as originals, certified copies, photocopies, facsimiles, scans or other copies.

b. Individuals who submitted notarized copies of citizenship and identity documents as part of an application or redetermination before January 1, 2008 shall not be required to submit originals or copies certified by the issuing agency for any application or redetermination processed on or after January 1, 2008.

c. All citizenship and identity documents shall be presumed to be genuine unless the authenticity of the document is questionable.

d. Individuals shall not be required to submit citizenship and identity documentation in person. Documents shall be accepted from a Medical Assistance applicant or client or from his or her guardian or authorized representative in person or by mail.

i) Individuals are strongly encouraged to use alternatives to mailing original documents to counties, such as those described in 8.100.3.H.4.e.

e. Individuals may present original citizenship and identity documents or copies certified by the issuing agency to Medical Assistance (MA) sites, School-based Medical Assistance sites, Presumptive Eligibility (PE) sites, Federally Qualified Health Centers (FQHCs), Disproportionate Share Hospitals (DSHs), or any other location designated by the Department by published agency letter.

i) Staff at these locations shall make a copy of the original documents and shall complete a “Citizenship and Identity Documentation Received” form, stamp the copy, or provide other verification that identifies that the documents presented were originals. The verification shall include the name, telephone number, organization name and address, and signature of the individual who reviewed the document(s). This form, stamp, or other verification shall be attached to or directly applied to the copy.

ii) Upon request by the client or eligibility site, the copy of the original document with the “Citizenship and Identity Documentation Received” form, stamp, or other verification as described in 8.100.3.H.4.e. i) shall be mailed or delivered directly to the eligibility site within five business days.

f. Counties shall accept photocopies of citizenship and identity documents from any location described in 8.100.3.H.4.e provided the photocopies include the form, stamp, or verification described in 8.100.3.H.4.e.i).

g. Counties shall develop procedures for handling original citizenship and identity documents to ensure that these documents are not lost, damaged, or destroyed.

i) Upon receiving the original documents, eligibility site staff shall make a copy of the original documents and shall complete a “Citizenship and Identity Documentation Received” form, stamp the copy, or provide other verification that identifies that the documents presented were originals, as described in 8.100.3.H.4.e. i). This form, stamp, or other verification shall be attached to or directly applied to the copy.

ii) The original documents shall be sent by mail or returned to the individual in person within five business days of the date on which they were received.

iii) To limit the risk of original documents being lost, damaged, or destroyed, counties are strongly encouraged to make copies of documents immediately upon receipt and to return original documents to the individual while he or she is present.

h. Once an individual has provided the required citizenship and identity documentation, he or she shall not be required to submit the documentation again unless:

i) Later evidence raises a question about the individual's citizenship or identity; or ii) There is a gap of more than five years between the ending date of the individual's last period of eligibility and a subsequent application for The Medical Assistance Program and the eligibility site has not retained the citizenship and identity documentation the individual previously provided.

Record Retention Requirements a. The eligibility site shall retain a paper or electronically scanned copy of an individual's citizenship and identity documentation, including any verification described in 8.100.3.H.4.e.i), for at least five years from the ending date of the individual's last period of Medical Assistance eligibility.
Name Change Provisions a. An individual who has changed his or her last name for reasons including, but not limited to, marriage, divorce, or court order shall not be required to produce any additional documentation concerning the name change unless:

i) With the exception of the last name, the personal information in the citizenship and identity documentation provided by the individual does not match in every way;

ii) In addition to changing his or her last name, the individual also changed his or her first name and/or middle name; or iii) There is a reasonable basis for questioning whether the citizenship and identity documents belong to the same individual.

Reasonable Level of Assistance a. The eligibility site shall provide a reasonable level of assistance to applicants and clients in obtaining the required citizenship and identity b. Examples of a reasonable level of assistance include, but are not limited i) Providing contact information for the appropriate agencies that issue the required documents;

ii) Explaining the documentation requirements and how the client or applicant may provide the documentation; or iii) Referring the applicant or client to other agencies or organizations which may be able to provide further assistance.

c. The eligibility site shall not be required to pay for the cost of obtaining required documentation.

Individuals Requiring Additional Assistance a. The eligibility site shall provide additional assistance beyond the level described in 8.100.3.H.7 to applicants and clients in obtaining the required citizenship and identity documentation if the client or applicant:

i) Is unable to comply with the requirements due to physical or mental impairments or homelessness; and ii) The individual lacks a guardian or representative who can provide b. Examples of additional assistance include, but are not limited to:

i) Contacting any known family members who may have the required documentation;

ii) Contacting any known current or past health care providers who may have the required documentation; or iii) Contacting other social services agencies that are known to have provided assistance to the individual.

c. The eligibility site shall document its efforts to provide additional assistance to the client or applicant. Such documentation shall be subject to the record retention requirements described in 8.100.3.H.5.a.

Reasonable Opportunity Period a. If a Medical Assistance applicant does not have the required documentation, he or she must be given a reasonable opportunity period to provide the required documentation. The reasonable opportunity period will begin as of the date of the Notice of Action. The required documentation must be received within the reasonable opportunity period.

If the applicant does not provide the required documentation within the reasonable opportunity period, then the applicant's Medical Assistance benefits shall not be terminated during the federal Coronavirus COVID-19 Public Health Emergency. Required documentation will be requested during the federal Coronavirus COVID-19 Public Health Emergency. When the federal COVID-19 Public Health Emergency has ended, a reasonable opportunity period will be given to request proper documentation from the i) During the federal Coronavirus COVID-19 Public Health Emergency the Department will continue eligibility for all Medical Assistance categories, regardless of requested documentation and/or reported change for these individuals to ensure continuity of eligibility for Medical Assistance coverage.

Effective May 11, 2023 the Public Health Emergency declaration has ended and continuous coverage for individuals who have not provided required documentation by their renewal date will be terminated.

b. The reasonable opportunity period is 90 calendar days if unable to verify proof of citizenship/identity and applies to MAGI, Adult, and Buy-In Programs:

i) For the purpose of this section only, MAGI Programs for persons covered pursuant to 8.100.4.G or 8.100.4.I, include the following:

Commonly Used Program Name Rule Citation Children’s Medical Assistance 8.100.4.G.2 Parent and Caretaker Relative Medical 8.100.4.G.3 Adult Medical Assistance 8.100.4.G.4 Pregnant Women Medical Assistance 8.100.4.G.5 Transitional Medical Assistance 8.100.4.I.1-5 ii) For the purpose of this section only, Adult and Buy-In Programs for persons covered pursuant to 8.100.3.F, 8.100.6.P, 8.100.6.Q, or 8.715 include the following:

Commonly Used Program Name Rule Citation Old Age Pension A (OAP-A) 8.100.3.F.1.c Old Age Pension B (OAP-B) 8.100.3.F.1.c Qualified Disabled Widow/Widower 8.100.3.F.1.e Pickle 8.100.3.F.1.e Long-Term Care 8.100.3.F.1.fh Medicaid Buy-In Program for Working Adults with Disabilities 8.100.6.P Medicaid Buy-In Program for Children with 8.100.6.Q Breast and Cervical Cancer Program (BCCP) 8.715 10. Good Faith Effort a. In some cases, a Medical Assistance client or applicant may not be able to obtain the required documentation within the applicable reasonable opportunity period. If the client or applicant is making a good faith effort to obtain the required documentation, then the reasonable opportunity period should be extended. The amount of time given should be determined on a case-by-case basis and should be based on the amount of time the individual needs to obtain the required documentation.

Examples of good faith effort include, but are not limited to:

i) Providing verbal or written statements describing the individual’s effort at obtaining the required documentation;

ii) Providing copies of emails, letters, applications, checks, receipts, or other materials sent or received in connection with a request for documentation; or iii) Providing verbal or written statements of the individuals’ efforts at identifying people who could attest to the individual’s citizenship or identity, if citizenship and/or identity are included in missing An individual’s verbal statement describing his or her efforts at securing the required documentation should be accepted without further verification unless the accuracy or truthfulness of the statement is questionable. The individual’s good faith efforts should be documented in the case file and are subject to all record retention requirements. 8.100.3.I. Additional General Eligibility Requirements 1. Each person for whom Medical Assistance is being requested shall furnish a Social Security Number (SSN); or, if one has not been issued or is unknown, shall apply for the number and submit verification of the application, unless an exception below applies. The application for an SSN shall be documented in the case record by the eligibility site. Upon receipt of the assigned SSN, the client shall provide the number to the eligibility site. This requirement does not apply to those individuals who are not requesting Medical Assistance yet appear on the application, nor does it apply to individuals applying for emergency medical services, limited reproductive health services, or eligible newborns born to a Medical Assistance eligible mother.

a. An applicant's or client's refusal to furnish or apply for a Social Security Number affects the family's eligibility for assistance as follows:

i) that person cannot be determined eligible for the Medical Assistance Program; and/or ii) if the person with no SSN or proof of application for SSN is the only dependent child on whose behalf assistance is requested or received, assistance shall be denied or terminated.

b. Exception: An individual who qualifies for any of the following exceptions must not be required to provide an SSN: i.) The individual is not eligible to receive an SSN; or ii) The individual does not have an SSN and may only be issued an SSN for a valid non-work reason in accordance with 20 CFR 422.104; or iii) The individual refuses to obtain an SSN because of a wellestablished religious objection.

c. Due to the COVID-19 Public Health Emergency, the Department will accept self-attestations for SSN verification. At the end of the COVID-19 Public Health Emergency, verification for eligibility criteria will be required as specified prior to the public health emergency. Effective May 11, 2023 the Coronavirus COVID-19 Public Health Emergency has been declared to end.

A person who is applying for or receiving Medical Assistance shall assign to the State all rights against any other person (including but not limited to the sponsor of an alien) for medical support or payments for medical expenses paid on the applicant's or client's behalf or on the behalf of any other person for whom application is made or assistance is received.

All appropriate clients of the Medical Assistance Program shall have the option to be referred for child support enforcement services using the form as specified by the Department.

A person who is applying for or receiving Medical Assistance shall provide information regarding any third party resources available to any member of the assistance unit. Third party resources are any health coverage or insurance other than the Medical Assistance Program. A client’s refusal to supply information regarding third party resources may result in loss of Medical Assistance Program 4. A person who is eligible for Medical Assistance shall be free to choose any qualified and approved participating institution, agency, or person offering care and services which are benefits of the program unless that person is enrolled in a managed care program operating under Federal waiver authority. 8.100.3.J. Supplemental Security Income (SSI) And Aid To The Needy Disabled (AND) Recipients 1. Persons who may be eligible for benefits under either MAGI Medical Assistance or SSI:

a. shall be advised of the benefits available under each program;

b. may apply for a determination of eligibility under either or both programs;

c. have the option to receive benefits under the program of their choice, but may not receive benefits under both programs at the same time; and d. may change their selection if their circumstances change or if they decide later that it would be more advantageous to receive benefits from the other program.

Any family member who is receiving financial assistance from SSI or OAP-A is not considered a member of the Medical Assistance required household, is not counted as a member of the household, and the individual's income and resources are disregarded in making the determination of need for Medical a. Exception: For MAGI Medical Assistance a family member who is receiving SSI, when appropriate can be counted as a member of the household and their income when appropriate can be considered in making the determination of eligibility for MAGI Medical Assistance. For treatment of income and household construction for MAGI Medical Assistance cases, see section 8.100.4.
An individual receiving Aid to the Needy Disabled (AND) may also receive MAGI Medical Assistance, if the recipient meets the eligibility requirements for MAGI Medical Assistance. For these individuals, eligibility sites shall not include the applicant’s AND payment when calculating income to determine the household’s financial eligibility for MAGI Medical Assistance. 8.100.3.K. Consideration of Income 1. Income or resources of an alien sponsor or an alien sponsor’s spouse shall be countable to the sponsored alien effective December 19, 1997. Forms used prior to December 19, 1997, including but not limited to forms I-134 or I-136 are legally unenforceable affidavits of support. The attribution of the income and resources of the sponsor and the sponsor's spouse to the alien will continue until the alien becomes a U.S. citizen or has worked or can be credited with 40 qualifying quarters of work, provided that an alien crediting the quarters to the applicant/client has not received any public benefit during any creditable quarter for any period after December 31, 1996.

a. Exception: When the sponsored alien is a pregnant woman or a child the income or resources of an alien sponsor or an alien sponsor’s spouse will not be countable to the sponsored alien.

Income, in general, is the receipt by an individual of a gain or benefit in cash or in kind during a calendar month. Income means any cash, payments, wages, inkind receipt, inheritance, gift, prize, rents, dividends, interest, etc., that are received by an individual or family.
Earned income is payment in cash or in kind for services performed as an employee or from self-employment.
Earned in kind income shall be income produced as a result of the performance of services by the applicant/client, for which he/she is compensated in shelter or other items in lieu of wages.
Received means “actually” received or legally becomes available, whichever occurs first; the point at which the income first is available to the individual for use. For example, interest income on a savings account is counted when it is credited to the account.
All Home Care Allowance (HCA) income paid to a Medical Assistance applicant or member by the HCA recipient to provide home care services is countable 7. An applicant or member who is a live-In home care provider to a care recipient receiving a Difficulty of Care Payment and who is being determined for a MAGI Medical Assistance program, must meet the following requirements for Difficulty of Care payments to be excluded as countable income:

a. The care provider receiving payments for personal care or supportive services provided to a care recipient must live full-time in the same home with the care recipient; and b. The care recipient must either i) receiving personal care or supportive services must be enrolled in Long Term Service Supports (LTSS), with additional services through a Home-Based Services (HCBS) waiver program; or ii) The care recipient must be enrolled in the Buy-In Program for Working Adults with Disabilities, and receive additional services through the Home and Community Based Services (HCBS) waiver program.

c. Exception: Difficulty of Care Payments are not excluded if the payments are for more than 10 qualified foster individuals under the age of 19 or 5 qualified foster individuals who are over the age of 19 8. Participation in the Workforce Investment Act (WIA) affects eligibility for Medical Assistance as follows:

a. Wages derived from participation in a program carried out under WIA (work experience or on-the-job training) and paid to a caretaker relative is considered countable earned income.

b. Training allowances granted by WIA to a dependent child or a caretaker relative of a dependent child to participate in a training program is exempt.

c. Wages derived from participation in a program carried out the under Workforce Investment Act (WIA) and paid to any dependent child who is applying for or receiving Medical Assistance are exempt in determining eligibility for a period not to exceed six months in each calendar year.

An individual involved in a profit-making activity as a sole proprietor, partner in a partnership, independent contractor, or consultant shall be classified as selfemployed.

a. To determine the net profit of a self-employed applicant/client deduct the cost of doing business from the gross income. These business expenses include, but are not limited to:

i) the rent of business premises, ii) wholesale cost of merchandise, iii) utilities, iv) taxes, v) labor, and vi) upkeep of necessary equipment.

b. The following are not allowed as business expenses:

i) Depreciation of equipment;

Exception: For the purpose of calculating MAGI-based income, depreciation of equipment is an allowable business expense if the equipment is not used for capital improvements.

ii) The cost of and payment on the principal of loans for capital asset or durable goods;

iii) Personal expenses such as personal income tax payments, lunches, and transportation to and from work.

c. Appropriate allowances for cost of doing business for Medical Assistance clients who are licensed, certified or approved day care providers are (1) $ 55 for the first child for whom day care is provided, and (2) $ 22 for each additional child. If the client can document a cost of doing business which is greater than the amounts above set forth, the procedure described in A, shall be used.

d. When determining self-employment expenses and distinguishing personal expenses from business expenses it is a requirement to only allow the percentage of the expense that is business related.

Self-employment income includes, but is not limited to, the following:

a. Farm income - shall be considered as income in the month it is received.

When an individual ceases to farm the land, the self-employment deductions are no longer allowable.

b. Rental income - shall be considered as self-employment income only if the Medical Assistance client actively manages the property at least an average of 20 hours per week.

c. Board (to provide a person with regular meals only) payment shall be considered earned income in the month received to the extent that the board payment exceeds the maximum food stamp allotment for oneperson household per boarder and other documentable expenses directly related to the provision of board.

d. Room (to provide a person with lodging only) payments shall be considered earned income in the month received to the extent that the room payment exceeds documentable expenses directly related to the provision of the room.

e. Room and board payments shall be considered earned income in the month received to the extent that the payment for room and board exceeds the food stamp allotment for a one-person household per room and boarder and documentable expenses directly related to the provision of room and board.

Unearned income is the gross amount received in cash or kind that is not earned from employment or self-employment. Unearned income includes, but is not limited to, the following:

a. Pensions and other period payments, such as:

i) Private pensions or disability benefits 1) Exception: Refer to section 8.100.4 for treatment of private disability benefits for MAGI Medical Assistance.

ii) Social Security benefits (Retirement, survivors, and disability)

iii) Workers' Compensation payments iv) Railroad retirement annuities v) Unemployment insurance payments vi) Veterans benefits other than Aid and Attendance (A&A) and Unusual Medical Expenses (UME).

vii) Alimony and support payments viii) Interest, dividends and certain royalties on countable resources 12. For all Medical Assistance categories, the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and American Rescue Plan (ARP) Act Recovery Rebate, known as the COVID-19 Economic Stimulus, shall be exempt from consideration as income.

Federal Pandemic Unemployment Compensation (FPUC) program, which provides an extra $600.00 a week for qualifying individuals, is exempt as countable unearned income for all Medical Assistance categories.
Federal Income Tax refunds, Earned Income Tax Credit payments, or Child Tax Credits, are exempt from consideration as income. 8.100.3.L Consideration of Resources Consideration of Resources 1. Resources are counted in determining eligibility for the Aged, Blind and Disabled, and Long-Term Care institutionalized and Home and Community Based Services categories of Medical Assistance. Resources are not counted in determining eligibility for the MAGI Medical Assistance programs, the Medicaid Buy-in Program for Working Adults with Disabilities, or the Medicaid Buy-In Program for Children with Disabilities, See section 8.100.5 for rules regarding consideration of resources.
The federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and American Rescue Plan (ARP) Act Recovery Rebate known as COVID-19 Economic Stimulus, shall be an exempt resource for the first 12 months following the receipt of the Recovery Rebate, after which the remaining balance will be considered a countable resource for all Medical Assistance categories which include an asset test. 8.100.3.M. Federal Financial Participation (FFP)
The state is entitled to claim federal financial participation (FFP) for benefits paid on behalf of groups covered under the Colorado Medical Assistance Program and also for the Medicare supplementary medical insurance benefits (SMIB) premium payments made on behalf of certain groups of categorically needy persons.
The SISC codes are as follows:

a. Code A - for institutionalized persons whose income is under 300% of the SSI benefit level and who, except for the level of their income, would be eligible for an SSI payment; and non-institutionalized persons receiving Home and Community Based Services, whose income does not exceed 300% of the SSI benefit level and who, except for the level of their income, would be eligible for an SSI payment; code A signifies that FFP is available in expenditures for medical care and services which are benefits of the Medical Assistance program but not for SMIB premium payments;

b. Code B - for persons eligible to receive financial assistance under SSI; persons eligible to receive financial assistance under OAP “A” who, except for the level of their income, would be eligible for an SSI payment; persons who are receiving mandatory State supplementary payments; and persons who continue to be eligible for Medical Assistance after disregarding certain Social Security increases; code B signifies that FFP is available in expenditures for medical care and services which are benefits of the Medical Assistance program and also for SMIB premium payments;

c. Code C - for persons eligible to receive assistance under OAP “A”, OAP “B”, or OAP Refugee Assistance for financial assistance only; who do not receive SSI payment and do not otherwise qualify under SISC code B as described in item B. above; code C signifies that no FFP is available in Medical Assistance program expenditures.

d. Code D1 – for persons eligible to receive assistance under AwDC from program implementation through 12/31/2013; Code D1 signifies 50% FFP is available in expenditures for medical care and services which are benefits of the Medical Assistance program.

e. Code E1 - for persons eligible to receive assistance under the Medicaid Buy-In Program for Working Adults with Disabilities and whose annual adjusted gross income, as defined under IRS statute, is less than or equal to 450% of FPL – after SSI earned income deductions; as well as for children eligible to receive assistance under the Medicaid Buy-In Program for Children with Disabilities and whose household income is less than or equal to 300% of FPL after income disregards. Code E1 signifies that FFP is available in expenditures for medical care and services which are benefits of the Medical Assistance program but not for SMIB premium payments.

Recipients of financial assistance under State AND, State AB, or OAP “C” are not automatically eligible for Medical Assistance and the SISC code which shall be entered on the eligibility reporting form is C. 8.100.3.N. Confidentiality 1. All information obtained by the eligibility site concerning an applicant for or a recipient of Medical Assistance is confidential information.
A signature on the Single Streamlined Application and the Application for Public Assistance allows an eligibility site worker to consult banks, employers, or any other agency or person to obtain information or verification to determine eligibility.

The identification of the worker as an eligibility site employee will, in itself, disclose that an application for the Medical Assistance Program has been made by an individual. In this type of contact, as well as other community contacts, the eligibility site should strive to maintain confidentiality. The signature on the Single Streamlined Application and the Application for Public Assistance also provides permission for the release of the client's medical information to be provided by health care providers to the State and its agents for purpose of administration of the Medical Assistance Program.

Eligibility site staff may release a client's Medical Assistance state identification number and approval eligibility spans to a Medical Assistance provider for billing purposes.

Eligibility site staff may inform a Medical Assistance provider that an application has been denied but may not inform them of the reason why.

Access to information concerning applicants or recipients must be restricted to persons or agency representatives who are subject to standards of confidentiality that are comparable to those of the State and the eligibility site.
The eligibility site must obtain permission from a family, individual, or authorized representative, whenever possible, before responding to a request for information from an outside source, unless the information is to be used to verify income, eligibility and the amount of Medical Assistance payment. This permission must be obtained unless the request is from State authorities, federal authorities, or State contractors acting within the scope of their contract. If, because of an emergency situation, time does not permit obtaining consent before release, the eligibility site must notify the family or individual immediately after supplying the information.
The eligibility site policies must apply to all requests for information from outside sources, including government bodies, the courts, or law enforcement officials. If a court issues a subpoena for a case record or for any eligibility site representative to testify concerning an applicant or recipient, the eligibility site must inform the court of the applicable statutory provisions, policies, and regulations restricting disclosure of information.
The following types of information are confidential and shall be safeguarded:

a. Names and addresses of applicants for and recipients of the Medical Assistance Program;

b. Medical services provided;

c. Social and economic conditions or circumstances;

d. Agency evaluation of personal information;

e. Medical data, including diagnosis and past history of disease or disability;

f. All information obtained through the Income and Eligibility Verification System (IEVS), the Federal Data Services Hub (FDSH), Equifax The Work Number (TWN), Colorado Department of Labor and Employment, SSA or Internal Revenue Service;

g. Any information received in connection with identification of legally liable third party resources;

h. Any information received for verifying income and resources if applicable, or other eligibility and the amount of Medical Assistance payments;

i. Social Security Numbers.

The confidential information listed above may be released to persons outside the eligibility site only as follows:

a. In response to a valid subpoena or court order;

b. To State or Federal auditors, investigators or others designated by the Federal or State departments on a need-to-know basis;

c. To individuals executing Income and Eligibility Verification System;

d. Child Support enforcement officials;

e. To a recipient or applicant themselves or their designated representative.

f. To a Long Term Care institution on the AP-5615 form.

The applicant/recipient may give a formal written release for disclosure of information to other agencies, such as hospitals, or the permission may be implied by the action of the other agency in rendering service to the client. Before information is released, the eligibility site should be reasonably certain the confidential nature of information will be preserved, the information will be used only for purposes related to the function of the inquiring agency, and the standards of protection established by the inquiring agency are equal to those established by the State Department. If the standards for protection of information are unknown, a written consent from the recipient shall be obtained. 8.100.3.O. Protection Against Discrimination 1. Eligibility sites are to administer the Medical Assistance Program in such a manner that no person will, on the basis of race, color, sex, age, religion, political belief, national origin, or handicap, be excluded from participation, be denied any aid, care, services, or other benefits of, or be otherwise subjected to discrimination in such program.
The eligibility site shall not, directly or through contractual or other arrangements, on the grounds of race, color, sex, age, religion, political belief, national origin, or handicap:

a. Provide aid, care, services, or other benefits to an individual which is different, or provided in a different manner, from that of others;

b. Subject an individual to segregation barriers or separate treatment in any manner related to access to or receipt of assistance, care services, or other benefits;

c. Restrict an individual in any way in the enjoyment or any advantage or privilege enjoyed by others receiving aid, care, services, or other benefits provided under the Medical Assistance Program;

d. Treat an individual differently from others in determining whether he/she satisfies any eligibility or other requirements or conditions which individuals shall meet in order to receive aid, care, services, or other benefits provided under the Medical Assistance Programs;

e. Deny an individual an opportunity to participate in programs of assistance through the provision of services or otherwise, or afford him/her an opportunity to do so which is different from that afforded others under the 3. No distinction on the grounds of race, color, sex, age, religion, political belief, national origin, or handicap is permitted in relation to the use of physical facilities, intake and application procedures, caseload assignments, determination of eligibility, and the amount and type of benefits extended by the eligibility site to Medical Assistance recipients.

An individual who believes he/she is being discriminated against may file a complaint with the eligibility site, the Department, or directly with the Federal government. When a complaint is filed with the eligibility site, the county director is responsible for an immediate investigation of the matter and taking necessary corrective action to eliminate any discriminatory activities found. If such activities are not found, the individual is given an explanation. If the person is not satisfied, he/she is requested to direct his/her complaint, in writing, to the State Department, Complaint Section, which will be responsible for further investigation and other necessary action consistent with the provisions of Title VI of the 1963 Civil Rights Act, as amended 42 U.S.C. §2000e et seq. and section 504 of the Rehabilitation Act of 1973, as amended 29 U.S.C. §791. 8.100.3.P. Redetermination of Eligibility 1. “Redetermination of eligibility” is a case review and/or the request for necessary verification to determine whether a member enrolled in a Medical Assistance Program continues to be eligible.

Eligibility shall be redetermined at least every twelve months since a member’s last eligibility determination. Eligibility may be redetermined through telephone, mail, or online electronic means. Prior to making a determination of ineligibility, the eligibility site must review on all bases of Medical Assistance eligibility for a 2. “Ex Parte Review” is a redetermination of eligibility for a member without requesting verification by utilizing available information from the member’s account, electronic sources, and other assistance programs. Ex parte Reviews will be conducted as follows:

a. If verified information is available for any of the six months prior to the redetermination month, and the member meets all other eligibility requirements, then an approval notice will be sent to eligible members of the household who are requesting assistance. This approval notice shall include directions on how to view the information used to determine eligibility and the member is not required to sign and return such notice if all information provided on such notice is accurate.

b. If all required information is not available and/or the information on file does not support a finding of eligibility, a redetermination form, as described in Section 8.100.3.P.3, and/or a verification form will be issued to the household at least 30 days before the end of the eligibility period.

Redetermination forms shall direct members to verify that the information provided on the form is accurate or to report any changes to the information. The following procedures pertain to the redetermination forms:

a. A redetermination form shall be sent to the member along with any required verifications to be completed.

b. The member must complete and return the redetermination with the necessary verifications and the signature form.

c. If the member is unable to complete the redetermination forms due to a disability (a physical or mental impairment that substantially limits one or more major life activity) or other good cause, in response to a request from the member, the eligibility site shall assist the member in accordance with its Civil Rights Plan as described in Section 10 CCR 2505-5 1.020.7.1.d. The assistance of the eligibility site shall be recorded in the case record and CBMS case comments.

d. The redetermination form shall require that a recipient and community spouse of a recipient of HCBS, PACE, or institutional services disclose a description of any interest the member or community spouse has in an annuity or similar financial instrument regardless of whether the annuity is irrevocable or treated as an asset. The redetermination form shall include a statement that the Department shall be a remainder beneficiary for any annuity or similar financial instrument purchased on or after February 8, 2006, for the total amount of Medical Assistance provided to the member.

e. The eligibility site shall notify in writing the issuer of any annuity or financial instrument that the Department is a preferred remainder beneficiary in the annuity or similar financial instrument for the total amount of Medical Assistance provided to the member. This notice shall require the issuer to notify the eligibility site when there is a change in the amount of income or principal that is being withdrawn from the annuity.

f. If the member submits the redetermination form and/or verification information before the end of the eligibility period, the member must maintain coverage until the eligibility site can make a final determination.

g. If the member submits the redetermination form and/or verification information after the end of the eligibility period, the member will not maintain coverage.

h. If a member fails to sign the signature form or comply with any of these requirements, the member will be terminated from the program for failure to complete the redetermination process.

The eligibility site shall perform the following actions upon receiving the redetermination form and/or verification information:

a. Date-stamp all submitted documentation upon receipt to ensure accurate processing timeliness.

b. Thoroughly review the submitted documentation for completeness, accuracy, and consistency.

c. Document verifications in the case file and CBMS case comments. The case file shall be used as a checklist in the redetermination process and shall be used to keep track of matters requiring further action.

d. Determine eligibility 30 calendar days from the date of receiving the redetermination form and/or verification information.

e. If incomplete information is submitted or a member reports new changes, contact the member by telephone or in writing to provide required documents or requested verifications. If requested verifications are needed, the eligibility site must send a form with a letter specifying the items that require completion. The member shall return the completed request form to the eligibility site no later than ten working days. The eligibility site will have fifteen working days from the date the documents are received to make a final determination.

“Reconsideration period” is the 90-day time period after a member's eligibility is terminated due to failure to return the redetermination with the necessary verifications and the signature. The member’s eligibility must be reconsidered if the member submits the requested information within 90 days following termination of eligibility.

a. Members who return properly completed redetermination forms and requested information during the reconsideration period will not be required to submit a new application for eligibility. If redetermination form and requested information are not returned within 90 days after the termination, the member must submit a new application for enrollment in the program.

b. For members who are determined to be eligible for Medical Assistance within the reconsideration period, the effective date of coverage will be the first day of the month in which the redetermination form was returned. If the member has a gap in coverage due to submitting the redetermination within the reconsideration period, the member can request up to three months in retroactive coverage. 8.100.3.Q. Continuous Eligibility (CE) for Medical Assistance programs 1. Continuous eligibility applies to children under age 19, who through an eligibility determination, reassessment or redetermination, are found eligible for a Medical Assistance program. The continuous eligibility period may last for up to 12 months.

a. The continuous eligibility period applies without regard to changes in income or other factors that would otherwise cause the child to be ineligible.

b. Exception: A child’s continuous eligibility period will end effective the earliest possible month if any of the following occur:

i) Child is deceased;

ii) Becomes an inmate of a public institution;

Incarcerated children receiving a full medical assistance program will move to a limited Incarceration benefit. If the child is released within the initial 12 months of the CE period, full coverage will be reinstated for the remaining 12-month CE period, unless any of the other exceptions apply;

iii) The child is no longer part of the Medical Assistance required household;

iv) Is no longer a Colorado resident;

v) Is unable to be located; based on evidence or reasonable assumption;

vi) Requests to be withdrawn from continuous eligibility;

vii) Fails to provide documentation during a reasonable opportunity period as specified in section 8.100.3.G.3 and 8.100.3.H.9; or viii) Eligibility was erroneously granted at the most recent determination, redetermination, or renewal of eligibility because of agency error, or a finding of fraud or perjury attributed to the child or the child's responsible party.

The continuous eligibility period will begin on the first day of the month the application is received, or from the date all criteria are met. For a child transitioning from CHP+ to the MAGI Medical Assistance program specified in

section 8.100.4.G.2, a new 12-month continuous eligibility period will begin on the first day of the month of the transition. Continuous eligibility applies to children enrolled in the following Medical Assistance programs:

a. MAGI-Medical Assistance, program as specified in section 8.100.4.G.2;

b. SSI Mandatory, as specified in section 8.100.6.C i.) When a child is no longer eligible for SSI Mandatory they will be categorized as eligible within the MAGI-Child category for the remainder of the eligibility period;

c. Long- Term Care services i.) When a child is no longer eligible for Long-Term Care services they will be categorized as eligible within the MAGI- Child category for the remainder of the eligibility period;

d. Medicaid Buy-In program specified in section 8.100.6.Q i) Exception: Enrollment will be discontinued if there is a failure to pay premiums;

e. Pickle (Title II COLA/Pickle Amendment of 1977);

f. Disabled Adult Child (DAC); and g. Limited Family Planning Medical Assistance.

Children, under the age of 19, no longer enrolled in Foster Care Medicaid will be eligible for the MAGI-Medical Assistance program. The continuous eligibility period will begin the month the child is no longer enrolled in Foster Care Medicaid as long as they meet one of the following conditions:

a. Begin living with other Relatives;

b. Are reunited with Parents; or c. Have received guardianship. 8.100.3.R. Presumptive Eligibility by Qualified Hospitals 1. Hospital Presumptive Eligibility is for inpatient and/or outpatient services through a qualified hospital presumptive eligibility site that assists individuals in completing a medical assistance application. These presumptive eligibility services are for ambulatory services, state plan approved medical services, or limited family planning.

a. A pregnant woman may apply for presumptive eligibility for ambulatory services through a qualified hospital presumptive eligibility site.

b. A child or youth under the age of 19 may apply for themself or have an adult apply on their behalf for presumptive eligibility for state plan approved medical services through a qualified hospital presumptive eligibility site.

c. An applicant aged 19-65, an applicant who is a parent or caretaker relative of dependent children, or an applicant age 16 or older who is currently employed and meet the Social Security Administration’s definition of disability or have a limited disability as determined by a state contractor may apply for presumptive eligibility for state plan approved medical services through a qualified hospital presumptive eligibility site.

d. Presumptive eligibility is also available to applicants for limited family planning who are not pregnant. There are no age or gender restrictions under the limited family planning presumptive eligibility category.

To be eligible for presumptive eligibility:

a. A pregnant woman must have an attested pregnancy, declare that her household's income shall not exceed 195% of the federal poverty level and declare that she is a United States citizen or a lawfully residing immigrant unless they meet the exceptions outlined under 8.100.3.G. 1.g. viii.

b. A child or youth under the age of 19 must have a declared household income that does not exceed 142% of federal poverty level and declare that the child or youth is a United States citizen or a documented immigrant unless they meet the exceptions outlined under 8.100.3.G. 1.g.viii.

c. To qualify for limited family planning presumptive eligibility, an applicant must have declared household income greater than 133% but not exceeding 260% of the federal poverty level. The applicant cannot be eligible for a Medicaid eligibility category that provides full coverage. The applicant must declare they are a United States citizen or a lawfully residing immigrant. An applicant applying for limited family planning presumptive eligibility will be counted individually as a household member of two.

d. An applicant age 19 to 65, must have a declared household income that does not exceed 133% of the federal poverty level and declare themself as a United States citizen or a documented immigrant. This category includes adults who are parents or caretaker relatives of dependent children whose income exceeds the income threshold to qualify for the Parents and Caretaker Relatives MAGI category and who meet all other eligibility criteria.

e. An applicant who is a parent or caretaker relative or legally appointed guardian or conservator of dependent children, must have a declared household income that does not exceed 68% of the federal poverty level and declare themself as a United States citizen or a documented immigrant.

f. An applicant age 16 or older who has declared they are currently employed with income less than or equal to 450% of FPL and declare they are a United States citizen or a documented immigrant unless they meet the exceptions outlined under 8.100.3.G. 1.g. viii. Only the applicant’s income will be considered. Resources are not counted in determining eligibility. Applicants must also declare they have a disability as defined as Social Security Administration medical listing or a limited disability as determined by a state contractor.

Qualified hospital presumptive eligibility sites must be certified by the Department to make presumptive eligibility determinations. Sites shall be re-certified by the Department every year to remain approved as a qualified hospital presumptive eligibility site.
The qualified hospital presumptive eligibility site must forward the medical assistance application to the County Department of Human Services within five business days.
The presumptive eligibility period begins on the date the applicant(s) is determined eligible and ends with the day an eligibility determination for Medical Assistance is made for the applicant(s).
A presumptively eligible member may not appeal the end of a presumptive eligibility period.
Medical Assistance applicants may appeal if a County Department of Human Services is unable to act within 45 days or 90 days (if a disability determination is required) of the medical assistance application date or the denial of a medical assistance application. Appeal procedures are outlined in the State Hearings

section of this volume.

Applicants cannot receive presumptive eligibility if they already are in receipt of another medical assistance program.
An applicant may only receive presumptive eligibility once every 12 months with the exception of pregnant women who may receive presumptive eligibility once every pregnancy. 8.100.4 MAGI Medical Assistance Eligibility [Eff. 01/01/2014] 8.100.4.A. MAGI Application Requirements 1. Persons requesting a MAGI Medical Assistance category need only to complete the Single Streamlined Application.
Parents and Caretaker Relatives, Pregnant Women, Children, and Adults may apply for Medical Assistance at sites other than the County Department of Social Services, including eligibility sites and Certified Application Assistance Sites (CAAS). The Department shall approve these sites to receive and initially process these applications. The application used shall be the Single Streamlined Application. The eligibility site shall determine eligibility.
The eligibility sites shall refer Medical Assistance clients who are pregnant and/or age 20 and under to EPSDT offices (designated by the Department) by:

a. Copying the page of the Single Streamlined Application that includes the EPSDT benefit questions. The eligibility site will then forward this page to the EPSDT office within five working days from the date of application approval; or by:

b. Means of secure, electronic data transfer approved by the Department 8.100.4.B. MAGI Category Verification Requirements 1. Minimal Verification – At minimum, applicants seeking Medical Assistance shall provide all of the following:

a. Social Security Number: Each individual requesting assistance on the application shall provide a Social Security Number (SSN), or each shall submit proof of an application to obtain an SSN, unless they qualify for an exception listed in 8.100.3.I.1.b. Individuals who qualify for an exception must not be required to provide an SSN.

i) Due to the COVID-19 Public Health Emergency, at the time of application, self-attestation is acceptable for SSN criteria, with the exception of verification of citizenship and immigration status. At the end of the federally declared COVID-19 Public Health Emergency, verification for SSN eligibility criteria will be required at the time of application. Effective May 11, 2023 the Coronavirus COVID-19 Public Health Emergency has been declared to end.

Applicants who meet the criteria for any categorical Medical Assistance programs, but do not meet federal and state citizenship and immigration status requirements, are only eligible to receive emergency medical services.

b. Verification of citizenship and identity as outlined in section 8.100.3.H under Citizenship and Identity Documentation Requirements.

c. Earned Income: Income -may be self-attested by an applicant or member and verified through an electronic data source. Individuals who provide self-attestation of income - may provide a SSN for electronic wage verification purposes.

If the self-attested earned income cannot be verified electronically, due to a missing SSN, the applicant must provide documentation of income.

Earned income must be verified by wage stubs, tax documents, written documentation from the employer stating the employee’s gross income or a telephone call to an employer. Applicants may request that communication with their employers be made in writing.

Estimated earned income shall be used to determine eligibility if the applicant/client provides less than a full calendar month of wage stubs for the application month. A single recent wage stub shall be sufficient if the applicant's income is expected to be the same amount for the month of application. Verification of earned income received during the month prior to the month of application shall be acceptable if the application month verification is not yet available. Actual earned income shall be used to determine eligibility if the client provides verification for the full calendar month.

Due to the Coronavirus COVID -19 Public Health Emergency, the Department will not take action on any electronic interfaces that notify that the individual’s income has changed for all Medical Assistance programs in which the individual is currently enrolled. The Department will take action and require documentation from the individual once the federal emergency declaration has concluded. Effective May 11, 2023 the Coronavirus COVID-19 Public Health Emergency has been declared to end.

d. Unearned income: Unearned income can be self-attested by an applicant.

Certain types of unearned income, such as unemployment and survivor benefits may be verified through electronic data sources. Due to the Coronavirus COVID -19 Public Health Emergency, the Department will not take action on any electronic interfaces that notify that the individual’s income has changed for all Medical Assistance programs in which the individual is currently enrolled. The Department will take action and require documentation from the individual once the federal emergency declaration has concluded, for all people whose eligibility was maintained during the emergency declaration, for these individuals to maintain eligibility.

Emergency has been declared to end.

e. Verification of Legal Immigrant Status: Immigration status may be selfdeclared by an applicant applying for Medical Assistance, to determine eligibility for full Medical Assistance benefits. This declaration of legal immigration status will be verified through the Verify Lawful Presence (VLP) interface. The VLP interface connects to the Systematic Alien Verification for Entitlements (SAVE) program to verify legal immigration status. See section 8.100.3.G for a description of the VLP interface. If status cannot be verified, or if the applicant does not provide the necessary documents within the reasonable opportunity period, then the applicant’s Medical Assistance application shall be terminated.

Additional Verification: No other verification shall be required of the client unless information is found to be questionable on the basis of fact.
The determination that information is questionable shall be documented in the applicant's case file and CBMS case comments.
Information that exists in another case record or in CBMS shall be used by the eligibility site to verify those factors that are not subject to change, if the information is reasonably accessible.
The criteria of age and relationship may be declared by the client unless questionable. If questionable, these criteria may be established with information provided from:

a. official papers such as: a birth certificate, order of adoption, marriage license, immigration or naturalization papers; or b. records or statements from sources such as: a court, school, government agency, hospital, or physician.

Establishing that a dependent child meets the eligibility criteria of:

a. age, if questionable requires (1) viewing the birth certificate or comparably reliable document at eligibility site discretion, and (2) documenting the source of verification in the case file and CBMS case comments;

b. living in the home of the caretaker relative, if questionable requires (1) viewing the appropriate documents which identify the relationship, (2) documenting these sources of verification in the case file and CBMS case comments. 8.100.4.C. MAGI Methodology for Income Calculation 1. For an in depth treatment of gross income, refer to 26 U.S.C. § 61, which is hereby incorporated by reference. The incorporation of 26 U.S.C. § 61 (2014) excludes later amendments to, or editions of, the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular 1570 Grant Street, Denver CO 80203. Certified copies of incorporated materials are provided at cost upon request. Except as otherwise provided, pursuant to 26 U.S.C. § 61 gross income means all income from all derived sources, The Modified Adjusted Gross Income calculation for the purposes of determining a household’s financial eligibility for Medical Assistance shall consist of, but is not limited to, the following:

a. Earned Income:

i) Wages, salaries, tips;

ii) Gross income derived from business;

iii) Gains derived from dealings in property;

iv) Distributive share of partnership gross income (not a limited partner);

v) Compensation for services, including fees, commissions, fringe benefits and similar items; and vi) Taxable private disability income.

b. Unearned Income:

i) Interest (includes tax exempt interest);

ii) Rents;

iii) Royalties;

iv) Dividends;

v) Alimony received counts as unearned income if the divorce or legal separation is executed on or before December 31, 2018. Alimony received will not be countable income if the divorce or legal separation is modified or executed on or after January 1, 2019;

vi) Pensions and annuities;

vii) Income from life insurance and endowment contracts;

viii) Income from discharge of indebtedness;

ix) Income in respect of a decedent;

x) Income from an interest in an estate or trust;

xi) Social Security (SSA) income;

xii) Distributive share of partnership gross income (limited partner);

xiii) Capital gains;

xiv) Lottery/Gambling Winnings;

If less than $79,999 winnings are counted as income in the month received.
If over $79,999 but less than $89,999 it is counted as income and it is divided equally between two months.
For every additional $10,000 over $89,999, one month is added, and divided equally and counted as income for each month.
Lottery/gambling winnings of an individual will continue to count only in the month received in determining the eligibility for the members of their household.
An applicant/member may request a hardship exemption when an application is denied or enrollment is terminated due to Lottery/Gambling winnings.

a. The applicant/member must demonstrate a severe medical or financial hardship.

b. The applicant/member must provide a written request and documentation to their County Department of Human Services, within 30 calendar days from the date of their denial or termination notice.

xv) Student loan debt that is discharged, forgiven, or cancelled is treated as taxable income to the borrower, with certain exceptions.

This debt will not be considered income for the borrower in the event of death or permanent and total disability of the student (the borrower and the student may or may not be the same person) if discharged during tax years 2018 through 2025.
At the Departments discretion, this debt will not be considered countable income for the borrower if discharged, forgiven, or cancelled under programs which include, but not limited to:

a) Public Service loan forgiveness;

b) Teacher loan forgiveness;

c) Healthcare loan forgiveness; and d) Closed School discharge.

c. Additional Income: In addition to the types of income identified in section 8.100.4.C.1.a-b., the following income is included in the MAGI calculation.

i) Any tax exempt interest income.

ii) Untaxed foreign wages and salaries.

iii) Social Security Title II Benefits (Old Age, Disability and Survivor’s benefits).

d. The following are Income exclusions:

i) An amount received as a lump sum is counted as income only in the month received;

ii) Scholarships, awards, or fellowship grants used for educational purposes and not for living expenses;

iii) Child support received;

iv) Worker’s Compensation;

v) Supplemental Security Income (SSI);

vi) Veteran’s Benefits;

vii) The federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and the American Rescue Plan (ARP) Act Recovery Rebate, also known as the COVID-19 Economic Stimulus, shall be exempt from consideration as income.

viii) Federal Pandemic Unemployment Compensation (FPUC) program, which provides an extra $600.00 a week for qualified individuals, is exempt as countable unearned income.

ix) American Indian/Alaskan Native income exceptions listed at 42 C.F.R. § 435.603(e) (2012) is hereby incorporated by reference.

The incorporation of 42 C.F.R. § 435.603(e) (2012) excludes later amendments to, or editions of, the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203.

Certified copies of incorporated materials are provided at cost upon request.

e. Allowable Deductions: For an in-depth treatment of allowable deductions from gross income, refer to 26 U.S.C. 62, which is hereby incorporated by reference. The incorporation of 26 U.S.C. 62 (2014) excludes later amendments to, or editions of, the referenced material. Pursuant to § 24- 4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver CO 80203. Certified copies of incorporated materials The following deductions may be subtracted from an individual’s taxable gross income, in order to calculate the Adjusted Gross Income (AGI) including (but not limited to):

i) Student loan interest deductions;

ii) Certain Self- employment expenses SEP, SIMPLE and qualified plans, and health insurance deductions;

iii) Deductible part of self-employment tax;

iv) Health savings account deduction;

v) Certain business expenses of reservists, performing artist, and fee-

basis government officials;

vi) Reimbursed expenses of employees;

vii) Moving expenses for active duty military who are moving due to a permanent change of station;

viii) IRA deduction: Regular Individual Retirement Account (IRA) contributions claimed on a federal income tax return and which does not exceed the IRA contributions limits; (Pre-tax contributions to a 401(k) or 403(b) retirement plan are excluded from earned income);

ix) Penalty on early withdrawal of savings;

x) Domestic production activities deduction;

xi) Alimony paid may be deducted only if the divorce or legal separation is executed on or before December 31, 2018. It cannot be deducted if the divorce or separation is modified or executed on or after January 1, 20019;

xii) Certain educator expenses;

xiii) Certain pre-tax contributions;

xiv) Net operating losses; and xv) Capital losses.

f. Income of children and tax dependents:

i) The income of a child who is included in the household of their natural, adopted, or step parent will not be included in the household income unless that child has income above the tax filing threshold.

Income from Title II Social Security benefits and Tier I Railroad benefits are excluded when determining if a child is required to file taxes.

ii) The income of a person, other than a child or spouse, who expects to be claimed as a tax dependent will not be included in the household income of the taxpayer unless that tax dependent has income above the tax filing threshold.

Income from Title II Social Security benefits and Tier I Railroad benefits are excluded when determining if a tax dependent is required to file taxes.

ii) The income of a child or tax dependent who does not live with their natural, adopted, or step parent will always count towards the determination of their own eligibility, even if the child’s or tax dependent’s income is below the tax filing threshold.

Income verifications: When discrepancies arise between self-attested income and electronic data source results, the applicant shall receive a reasonable opportunity to establish his/her financial eligibility through the test for reasonable compatibility, by providing a reasonable explanation of the discrepancy, or by providing supporting documentation within the Reasonable Opportunity Period of 30 calendar days.

a. Income information obtained through an electronic data source shall be considered reasonably compatible with income information provided by or on behalf of an applicant in the following circumstances:

i) If the amount attested by the applicant and the amount reported by an electronic data source are both below the applicable MAGI Medical Assistance program income standard, that income shall be determined reasonably compatible and the applicant shall be determined eligible.

ii) If the amount attested by the applicant is below the applicable MAGI Medical Assistance program income standard, but the amount reported by the electronic data source is above, and the difference is within the reasonable compatibility threshold percentage of 20%, the income shall be determined reasonably compatible and the applicant shall be determined eligible.

iii) If both amounts are above the applicable MAGI Medical Assistance program income standard the income shall be determined reasonably compatible, and the applicant shall continue to be determined eligible during the federal Coronavirus COVID-19 Public Health Emergency.

May 11,2023 is if both amounts are above the applicable income standard for that program, the income shall be determined reasonably compatible, and the applicant shall be determined ineligible due to income.

b. If income information provided by or on behalf of an applicant is not determined reasonably compatible with income information obtained through an electronic data source, a reasonable explanation of the discrepancy shall be requested during the federal Coronavirus COVID-19 Public Health Emergency. If the applicant does not provide the required documentation within the reasonable opportunity period, then the applicant's Medical Assistance benefits shall not be terminated during the federal Coronavirus COVID-19 Public Health Emergency. When the federal COVID-19 Public Health Emergency has ended, a reasonable opportunity period will be given to request proper documentation from the i) During the federal Coronavirus COVID-19 Public Health Emergency the Department may request paper documentation when the Department does not find income to be reasonably compatible. If the member does or does not provide paper documentation they will remain eligible during the public health emergency period.

May 11, 2023 is the Department may request paper documentation only if the Department does not find income to be reasonably compatible and if the applicant does not provide a reasonable explanation or if electronic data are not available.

Self-Employment – If the applicant is self-employed the ledger included in the Single Streamlined Application shall be sufficient verification of earnings, unless questionable.
Budget Periods for MAGI-based Income determination – The financial eligibility of applicants for Medical Assistance shall be determined based on current or previous monthly household income and family size.

a. Applicants who are found financially ineligible based on current or previous monthly household income and family size, and whose household has earned income from self-employment, seasonal employment, and/or commission-based employment, shall have their financial eligibility determined using annualized self-employment, seasonal employment, and commission-based employment income.

If an applicant does not meet the financial eligibility requirements for Medical Assistance based on MAGI, but meets all other eligibility requirements, the applicant shall be found eligible for MAGI Medical Assistance if the applicant’s income, as calculated using the methodology for determining eligibility for Advanced Premium Tax Credits or Cost Sharing Reductions through the marketplace, is below 100% of the federal poverty level. 8.100.4.D. Income Disregard 1. An income disregard equivalent to five percentage points of the Federal Poverty Level for the applicable family size will be subtracted from MAGI-based income.

a. If an individual’s MAGI-based countable income is above the income threshold for the applicable MAGI program under title XIX (Medicaid) or title XXI (CHP+) of the Social Security Act, the five percent (5%) disregard will be applied for each qualifying MAGI program as the last step to determine eligibility.

b. If the countable income is below the income threshold for the applicable MAGI program, the individual is income eligible and the five percent (5%) disregard will not be applied to determine eligibility. 8.100.4.E. Determining MAGI Household Composition.

MAGI household composition is similar to, but not necessarily the same as a tax household. To determine MAGI household composition, the individual’s relationship to the tax filer must be established as declared on the Single Streamlined Application.

a. In the case of an applicant who expects to file a tax return for the taxable year in which an initial determination or renewal of eligibility is being made, and does not expect to be claimed as a tax dependent by anyone else, then the applicant’s MAGI household shall consist of the following:

i) The Tax-Filer;

ii) The Tax-Filer’s spouse if living in the home;

iii) All persons whom the Tax-Filer expects to claim as a tax dependent on their personal income tax return b. In the case of an applicant who expects to be claimed as a tax dependent by another taxpayer for the taxable year in which an initial determination or renewal of eligibility is being made, the applicant’s MAGI household shall be:

i) The Tax Dependent;

ii) The Tax-Filer and their spouse if living in the home;

iii) The Tax-Filer’s other tax dependents;

iv) The Tax Dependent’s spouse, if living with the Tax Dependent.

c. The MAGI household of an applicant who expects to be claimed as a tax dependent is as outlined in 8.100.4.E.b above, except in the following circumstances:

i) The applicant expects to be claimed as a tax dependent by someone other than a spouse, biological, adoptive or step parent.

ii) The applicant is a child under 19 who is expected to be claimed by one parent as a tax dependent and is living with both parents, but the parents do not expect to file a joint tax return.

iii) The applicant is a child under 19 and who expects to be claimed as a tax dependent by anon-custodial parent.

d. If the applicant meets one of the exceptions in 8.100.4.E.c above or is a non-filer, household composition shall be determined using the following non-filer rules and the applicant’s household shall consist of the following:

i) The applicant;

ii) The applicant’s spouse who lives in the household;

iii) The applicant’s natural, adopted, and step children under the age of 19, who live in the household; and iv) In the case of applicants under the age of 19, the applicant’s natural, adoptive, and step parents and natural, adoptive, and step siblings under age 19, who live in the household.

When a household includes a pregnant woman, regardless of the Medical Assistance category, the pregnant woman is counted as herself plus the number of children she is expected to deliver.
When a household includes an individual applying for the limited Family Planning Medical Assistance category, the individual is counted as a household of two in addition to any other household members.
Married couples living together will each be included in the other’s MAGI household regardless of whether or not they expect to file taxes jointly, separately or if one expects to be claimed as a tax dependent of the other.
If a child is claimed as a tax dependent by both parents who are married and who will file taxes jointly but one parent lives outside of the household due to separation or pending divorce, the child’s household composition is determined by non-filer rules. The parent living outside of the household will not be counted as part of the household.
An individual who is both a tax dependent and a tax filer will be considered a tax dependent for the purpose of determining eligibility for Medical Assistance. 8.100.4.F. MAGI Category Presumptive Eligibility 1. A pregnant woman may apply for presumptive eligibility for ambulatory services through Medical Assistance presumptive eligibility sites. A child under the age of 19 may apply or have an adult apply on their behalf for presumptive eligibility for State Plan approved medical services through presumptive eligibility sites.

Presumptive eligibility is available to applicants for limited family planning who are not pregnant. There are no restrictions of age or gender under the limited family planning presumptive eligibility category.

To be eligible for presumptive eligibility:

a. a pregnant woman must have an attested pregnancy, declare that her household's income shall not exceed 195% of the federal poverty level and declare that she is a United States citizen or a lawfully residing immigrant. Unless they meet the exceptions outlined under 8.100.3.G.1.g.viii.

b. a child or youth under the age of 19 shall have a declared household income that does not exceed 142% of federal poverty level and declare that the child is a United States citizen or a documented immigrant unless they meet the exceptions outlined under 8.100.3.G.1.g.viii.

Presumptive eligibility sites shall be certified by the Department to make presumptive eligibility determinations. Sites shall be re-certified by the Department every year to remain approved presumptive eligibility sites.
The presumptive eligibility site shall forward the medical assistance application to the County Department of Human Services within five business days.
The presumptive eligibility period begins on the date the applicant(s) is determined eligible and ends with the day an eligibility determination for Medical Assistance is made for the applicant(s)
A presumptively eligible member may not appeal the end of a presumptive eligibility period.
Medical Assistance applicants may appeal if a County Department of Human Services is unable to act within 45 days or 90 days (if a disability determination is required) of the medical assistance application date or the denial of a medical assistance application. Appeal procedures are outlined in the State Hearings

section of this volume.

Applicants cannot receive presumptive eligibility if they are already in receipt of another medical assistance program.
An applicant may only receive presumptive eligibility once every 12 months with the exception of pregnant women who may receive presumptive eligibility once every pregnancy. 8.100.4.G. MAGI Covered Groups 1. For MAGI Medical Assistance, any person who is determined to be eligible for Medical Assistance based on MAGI at any time during a calendar month shall be eligible for benefits during the entire month.
Children applying for Medical Assistance whose total household income does not exceed 142% of the federal poverty level shall be determined financially eligible for Medical Assistance. Refer to the MAGI-Medicaid income guidelines chart available on the Department’s website.

a. Children are eligible for Children’s MAGI Medical Assistance through the end of the month in which they turn 19 years old. After turning 19, the individual may be eligible for a different Medical Assistance category.

Parents and Caretaker Relatives applying for Medical Assistance whose total household income does not exceed 68% of the federal poverty level (MAGIequivalent) shall be determined financially eligible for Medical Assistance.

Parents or Caretaker Relatives eligible for this category shall have a dependent child in the household.

a. A dependent child is considered to be living in the home of the parent or caretaker relative as long as the parent or specified relative exercises responsibility for the care and control of the child even if:

i) The child is under the jurisdiction of the court (for example, receiving probation services);

ii) Legal custody is held by an agency that does not have physical possession of the child;

iii) The child is in regular attendance at a school away from home;

iv) Either the child or the relative is away from the home to receive medical treatment;

v) Either the child or the relative is temporarily absent from the home;

vi) The child is in voluntary foster care placement for a period not expected to exceed three months. Should the foster care plan change within the three months and the placement become court ordered, the child is no longer considered to be living in the home as of the time the foster care plan is changed.

Adults applying for Medical Assistance whose total household income does not exceed 133% of the federal poverty level shall be determined financially eligible for Medical Assistance. This category includes adults who are parents or caretaker relatives of dependent children whose income exceeds the income threshold to qualify for the Parents and Caretaker Relatives MAGI category and who meet all other eligibility criteria.

a. A dependent child living in the household of a parent or caretaker relative shall have minimum essential coverage, in order for the parent or caretaker relative to be eligible for Medical Assistance under this category.

Refer to section 8.100.4.G.3.a on who is considered a dependent child.

b. Due to the COVID-19 Public Health Emergency an applicant who is not eligible for Medical Assistance but has been impacted through exposure to or potential infection with COVID-19 may be eligible to receive services for COVID-19 testing only. To qualify for this limited benefit, the applicant must satisfy residency and immigration or citizenship status and not be enrolled in other health insurance.

Pregnant Women whose household income does not exceed 195% of the federal poverty level (MAGI-equivalent) are eligible for the Pregnant Women MAGI Medical Assistance program. Medical Assistance shall be provided to a pregnant woman for a period beginning with the date of application for Medical Assistance through the last day of the 12 month following the date the pregnancy ends.

Once eligibility has been approved, Medical Assistance coverage will be provided regardless of changes in the woman's financial circumstances once the income verification requirements are met.

a. A pregnant women’s eligibility period will end effective the earliest possible month, if the following occurs:

i) Fails to provide a reasonable explanation or paper documentation when self- attested income is not reasonably compatible with income information from an electronic data source, by the end of the 30day reasonable opportunity period. This exception only applies the first-time income is verified following an initial eligibility determination or an annual redetermination.

A lawfully admitted non-citizen who is pregnant and who has been in the United States for less than five years is eligible for Medical Assistance if she meets all of the other eligibility requirements specified at 8.100.4.G.5 and fits into one of the immigration categories listed in 8.100.3.G.1.g.iii.1-5 and 8.100.3.G.1.g.vi.1-15.

This population is referenced as Legal Immigrant Prenatal.

A child whose mother is receiving Medical Assistance at the time of the child's birth is continuously eligible for one year. This population is referred to as “Eligible Needy Newborn”. This coverage also applies in instances where the mother received Medical Assistance to cover the child’s birth through retroactive Medical Assistance. The child is not required to live with the mother receiving Medical Assistance to qualify as an Eligible Needy Newborn.

a. To receive Medical Assistance under this category, the birth must be reported verbally or in writing to the County Department of Human Services or eligibility site. Information provided shall include the baby’s name, date of birth, and mother’s name or Medical Assistance number. A newborn can be reported at any time by any person. Once reported, a newborn meeting the above criteria shall be added to the mother’s Medical Assistance case, or his or her own case if the newborn does not reside with the mother, according to timelines defined by the Department.

If adopted, the newborn’s agent does not need to file an application or provide a Social Security Number or proof of application for a Social Security Number for the newborn 8. Applicants applying for Medical Assistance whose total household income is greater than 133% but does not exceed 260% of the federal poverty level shall be determined financially eligible for limited Family Planning Medical Assistance services. The applicant must satisfy residency and immigration or citizenship status to qualify for this limited benefit. The limited family planning services eligibility category has no age or gender restriction and is available for those not eligible for a Medicaid eligibility category that provides full coverage. 8.100.4.H. Needy Persons 1. Medical Assistance shall be provided to certain needy persons under 21 years of age, including the following:

a. Those receiving care in a Long Term Care Institution eligible for Medical Assistance reimbursement or receiving active treatment as inpatients in a psychiatric facility eligible for Medical Assistance reimbursement and whose household income is less than the MAGI needs standard for his/her family size when the client applies for assistance. Clients that are receiving benefits under this category and are still receiving active inpatient treatment in the facility at age 21 shall be eligible to age 22. This population is referenced as Psych <21.

b. Those for whom the Department of Human Services is assuming full or partial financial responsibility and who are in foster care, in homes or private institutions or in subsidized adoptive homes. A child shall be the responsibility of the county, even if the child may be in a medical institution at that time. See Colorado Department of Human Services “Social Services Staff Manual” section 7 for specific eligibility requirements (12 CCR § 2509-1). 12 CCR § 2509-1 (2013) is hereby incorporated by reference. The incorporation of 12 CCR § 2509-1 excludes later amendments to, or editions of, the referenced material. Pursuant to § 24- 4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver CO 80203. Certified copies of incorporated materials c. Those for whom the Department of Human Services is assuming full or partial financial responsibility and who are in independent living situations subsequent to being in foster care.

d. Those for whom the Department of Human Services is assuming full or partial responsibility and who are receiving services under the state’s Alternatives to Foster Care Program and would be in foster care except for this program and whose household income is less than the MAGI needs standard for his/her family size.

e. Those for whom the Department of Human Services is assuming full or partial responsibility and who are removed from their home either with or without (court ordered) parental consent, placed in the custody of the county and residing in a county approved foster home.

f. Those for whom the Department of Human Services is assuming full or partial responsibility and who are receiving services under the state’s subsidized adoption program, including a clause in the subsidized adoption agreement to provide Medical Assistance for the child.

g. Those for whom the Department of Human Services is assuming full or partial financial responsibility on their 18th birthday or at the time of emancipation. These individuals also must have received foster care maintenance payments or subsidized adoption payments from the State of Colorado pursuant to article 7 of title 26, C.R.S. immediately prior to the date the individual attained 18 years of age or was emancipated. Eligibility shall be extended until the individual’s 21st birthday for these individuals with the exception of those receiving subsidized adoption payments.

Medical Assistance shall be extended to certain needy persons until the end of the month of the individual’s 26 birthday, including the following:

a. Those individuals that were formerly in foster care under the responsibility of Colorado or Tribe on their 18 , 19 , 20 or up to their 21 st birthday and were receiving Medical Assistance.

i) This extension does not apply to youth that are receiving subsidized adoption payments or ii) To youth that are enrolled in mandatory Medical Assistance.

iii) This extension applies to Individuals who were in foster care at the age 18 on or after January 1, 2023, and were enrolled in Medicaid in another state, and who have become a resident of Colorado.

b) Former Foster Care youth are not subject to either an income or resource test.

c) Former Foster Care youth’s newborn shall be considered a needy newborn. 8.100.4.I. Transitional Medical Assistance and 4 Month Extended Medical 1. Eligibility for Transitional Medical Assistance shall be granted for twelve months (beginning with the first month of ineligibility) to individuals who are no longer eligible for the Parent/Caretaker Relative category due to a change in income.

The extension shall be applied to individuals who:

a. Were eligible for the Parent/Caretaker Relative category in at least three of the six months preceding the month in which the individual would have become ineligible, and b. Are no longer eligible for coverage under the Parent/Caretaker Relative category because of new or increased income from employment or hours of employment i) At least one Parent/Caretaker Relative must continue to be employed and cannot terminate employment without good cause.

This does not need to be the same person for the whole period the family is receiving Transitional Medical Assistance.

Any dependent child or Parent/Caretaker Relative who was or becomes part of the Medical Assistance household after the individual has begun receiving Transitional Medical Assistance is eligible for the remaining months of Transitional Medical Assistance.

a. A dependent child in the household who received Medical Assistance through continuous eligibility, but is no longer eligible for Medical Assistance based on a redetermination, is eligible for the family’s remaining months of Transitional Medical Assistance.

b. An individual in the household who received Medical Assistance, but is no longer eligible for Medical Assistance based on a redetermination, is eligible for the family’s remaining months of Transitional Medical 3. To become or remain eligible for Transitional Medical Assistance the household must include a dependent child. If it is determined that the household no longer has a child living in the home, Transitional Medicaid Assistance shall discontinue at the end of the month in which the household does not include a dependent child.

When Transitional Medical Assistance ends the case will be reassessed for all other categories of Medical Assistance for which the family members may be eligible. A new application shall not be required for this process.
Eligibility for Medical Assistance shall be extended for four months (beginning with the first month of ineligibility) for certain families who become ineligible for Medical Assistance due solely or partially to the receipt of support income, such as alimony. The extension shall be applied for a family which receives assistance under Medical Assistance in at least three of the six months immediately preceding the month in which the family becomes ineligible for assistance. To be eligible for the four month Medical Assistance extension, the family shall meet all other eligibility criteria for Medical Assistance before the alimony income is applied.

a. Alimony received will be countable income only if the divorce or legal separation is executed on or before December 31, 2018. Alimony will not be countable income if the divorce or legal separation is modified or executed on or after January 1, 2019. 8.100.4.J. Express Lane Eligibility Express Lane Eligibility shall allow for automatic initiation of Medical Assistance enrollment by using available data and findings from other programs as listed below.

Free/Reduced Lunch Program a. Recipients of the Free/Reduced Lunch Program who have submitted a Free/Reduced Lunch application at a participating school districti) Families shall be given the option to opt into Medical Assistance coverage for their potentially eligible child.

ii) Children who meet all necessary eligibility requirements as outlined in this volume shall be automatically enrolled.

iii) Children who meet all necessary eligibility requirements except verification of U.S. citizenship and identity shall receive 90days of eligibility while awaiting this verification.

iv) Any additionally required verification shall be requested from the client through CBMS prior to being automatically enrolled.

v) Eligibility is based on income declared on the Free/Reduced Lunch application as well as eligibility requirements outlined in this volume.

vi) If it would be found that a child does not satisfy an eligibility requirement for Medical Assistance, the child’s eligibility will be evaluated using the Single Streamlined Application for Medical b. Recipients of the Free/Reduced Lunch Program who were not required to submit a Free/Reduced Lunch application at a participating school districti) Families who are automatically enrolled Free/Reduced Lunch recipient children shall not be forwarded to the Department for Express Lane Eligibility in compliance USDA confidentiality guidelines.

ii) These families must apply for Medical Assistance in order to give consent for request of benefits.

Direct Certification a. Individuals who have submitted a Food Assistance or Colorado Works application i) Families shall be given the option to opt into Medical Assistance coverage for their potentially eligible child.

ii) Children who meet all necessary eligibility requirements as outlined throughout 8.100.4 shall be automatically enrolled iii) Children who meet all necessary eligibility requirements except verification of U.S. citizenship and identity will receive 90 days of eligibility while awaiting this verification.

iv) Any additionally required verification shall be requested from the client through CBMS prior to being automatically enrolled.

v) Eligibility is based on income declared on the Food Assistance or Colorado Works application as well as eligibility requirements outlined throughout this volume.

vi) If it would be found that a child does not satisfy an eligibility requirement for Medical Assistance, the child’s eligibility shall be evaluated using the Single Streamlined Application for Medical vii) Individuals whose eligibility is not determined through Express Lane Eligibility can also submit a separate Single Streamlined Application for Medical Assistance to determine eligibility. 8.100.5. Aged, Blind, and Disabled, Long Term Care, and Medicare Savings Plan Medical Assistance General Eligibility 8.100.5.A. Application Requirements 1. When an individual applies for Medical Assistance on the basis of disability or blindness, the eligibility sites shall take the application and determine whether the individual is eligible for Long Term Care or any of the Aged, Blind, and Disabled categories of assistance described in section 8.100.6. If the applicant does not qualify for Medical Assistance on one of those bases, he/she shall be referred to the local Social Security office to apply for SSI.

a. Applicants who apply for Long-Term Care Medical Assistance on the basis of disability or blindness, or who apply for the Medicaid Buy-In Program for Working Adults with Disabilities or the Medicaid Buy-In Program for Children with Disabilities without a current disability determination, shall complete a Medical Assistance disability determination application in addition to the required Single Streamlined Application. The disability determination application is not required for individuals that have already been determined disabled by the Social Security Administration.

b. The Medical Assistance disability determination application shall be collected by a designated eligibility site representative and shall be forwarded to the state disability determination contractor upon completion.

The state disability determination contractor shall conduct a client disability determination and shall forward the determination to the designated eligibility site representative.

c. For the Medicaid Buy-In Program for Working Adults with Disabilities, if an individual does not meet the Social Security Administration definition of disability, the state disability determination contractor can review the individual’s circumstances to determine if the individual meets limited disability.

d. Due to the Coronavirus COVID-19 Public Health Emergency, if a person’s existing disability determination has expired, the person shall remain enrolled in Medical Assistance until the emergency has ended and the state has processed the verification of eligibility, unless the individual requests a voluntary termination of eligibility. At the end of the Public Health Emergency a disability determination that has expired will require a new disability determination to make a proper determination of eligibility.

Members whose eligibility has been maintained during the Public Health Emergency will remain in their current category until their renewal due month and/or their renewal is processed.

Persons requesting Aged, Blind, and Disabled Medical Assistance need only to complete the Single Streamlined Application. 8.100.5.B. Verification Requirements 1. The particular circumstances of an applicant will dictate the appropriate documentation needed for a complete application. The following items shall be verified for individuals applying for Medical Assistance:

i) Due to the Coronavirus COVID-19 Public Health Emergency, at application, self-attestation is acceptable for SSN criteria, with the exception of verification of citizenship and immigration status. At the end of the COVID-19 Public Health Emergency, verification for SSN eligibility criteria will be required. Effective May 11, 2023 the Coronavirus COVID-19 Public Health Emergency has been declared to end. Members whose eligibility has been maintained during the Public Health Emergency will remain in their current category until their renewal due month and/or their renewal is processed.

Applicants who meet the criteria for any categorical Medical Assistance programs, but do not meet the federal and state criteria of citizenship and immigration status are only eligible to receive emergency medical services.

b. Verification of citizenship and identity as outlined in the section 8.100.3.H under Citizenship and Identity Documentation Requirements.

c. Earned income may be self-attested by an applicant or member and verified through an electronic data source through the IEVS, FDSH, or the TWN. Individuals who provide self-attestation of earned income may also provide a SSN for wage verification purposes. If the self-attested earned income cannot be verified electronically due to a missing SSN, the applicant must provide documentation of income. Verification of earned income must be provided in accordance to the requirements outlined in 8.100.4.B.1.c When discrepancies arise between self-attested income and electronic data source results, the applicant shall receive a reasonable opportunity to establish his/her financial eligibility through the test for reasonable compatibility, by providing a reasonable explanation of the discrepancy, or by providing paper documentation within the Reasonable Opportunity Period (ROP) of 30 calendar days.

Income information obtained through an electronic data source shall be considered reasonably compatible with income information provided by or on behalf of an applicant in the following circumstances:

i) If the amount attested by the applicant and the amount reported by an electronic data source are both below the applicable Medical Assistance program income standard, that income shall be determined reasonably compatible and the applicant shall be determined eligible.

ii) If the amount attested by the applicant is below the applicable income standard for that program, but the amount reported by the electronic data source is above, and the difference is within the reasonable compatibility threshold percentage of 20%, the income shall be determined reasonably compatible and the applicant shall be determined eligible.

iii) If both amounts are above the applicable income standard for that program, the income shall be determined reasonably compatible, and the applicant shall continue to be determined eligible during the federal Coronavirus COVID-19 Public Health Emergency.

May 11, 2023 is if both amounts are above the applicable income standard for that program, the income shall be determined reasonably compatible, and the applicant shall be determined ineligible due to income.

If income information provided by or on behalf of an applicant is not determined reasonably compatible with income information obtained through an electronic data source, a reasonable explanation of the discrepancy will not be requested during the federal COVID-19 Public Health Emergency. If the applicant does not provide the required documentation within the reasonable opportunity period, then the applicant's Medical Assistance benefits shall not be terminated during the federal Coronavirus COVID-19 Public Health Emergency. When the federal Public Health Emergency has ended, a reasonable opportunity period will be given to request proper documentation from the member.

iv) During the federal Coronavirus COVID-19 Public Health Emergency the Department may request paper documentation when the Department does not find income to be reasonably compatible. If the member does or does not provide paper documentation they will remain eligible during the public health emergency period.

If the applicant is self-employed, ledgers are sufficient for verification of earnings, if a ledger is not available, receipts are acceptable. The ledger included in the Medical Assistance application is sufficient verification of earnings, unless questionable. If an individual cannot provide verification through self-declaration, income shall be verified by wage stubs, written documentation from the employer stating the employees' gross income or a telephone call to an employer. Applicants may request that communication with their employers be made in writing.

As of CBMS implementation, estimated earned income shall be used to determine eligibility if the applicant/client provides less than a full calendar month of wage stubs for the application month. A single recent wage stub shall be sufficient if the applicant's income is expected to be the same amount for the month of application. Written documentation from the employer stating the employees' gross income or a telephone call to an employer, if the applicant authorizes the telephone call shall also be acceptable verification of earned income. Verification of earned income received during the month prior to the month of application shall be acceptable if the application month verification is not yet available. Actual earned income shall be used to determine eligibility if the client provides verification for the full calendar month.

v) During the federal COVID-19 Public Health Emergency, all earned income and self-employment may be reported by self-attestation.

The COVID -19 Public Health Emergency ended effective May 11, 2023. At the end of the federal COVID-19 Public Health Emergency, proof of any unverified income shall be provided.

d. Verification of all unearned income shall be provided if the unearned income was received in the month for which eligibility is being determined or during the previous month. If available, information that exists in another case record or verification system shall be used to verify unearned income.

i) During the federal COVID-19 Public Health Emergency, all unearned income may be reported by self-attestation. The COVID -19 Public Health Emergency ended effective May 11, 2023. At the end of the federal COVID-19 Public Health Emergency, proof of any unverified income shall be provided.

e. Verification of all resources shall be provided if the resources were available to the applicant in the month for which eligibility is being determined.

Resource information that is verified through an electronic data source, such as the Asset Verification Program, shall be a valid verification.

Supplemental physical verifications for the same resource is not required unless further information is needed for clarification.

i) During the federal COVID-19 Public Health Emergency, all resources may be reported by self-attestation. The COVID -19 Public Health Emergency ended effective May 11, 2023. At the end of the federal COVID-19 Public Health Emergency, proof of any unverified resources shall be provided.

f. Immigrant registration cards or papers, if applicable, to determine if the client is eligible for full Medical Assistance benefits. If an applicant does not provide this, he/she shall only be eligible for emergency Medical Assistance if they meet all other eligibility requirements.

g. Additional verification-If the requested verification is submitted by the applicant, no other additional verification shall be required unless the submitted verification is found to be questionable on the basis of fact.

h. The determination that information is questionable shall be documented in the applicant's case file and CBMS case comments. 8.100.5.C. Effective Date of Eligibility 1. Eligibility for the Aged, Blind and Disabled categories shall be approved effective on the later of:

a. The first day of the month of the Single Streamlined Application for Medical Assistance; or b. The first day of the month the person becomes eligible for Medical 2. The date that eligibility begins for Long-Term Care Medical Assistance is defined in section 8.100.7.A and B.

For the Medicaid Buy-In Program for Children with Disabilities, any child who is determined to be eligible for Medical Assistance at any time during a calendar month shall be eligible for benefits during the entire month.
Clients applying for Medical Assistance under the Aged, Blind and Disabled category shall be reviewed for retroactive eligibility as described at 8.100.3.E.

When reviewing for retroactive eligibility for an individual who is SSI eligible or applied and became SSI eligible in each of the retroactive months, the applicant must:

a. Be aged at least 65 years; or b. Meet the Social Security Administration definition of disability by:

i) Being approved as eligible to receive either SSI or SSDI, on or prior to the date of a medical service; or ii) Having a disability onset date determined on or prior to the date of a medical service; and c. Meet the financial requirements as described at 8.100.5.E. 8.100.5.D. Medical Assistance Estate Recovery Program 1. The eligibility site shall provide written information from the Department to the following people explaining the provisions of the Medical Assistance Estate Recovery Program and how those provisions may pertain to the applicant/client:

a. Applicants age 55 and older who are institutionalized.

b. Applicants/clients who will turn age 55 before their next eligibility redetermination who are institutionalized.

c. Clients age 55 and older who are approved for admittance to an institution 8.100.5.E. Availability of Resources and Income Consistent with the legislative declaration outlined at C.R.S. § 25.5-4-300.4, Medicaid should be the payer of last resort for payment of medically necessary goods and services furnished to clients. All other sources of payment, including an individual’s own countable income and resources, should be utilized to the fullest extent possible before Medicaid is accessed.

Income, which includes earned and unearned income, shall be calculated on a monthly basis regardless of whether it is received annually, semi-annually, quarterly or weekly.
For married couples, the income and resources of both spouses are counted in determining eligibility for either or both spouses. Refer to section 8.100.7.C for exceptions.
Resources and income shall be considered available when actually available; or, shall be deemed available when all of the following apply to the resources or income of the individual or individual’s spouse:

a. has any ownership interest in income or resources or equity value of a resource;

b. has the right, authority, or power to convert the resource or income to cash or to cause the resource or income to be converted to cash; and c. is not legally restricted from using the resource or income for his or her support and maintenance.

Resources and income shall not be considered unavailable merely because the individual or individual’s spouse may need to initiate legal proceedings to access the resources or income.
If the applicant or client demonstrates with clear and convincing evidence that appropriate steps are being taken to secure the resources, Medical Assistance shall not be delayed or terminated. Verification of efforts to secure the resources must be provided at regular intervals as requested by the Eligibility Site.
Resources will be considered available and Medical Assistance shall be denied or terminated if the applicant or client refuses or fails to make a reasonable effort to secure potential resources or income.
Timely and adequate notice must be given regarding a proposed action to deny, reduce, or terminate assistance due to failure to make reasonable efforts to secure resources or income. If upon receipt of the prior notice, the individual acts to secure the potential resource, the proposed action to deny, reduce, or terminate assistance must be withdrawn, and assistance must be approved or continued until the resource or income is, in fact, available.
If the resources or income has been transferred to a trust, the trust shall be submitted for review to the Department to determine the effect of the trust on eligibility in accordance with section 8.100.7.E.
A resource may not necessarily be unavailable by virtue that an individual may be unaware of his or her ownership of an asset. The Department will not treat the unknown asset as a resource during the period in which the individual was unaware of his/her ownership. However, the value of the previously unknown asset, including any monies such as interest that have accumulated on the asset through the month of discovery, is evaluated under regular income-counting rules in the month of discovery, and the asset is a resource subject to the resourcecounting rules following the month of discovery.

a. The burden is on the individual to prove by clear and convincing evidence that the asset was unavailable by virtue of being unknown by the recipient.

b. Unknown assets shall not be deemed an overpayment pursuant to Section 8.065 of the Department’s regulations where the asset was unknown through no fault of the individual.

c. If the previously unknown asset causes the individual to be ineligible, the individual may repay the Department from the excess resources to retain Medicaid eligibility. 8.100.5.F. Income Requirements 1. This section reviews how income is looked at for the ABD and Long Term Care Medical Programs and determining premiums for the Medicaid Buy-In Program for Working Adults with Disabilities. For more general income information and income types refer to the Medical Assistance General Eligibility Requirements

Section 8.100.3.

Income for the ABD Medical Programs eligibility is income which is received by an individual or family in the month in which they are applying for or receiving Medical Assistance, or the previous month if income for the current month is not yet available to determine eligibility.
A self-declared common law spouse retains the same financial responsibility as a legally married spouse. Once self-declared as married under the common law, financial responsibility remains unless legal separation or divorce occurs. If two persons live together, but are not married to each other, neither one has the legal responsibility to support the other. This is not changed by the fact that the unmarried individuals may share a common child.
Earned income is countable as income in the month received and a countable resource the following month. Earned Income includes the following:

a. Wages, which include salaries, commissions, bonuses, severance pay, and any other special payments received because of employment.

b. Net earnings from self-employment.

c. Payments for services performed in a sheltered workshop or work activities center.

d. Certain Royalties and honoraria.

Unearned income is the gross amount received in cash or in kind that is not earned from employment or self-employment.

Unearned income is countable as income in the month received and any unspent amount is a countable resource the following month. Unearned income includes, but is not limited to, the following:

a. Death benefits, reduced by the cost of last illness and burial.

b. Prizes and awards.

c. Gifts and inheritances.

d. Interest payments on promissory notes established on or after March 1, 2007.

e. Interest or dividend payments received from any resources.

f. Lump sum payments from workers’ compensation, insurance settlements, etc.

g. Dividends, royalties or other payments from mineral rights or other resources listed for sale within the resource limits.

h. Income from annuities that meet requirements for exclusion as a resource. i Lottery or gambling winnings.

An applicant/member may request a hardship exemption when denied/or terminated due to lottery or gambling winnings.

a. The applicant/member must demonstrate a severe medical or financial hardship, as determined by the Department.

b. The applicant/member must provide a written request and documentation to their County Department of Human Services, within 30 calendar days from the date of their denial or termination notice.

j. Pensions and other period payments, such as:

i) Private pensions or disability benefits;

ii) Social Security benefits (Retirement, survivors, and disability);

iii) Workers' Compensation payments;

iv) Railroad retirement annuities;

v) Unemployment insurance payments;

vi) Veterans benefits other than Aid and Attendance (A&A) and Unusual Medical Expenses (UME); and vii) Alimony and support payments.

k. In kind support and maintenance. – i) Any shelter given to an applicant/member or received by an applicant/member outside of a business arrangement requiring the payment of monthly rent equal to or exceeding the presumed maximum value. Shelter includes room, rent, mortgage payments, real property taxes, heating fuel, gas, electricity, water, sewage, and garbage collection services. Food is not included in the calculation of in-kind support and maintenance.

ii) This amount should not be greater than one third of the Federal Benefit Rate (FBR). Use the Presumed Maximum Value (PMV) of 1/3 of the recipient’s portion of the rent to determine the support and maintenance in kind amount. Use one third of the FBR if an amount is not declared by the applicant/member.

For the purpose of determining eligibility for the Long Term Care and Aged, Blind, and Disabled Medical Assistance categories the following shall be exempt from consideration as either income or resources:

a. A bona fide loan. Bona fide loans are loans, either private or commercial, which have a repayment agreement. Declaration of such loans is sufficient verification.

b. Benefits received under Title VII, Nutrition Program for the Elderly, of the Older Americans Act.

c. Title XVI (Supplemental Security Income) or Title II (Retirement Survivors or Disability Insurance) retroactive payments (lump sum) for nine months following receipt and the remainder countable as a resource thereafter.

d. The value of supplemental food assistance received under the special food services program for children provided for in the National School Lunch Act and under the Child Nutrition Act, including benefits received from the special supplemental food program for women, infants and children (WIC).

e. Home produce utilized for personal consumption.

f. Payments received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act. Relocation payments to a displaced homeowner toward the purchase of a replacement dwelling are considered exempt for up to 6 months.

g. The value of any assistance paid with respect to a dwelling unit is excluded from income and resources if paid under:

i) Experimental Housing Allowance Program (EHAP) payments made by HUD under section 23 of the U.S. Housing Act (12 USCA § 1701z-3);

ii) The United States Housing Act of 1937 (42 U.S.C. § 1437 et seq.);

iii) The National Housing Act (12 U.S.C. § 1701 et seq.);

iv) Section 101 of the Housing and Urban Development Act of 1965 (12 U.S.C. § 1701s; 42 U.S.C. § 1451);

v) Title V of the Housing Act of 1949 (42 U.S.C. § 1471 et seq.); or vi) Section 202(h) of the Housing Act of 1959.

h. Payments made from Indian judgment funds and tribal funds held in trust by the Secretary of the Interior and/or distributed per capita; and initial purchases made with such funds. (Public Law No 98-64 and Public Law No. 97-458).

i. Distributions from a native corporation formed pursuant to the Alaska Native Claims Settlement Act (ANCSA) which are in the form of: cash payments up to an amount not to exceed $ 2000 per individual per calendar year; stock; a partnership interest; or an interest in a settlement trust. Cash payments, up to $2000, received by an applicant/member in one calendar year which is retained into subsequent years is excluded as income and resources; however, cash payments up to $2000 received in the subsequent year would be excluded from income in the month(s) received but counted as a resource if retained beyond that month(s).

j. Assistance from other agencies and organizations.

k. Major disaster and emergency assistance provided to individuals and families, and comparable disaster assistance provided to states, local governments and disaster assistance organizations shall be exempt as income and resources in determining eligibility for Medical Assistance.

l. Payments received for providing foster care.

m. Payments to volunteers serving as foster grandparents, senior health aids, or senior companions, and to persons serving in the Service Corps of Retired Executives (SCORE) and Active Corps of Executives (ACE) and any other program under Title I (VISTA) when the value of all such payments adjusted to reflect the number of hours such volunteers are serving is not equivalent to or greater than the minimum wage, and Title II and Title III of the Domestic Volunteer Services Act.

n. The benefits provided to eligible persons or households through the Low Income Energy Assistance (LEAP) Program.

o. Training allowances granted by the Workforce Investment Act (WIA) to enable any individual whether dependent child or caretaker relative, to participate in a training program p. Payments received from the youth incentive entitlement pilot projects, the youth community conservation and improvement projects, and the youth employment and training programs under the Youth Employment and Demonstration Project Act.

q. Social Security benefit payments and the accrued amount thereof to a applicant/member when an individual plan for self-care and/or self-support has been developed. In order to disregard such income and resources, it shall be determined that (1) SSI permits such disregard under such developed plan for self-care-support goal, and (2) assurance exists that the funds involved will not be for purposes other than those intended.

r. Monies received pursuant to the “Civil Liberties Act of 1988” P.L. No. 100- 383, (by eligible persons of Japanese ancestry or certain specified survivors, and certain eligible Aleuts).

s. Payments made from the Agent Orange Settlement Fund or any fund established pursuant to the settlement in the In Re Agent Orange product liability litigation, M.D.L. No. 381 (E.D.N.Y).

t. A child receiving subsidized adoption funds shall be excluded from the Medical Assistance budget unit and his income shall be exempt from consideration in determining eligibility, unless such exclusion results in ineligibility for the other members of the household.

u. The Earned Income Tax Credit (EIC). EIC shall also be exempt as resources for the month it is received and for the following month.

v. Any money received from the Radiation Exposure Compensation Trust Fund, Including the Energy Employees Occupational Illness Compensation Program Act, pursuant to P.L. No. 101-426 as amended by P.L. No. 101-510.

w. Reimbursement or restoration of out-of-pocket expenses. Out-of-pocket expenses are actual expenses for food, housing, medical items, clothing, transportation, or personal needs items.

x. Payments to individuals because of their status as victims of Nazi persecution pursuant to Public Law No. 103-286.

y. General Assistance, SSI, OAP-A and cash assistance under the Temporary Assistance to Needy Families (TANF) funds.

z. All wages paid by the United States Census Bureau for temporary employment related to the decennial Census.

aa. Any grant or loan to an undergraduate student for educational purposes made or insured under any programs administered by the Commissioner of Education (Basic Education Opportunity Grants, Supplementary Education Opportunity Grants, National Direct Student Loans and Guaranteed Student Loans), Pell Grant Program, the PLUS Program, the BYRD Honor Scholarship programs, and the College Work Study bb. Any portion of educational loans and grants obtained and used under conditions that preclude their use for current living cost (need-based).

cc. Financial assistance received under the Carl D. Perkins Vocational and Applied Technology Education Act that is made available for attendance cost shall not be considered as income or resources. Attendance cost includes tuition, fees, rental or purchase of equipment, materials or supplies required of all students in the same course of study, books, supplies, transportation, dependent care, and miscellaneous personal expenses of students attending the institution on at least a half-time basis, as determined by the institution.

dd. The additional unemployment compensation of $25 a week enacted through the American Recovery and Reinvestment Act of 2009. 8.100.5.G. Deeming Of Income And Resources For The OAP Program 1. All aliens who apply for OAP on or after April 16, 1988, for three years after the date of admission into the United States, shall have the income and resources of their sponsors other than relatives deemed for their care. Refer to the Medical Assistance General Eligibility Requirements section 8.100.3.K for specific information on deeming of income and resources. 8.100.5.H. Income Allocations and Disregards 1. The following income allocations and disregards are only applicable to SSI related, OAP, Medicare Savings Programs (MSP), the Medicaid Buy-In Program for Children with Disabilities and the Medicaid Buy-In Program for Working Adults with Disabilities.

These allocations and disregards are not applicable to the HCBS waivers or the LTC programs.

For the Medicaid Buy-In Program for Working Adults with Disabilities, the applicant’s spouse’s income does not count toward the applicant.

a. Income of spouses living together is considered mutually available for SSI related, OAP, and Medicare Savings Programs (MSP).

b. For a person living in the household of another and not paying shelter costs, one third of the Federal Benefit Rate (FBR) is counted as in-kind income and is added to the countable income. This does not apply to unemancipated children.

For the purposes of this rule, the following definitions apply:

a. unemancipated child is:

i) a child under age 18 who is living in the same household with a parent or spouse of a parent, or ii) a child under age 21 who is living in the same household with a parent or spouse of a parent, if the child is regularly attending a school, college, or university, or is receiving technical training designed to prepare the child for gainful employment.

b. Ineligible child is a child who is not applying or eligible for SSI.

c. Ineligible parent/spouse is a parent or spouse who is not applying or eligible for SSI.

Countable income is calculated by reducing the gross income by the following allocations and disregards.

a. Income allocations are the part of the gross income that is allocated to individuals in the home who are not eligible for Supplemental Security Income or Old Age Pension. The allocation reduces the gross income that is deemed available to the applicant/client. The allocation is deducted from the gross income prior to applying the other disregards.

The allocations are:

i) An Ineligible Child Allocation is an amount equal to one half the current year’s SSI FBR that is disregarded from the ineligible parents’ gross income. This allocation is used to meet the needs of ineligible children in the household. This allocation is available for each ineligible child in the home. The amount of the allocation is reduced by any of the ineligible child’s own income.

ii) An Ineligible Parent(s) Allocation is an amount equal to the current year’s SSI FBR for a single individual or a couple, as applicable.

This amount is used to meet the needs of the ineligible parent(s) in the home with an applicant/client child.

iii) No allocations are allowed for applicant/recipient spouses who do not have children in the home.

b. Allocations are applied to the income in the following manner:

i) Allocation disregards are deducted from unearned income before ii) Ineligible child allocation disregards are deducted from parents’ income before any standard disregards are applied.

iii) Ineligible parent(s) allocation disregards are deducted after any ineligible child allocation disregards and after the standard income disregards.

Income disregards a. $20 General Income Disregard If there is unearned income left after the Ineligible Child and Parent(s)

Allocation Disregards are applied, a General Income Disregard of $20 shall be applied as follows:

i) The first $20 of total available unearned income (except for SSI income) must be disregarded. The remaining amount of unearned income is countable.

ii) If the client has less than $20 of unearned income, the difference between the gross unearned income and the $20 deduction shall be applied as an earned income disregard, if applicable.

iii) Only one $20 general income disregard is allowed per couple and is divided between the two spouses. If one of the spouses has no income the other spouse shall get the full $20 disregard.

b. $65 Plus One Half Remainder Earned Income Disregard i) If there is earned income left after the Ineligible Child and Parent(s)

Allocation Disregards are applied:

Deduct the first $65 of all earned income.
Divide the remaining income in half.
The result is the amount of earned income used for determining eligibility.

c. Child support received by an applicant/recipient child is reduced by one third of the total child support payment. This reduction does not apply to ineligible children when calculating the ineligible child allocation disregard.

d. The first $400 of the gross monthly earned income is exempt for a blind or disabled child who is a student that is regularly attending school. The exemption cannot exceed $1,620 in a calendar year.

e. Title 20 of the Code of Federal Regulations, § 416.1112 (2012) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material.

These regulations are available for public inspection at the Department of Health Care Policy and Financing, 303 E 17th Ave, Denver, CO 80203.

Certified copies of incorporated materials are provided at cost upon request. 8.100.5.I. Determining Ownership of Income 1. If payment is made solely to one individual, the income shall be considered available income to that individual.

If payment is made to more than one individual, the income shall be considered available to each individual in proportion to their interests.
In case of a married couple in which there is no document establishing specific ownership interests, one-half of the income shall be considered available to each 4. Income from the Community Spouse's Monthly Income Allowance, as defined in the spousal protection rules in this volume at 8.100.7.R, is income to the 8.100.5.J. Income-Producing Property 1. Net rental income from an exempt home or a life estate interest in an exempt home is countable after the following allowable deductions:

a. Property taxes and insurance b. Necessary reasonable routine maintenance expenses c. Reasonable management fee for a professional property manager.

Non-business property that is necessary to produce goods or services essential to self- support is excluded up to $6,000.
Property used in a trade or business which is essential to self-support is excluded up to a limit of $6,000 if it produces 6% return of the $6,000 excluded value. 8.100.5.K. Department of Veterans Affairs (VA) Payments The portion of the pension payments for Aid and Attendance (A&A) and Unusual Medical Expenses (UME), as determined by the VA, shall not be considered as income when determining eligibility.
The portion of the pension payments for Aid and Attendance (A&A) and Unusual Medical Expenses (UME), as determined by the VA, shall not be used as patient payment to the medical facility:

a. for a veteran or surviving spouse of a veteran in a medical facility other than State Veterans Home; or b. for a veteran or surviving spouse of a veteran in a State Veterans Home with dependents.

For a veteran or surviving spouse of a veteran in a State Veterans Home with no dependents the portion of the pension payments for Aid and Attendance (A&A) and Unusual Medical Expenses (UME), as determined by the VA, shall be used as patient payment to the medical facility. 8.100.5.L. Reverse Mortgages 1. In accordance with C.R.S. § 11-38-110, reverse mortgages payments made to a borrower shall not be treated as income for eligibility purposes.
Funds remaining the following month after the payment is made will be countable as a resource.
Any payments from a reverse mortgage that are transferred to another individual without fair consideration shall be analyzed in accordance with the rules on transfers without fair consideration in the Long-Term Care section and may result in a penalty period of ineligibility. 8.100.5.M. Resource Requirements 1. Consideration of resources: Resources are defined as cash or other assets or any real or personal property that an individual or spouse owns. The resource limit for an individual is $2,000. For a married couple, the resource limit is $3,000.

If one spouse is institutionalized, refer to Spousal Protection-Treatment of Income and Resources for Institutionalized Spouses. Effective January 1, 2011, the resource limits for the Qualified Medicare Beneficiaries (QMB), Specified Low Income Medicare Beneficiaries (SLMB), and Qualified Individuals 1 (QI-1) programs are $8,180 for a single individual and $13,020 for a married individual living with a spouse and no other dependents. The resource limits for the QMB, SLMB, and QI programs shall be adjusted annually by the Centers for Medicare and Medicaid Services on January 1 of each year. These resource limits are based upon the change in the annual consumer price index (CPI) as of September of the previous year. Resources are not counted for the Medicaid Buy-In Program for Working Adults with Disabilities or the Medicaid Buy-In Program for Children with Disabilities.

The following resources are exempt in determining eligibility:

a. A home, which is any property in which an individual or spouse of an individual has an ownership interest and which serves as the individual’s principal place of residence. The property includes the shelter in which an individual resides, the land on which the shelter is located and related outbuildings.

i) Only one principal place of residence is excluded for a single individual or a married couple.

ii) The individual’s ownership interest in the home must have an equity value that:

From January 1, 2006 thru December 31, 2010 is $500,000 or less, or;
Is less than the amount that results from the year to year percentage increase to the $500,000 limit. The increase is based upon the consumer price index for all urban consumers (all items; United States city average), rounded to the nearest $1,000.

iii) If an individual or spouse of an individual owns a home of any value located outside Colorado, and if the individual intends to return to that home, then the individual does not meet the residency requirement for Colorado Medicaid eligibility.

iv) If an individual or spouse of an individual owns a home of any value located outside Colorado, and if the individual does not intend to return to that home, then the home is a countable resource unless the individual’s spouse or dependent relative lives in the home.

v) If an individual or spouse of an individual owns a home located inside Colorado with an equity value lower than the limit in subparagraph (1), above, and if the individual intends to return to that home, then the home is considered an exempt resource if:

The individual is institutionalized; and 2) The intent to return home is documented in writing.

vi) If an individual or spouse of an individual owns a home with an equity value greater than the limit that is located inside Colorado, and if the individual intends to return to that home, then the home is considered to be a countable resource unless spouse or dependent relative lives in the home.

vii) If an individual or spouse of an individual owns a home of any value located inside Colorado, and if the individual does not intend to return to that home, then the home is a countable resource unless spouse or dependent relative lives in the home.

viii) If an individual or spouse moves out of his or her home without the intent to return, the home becomes a countable resource because it is no longer the individual's principal place of residence.

ix) If an individual leaves his or her home to live in an institution, the home shall still be considered the principal place of residence, irrespective of the individual's intent to return as long as the individual's spouse or dependent relative continues to live there.

x) The individual's equity in the former home becomes a countable resource effective with the first day of the month following the month it is no longer his or her principal place of residence.

xi) The intent to return home applies to the home in which the individual or spouse of the individual was living prior to being institutionalized or to a replacement home as long as the individual’s spouse or dependent relative continues to live in the home.

xii) The intent to return home also applies if the individual is living in an assisted living facility or alternative care facility and receives HCBS while in that facility or transfers into a Long-Term Care institution to receive services.

xiii) For an individual in a Long-Term Care institution, receiving HCBS, or enrolled in PACE, the exemption for the principal place of residence does not apply to a residence which has been transferred to a trust or other entity, such as a partnership or corporation.

The exemption shall be regained if the residence is transferred back into the name of the individual.

xiv) The principal place of residence, which is subject to estate recovery, becomes a countable resource upon the execution and recording of a beneficiary deed.

The exemption can be regained if a revocation of the beneficiary deed is executed and recorded.

b. Excess property will not be included in countable resources as long as reasonable efforts to sell it have been unsuccessful. Reasonable efforts to sell means: i.) The property is listed with a professional such as a real estate agent, broker, dealer, auction house, etc., at current market value.

ii) If owner listed, the property must be for sale at current market value, advertised and shown to the public.

iii) Any reasonable offer must be accepted.

iv) If an offer is received that is at least two-thirds of the current market value, that offer is presumed reasonable.

v) The client must continue reasonable efforts to sell and must submit verification of these efforts to the Eligibility Site on a quarterly

basis. Reasonable effort is at Eligibility Site discretion.

vi) If the exemption is used to become eligible under the Spousal Protection rules, the property shall continue to be viewed according to 8.100.7.L while efforts to sell it are being made.

vii) Eligibility under this exemption is conditional. Once the property sells, the client shall be ineligible until the resources are below the prescribed limit.

c. One automobile is totally excluded regardless of its value if it is used for transportation for the individual or a member of the individual's household.

An automobile includes, in addition to passenger cars, other vehicles used to provide necessary transportation.

d. Household goods are not counted as a resource to an individual (and spouse, if any) if they are:

i) Items of personal property, found in or near the home, that are used on a regular basis; or ii) Items needed by the household for maintenance, use and occupancy of the premises as a home.

iii) Such items include but are not limited to: furniture, appliances, electronic equipment such as personal computers and television sets, carpets, cooking and eating utensils, and dishes.

e. Personal effects are not counted as a resource to an individual (and spouse, if any) if they are:

i) Items of personal property ordinarily worn or carried by the individual; or ii) Articles otherwise having an intimate relation to the individual.

iii) Such items include but are not limited to: personal jewelry including wedding and engagement rings, personal care items, prosthetic devices, and educational or recreational items such as books or musical instruments.

iv) Items of cultural or religious significance to the individual and items required because of an individual’s impairment are also not counted as a resource.

f. The cash surrender value of all life insurance policies owned by an individual and spouse, if any, is exempt if the total face value of all life insurance policies does not exceed $1,500 on any person. If the total face value of all the life insurance policies exceeds $1,500 on one person, the cash surrender value of those policies will be counted.

g. Term life insurance having no cash surrender value, and burial insurance, the proceeds of which can be used only for burial expenses, are not countable toward the resource limit.

h. The total value of burial spaces for the applicant/recipient, his/her spouse and any other members of his/her immediate family is exempt as a resource. If any interest is earned on the value of an agreement for the purchase of a burial space, such interest is also exempt.

i. An applicant or recipient may own burial funds through an irrevocable trust or other irrevocable arrangement which are available for burial and are held in an irrevocable burial contract, an irrevocable burial trust, or in an irrevocable trust which is specifically identified as available for burial expenses without such funds affecting the person's eligibility for j. An applicant or recipient may also own up to $1,500 in burial funds through a revocable account, trust, or other arrangement for burial expenses, without such funds affecting the person's eligibility for assistance. This exclusion only applies if the funds set aside for burial expenses are kept separate from all other resources not intended for burial of the individual or spouse's burial expenses. Interest on the burial funds is also excluded if left to accumulate in the burial fund. For a married couple, a separate $1,500 exemption applies to each spouse.

The $1,500 exemption is reduced by:

i) the amount of any irrevocable burial funds such as are described in the preceding subparagraph, and ii) the face value of any life insurance policy whose cash surrender value is exempt.

k. Achieving a Better Life Experience (ABLE) Accounts.

Countable resources include the following:

a. Cash;

b. Funds held by a financial institution in a checking or savings account, certificate of deposit or money market account;

c. Current market value of stocks, bonds, and mutual funds;

d. All funds in a joint account are presumed to be a resource of the applicant or client. If there is more than one applicant or client account holder, it is presumed that the funds in the account belong to those individuals in equal shares. To rebut this presumption, evidence must be furnished that proves that some or all of the funds in a jointly held account do not belong to him or her. To rebut the sole ownership presumption, the following procedure must be followed:

i) Submit statements from all of the account holders regarding who owns the funds, why there is a joint account, who has made deposits and withdrawals, and how withdrawals have been spent.

ii) Submit account records showing deposits, withdrawals and interest in the months for which ownership of funds is at issue.

iii) Correct the account title and submit revised account records showing that the applicant or client is no longer an account holder or separate the funds to show they are solely owned by the individual within 45 days.

e. Any real property that is subject to a recorded beneficiary deed and on which an estate recovery claim can be made.

f. For applications filed on or after January 1, 2006, an individual’s home if the individual’s equity interest in the home exceeds the equity value limit described at 8.100.5.M.2.a.i)1).

g. Real property not exempt as the principal place of residence and not exempt as income producing property with a value of $6,000 or less, as described at 8.100.5.J.

h. When the applicant alleges that the sale of real property would cause undue hardship to the co-owner due to loss of housing, all of the following information must be obtained:

i) The applicant or client's signed statement to that effect.

ii) Verification of joint ownership.

iii) A statement from the co-owner verifying the following:

The property is used as his principal place of residence.
The co-owner would have to move if the property were sold.
The co-owner would be unable to buy the applicant or client's interest in the property.
There is no other readily available residence because there is no other affordable housing available or no other housing with the necessary modifications for the co-owner if he is a person with disabilities.

i. Personal property such as a mobile home or trailer or the like, that is not exempt as a principal place of residence or that is not income producing.

j. Personal effects acquired or held for their value or as an investment. Such items can include but are not limited to: gems, jewelry that is not worn or held for family significance, or collectibles.

k. The equity value of all automobiles that are in addition to one exempt vehicle.

l. The cash surrender value of all life insurance policies owned by an individual and spouse is counted if the total face value of all the policies combined exceeds $1,500 on any person.

m. Promissory notes established before April 1, 2006 are treated as follows:

i) The fair market value of a promissory note, mortgage, installment contract or similar instrument is an available countable resource.

ii) In order to determine the fair market value, the applicant shall obtain three estimates of fair market value from a private note broker, who is engaged in the business of purchasing such notes.

In order to obtain the estimates and locate willing buyers, the note shall be advertised in a newspaper with state wide circulation under business or investment opportunities.

iii) A note or similar instrument which transferred funds or assets for less than fair consideration shall be considered as a transfer for less than fair consideration and a period of ineligibility shall be imposed.

n. Promissory notes established on or after April 1, 2006 and before March 1, 2007 are treated as follows:

i) The value of a promissory note, loan or mortgage is an available countable resource unless the note, loan or mortgage:

Has a repayment term that is actuarially sound based on the individual’s life expectancy, found in the tables at 8.100.7.J, for annuities purchased on or after February 8, 2006;
Provides for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made; and 3) Prohibits the cancellation of the balance upon the death of the lender.

ii) The value of a promissory note, loan or mortgage which does not meet the criteria in outlined in 8.100.5.M.3.n.i)1)-3) is the outstanding balance due as of the date of the individual’s application for HCBS, PACE or institutional services and is subject to the transfer of assets without fair consideration provisions as outlined in section 8.100.7.F.

o. Promissory notes established on or after March 1, 2007 are treated as i) The value of a promissory note, loan or mortgage is the outstanding balance due as of the date of the individual’s application for HCBS, PACE or institutional services and is an available countable resource, and ii) A promissory note, loan or mortgage which does not meet the following criteria shall be considered to be a transfer without fair consideration and shall be subject to the provisions outlined at 8.100.7.F.

Has a repayment term that is actuarially sound based on the individual’s life expectancy as found in the tables in section 8.100.7.J for annuities purchased on or after February 8, 2006;
Provides for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made; and 3) Prohibits the cancellation of the balance upon the death of the lender.

p. Mineral rights represent ownership interest in natural resources such as coal, oil, or natural gas, which normally are extracted from the ground.

i) Ownership of land and mineral rights. If the individual owns the land to which the mineral rights pertain, the current market value of the land generally includes the value of the mineral rights.

ii) If the individual does not own the land to which the mineral rights pertain, the individual should obtain a current market value estimate from a knowledgeable source. Such sources may include:

any mining company that holds leases;
the Bureau of Land Management;
the U.S. Geological Survey. 8.100.5.N. Treatment of Self-Funded Retirement Accounts 1. The following regulations apply to self-funded retirement accounts such as an Individual Retirement Account (IRA), Keogh Plan, 401(k), 403(b) and any other self-funded retirement account.

Self-funded retirement accounts in the name of the applicant are countable as a resource to the applicant.
Self-funded retirement accounts in the name of the applicant's spouse who is living with the applicant are exempt in determining eligibility for the applicant, except as set forth in 4. below.
Self-funded retirement accounts in the name of a community spouse who is married to an applicant who is applying for Long Term Care in a Long Term Care institution, HCBS or PACE, are countable as a resource to the applicant and may be included in the Community Spouse Resource Allowance (CSRA) up to the maximum amount allowable. The terms community spouse and CSRA are further defined in the regulations on Spousal Protection in this volume.
The value of a self-funded retirement account is determined as follows:

a. The gross value of the account, less any taxes due, is the amount that is countable as a resource, regardless of whether any monthly income is being received from the account.

b. If the applicant is not able to provide the amount of taxes that are due, the value shall be determined by deducting 20% from the gross value of the account. 8.100.5.O. Treatment of Inheritances 1. An inheritance is cash, other liquid resources, non-cash items, or any right in real or personal property received at the death of another.

If an Individual or individual’s spouse is the beneficiary of a will, the inheritance is presumed to be available at the conclusion of the probate process or within 6 months if the estate is not in probate.
If an individual or individual’s spouse is eligible for a family allowance in a probate proceeding, that allowance will be considered available three months after death or when actually available, whichever is sooner.
Evidence demonstrating that the inheritance is not available due to probate or other legal restrictions must be provided to rebut the presumption. 8.100.5.P. Treatment of Proceeds from Disposition of Resources Treatment of proceeds from disposition of resources is determined as follows:
The net proceeds from the sale of exempt or non-exempt resources are considered available resources.
The net proceeds are the selling price less any valid encumbrances and costs of sale.
After deducting any amount necessary to raise the individual's and spouse's resources to the applicable limits, the balance of the net proceeds, in excess of the resource limits, shall be considered available resources. In lieu of terminating eligibility due to excess resources, the client may request that the proceeds be used to reimburse the Medical Assistance Program for previous payments for 4. The proceeds from the sale of an exempt home will be excluded to the extent they are intended to be used and are, in fact, used to purchase another home in which the individual, a spouse or dependent child resides, within three months of the date of the sale of the home. 8.100.6 Aged, Blind, and Disabled Medical Assistance Eligibility 8.100.6.A. Aged, Blind, and Disabled (ABD) General Information 1. Medical Assistance for ABD includes SSI eligible individuals, OAP recipients, and the Medicare Savings Program (MSP) individuals. Refer to section 8.100.5 of this volume for income and resource criteria for these categories of assistance. 8.100.6.B. Disability Determinations 1. Beginning on July 1, 2001, the Department or its contractor shall determine whether the client is disabled or blind in accordance with the requirements and procedures set forth elsewhere in this volume and according to Federal regulations regarding disability determinations.
A client who disagrees with the decision on disability or blindness shall have the right to appeal that decision to a state-level fair hearing in accordance with the procedures at 8.057. 8.100.6.C. SSI Eligibles 1. Benefits of the Colorado Medical Assistance Program must be provided to the a. persons receiving financial assistance under SSI;

b. persons who are eligible for financial assistance under SSI, but are not receiving SSI;

c. persons receiving SSI payments based on presumptive eligibility for SSI pending final determination of disability or blindness; and persons receiving SSI payments based on conditional eligibility for SSI pending disposal of excess resources.

The Department has entered into an agreement with SSA in which SSA shall determine Medical Assistance for all SSI applicants. Medical Assistance shall be provided to all individuals receiving SSI benefits as determined by SSA to be eligible for Medical Assistance.
The eligibility sites shall have access to a weekly unmatched listing of all individuals newly approved and a weekly SSI-Cases Denied or Discontinued listing. These lists shall include the necessary information for the eligibility site to authorize Medical Assistance.
Medical Assistance shall not be delayed due to the necessity to contact the SSI recipient and obtain third party medical resources.
Notification shall be sent to the SSI recipient advising him/her of the approval of 6. The SISC Code for this type of assistance is B.
Denied or terminated Medical Assistance based on a denial or termination of SSI which is later overturned, must be approved from the original SSI eligibility date.
Individuals who remain eligible as SSI recipients but are not receiving SSI payments shall receive Medical Assistance benefits. This group includes persons whose SSI payments are being withheld as a means of recovering an overpayment, whose checks are undeliverable due to change of address or representative payee, and persons who lost SSI financial assistance due to 9. If the eligibility site obtains information affecting the eligibility of these SSI recipients, they shall forward such information to the local Social Security office.
For individuals under 21 years of age who are eligible for or who are receiving SSI, the effective date of Medicaid eligibility shall be the date on which the individual applied for SSI or the date on which the individual became eligible for SSI, whichever is later.

a. Special Provisions for Infants i) For an infant who is eligible for or who is receiving SSI, the effective date of Medicaid eligibility shall be the infant’s date of birth if:

the infant was born in a hospital;
the disability onset date, as reported by the Social Security Administration, occurred during the infant’s hospital stay; and 3) the infant’s date of birth is within three (3) months of the date on which the infant became eligible for SSI 8.100.6.D. Pickle Amendment 1. Beginning July 1977, Medical Assistance must be provided to an individual if their countable income is below the current years SSI standard after a cost of living adjustment (COLA) disregard is applied to their OASDI (excluding Railroad Retirement Benefits) and they meet all other eligibility criteria. This is referred to as Pickle Disregard.

The Pickle Disregard applies to an individual who:

a. lost SSI and/or OAP because of a cost of living adjustment to his/her own OASDI benefits.

b. lost SSI and/or OAP because a cost of living adjustment to OASDI income deemed from a parent or spouse.

c. lost OAP and/or SSI due to the receipt of, or increase to, OASDI, and would be eligible for OAP and/or SSI if all COLA’S on the amount that caused them to lose eligibility is disregarded from their current OASDI amount. 8.100.6.E. Pickle Determination 1. To determine eligibility of Medical Assistance recipients to whom the Pickle disregards apply, the eligibility site must:

a. establish whether the person was eligible for SSI or OAP and, for the same month, was entitled to OASDI;

b. determine the previous amount of the OASDI that caused them to lose SSI and/or OAP;

c. determine the current OASDI income;

d. subtract the previous OASDI income from the current OASDI income to find the cumulative OASDI COLAs since SSI and/or OAP was lost. This is the Pickle Disregard amount;

e. subtract the Pickle Disregard amount from the current OASDI income to get the countable OASDI income.

If the countable OASDI income and all other countable income is less than the current SSI or OAP standard, and the individual meets all other eligibility criteria then medical eligibility must continue or be reinstated.
This disregard must also be applied to any OASDI cost of living increases paid to any financially responsible individual such as a parent or spouse whose income is considered in determining the person's continued eligibility for Medical 4. The cost of living increase disregard specified in the preceding action must continue to be applied at each eligibility redetermination.
An SSI medical only individual who loses SSI due to an OASDI cost-of-living increase shall be contacted by the eligibility site to determine if the individual would continue to remain eligible for Medical Assistance under the provisions for SSI related cases. The individual must complete an application for assistance to continue receiving benefits. 8.100.6.F. 1972 Disregard Individuals 1. Medical Assistance must be provided to a person who was receiving financial assistance under AND or Aid to the Blind (AB) for August 1972 and who – except for the October 1972 Social Security (includes RRB) 20% increase amount would currently be eligible for financial assistance. This disregard must also be applied to a person receiving Medical Assistance in August 1972 who was eligible for financial assistance but was not receiving the money payment and to a person receiving Medical Assistance as a resident in a medical institution in August 1972.
To redetermine the eligibility of Medical Assistance recipients to whom the 1972 disregard applies, the eligibility site must:

a. review the case against the current applicable program definitions and requirements;

b. apply the resource and income criteria specified in section 8.100.5;

c. subtract the 1972 disregard amount from the income;

d. consider the remainder against the current appropriate SSI benefit level. 8.100.6.G. Individuals Eligible in 1973 1. Medical Assistance must be provided to ABD persons who are receiving mandatory state supplementary payments (SSP). Such persons are those with income below their December 1973 minimum income level (MIL).

Medical Assistance must be provided to a person who was eligible for Medical Assistance in December 1973 as an inpatient of a medical facility, who continues to meet the December 1973 eligibility criteria for institutionalized persons and who remains institutionalized.
Medical Assistance must be provided to a person who was eligible for Medical Assistance in December 1973 as an “essential spouse” of an AND or AB financial assistance recipient, and who continues to be in the grant and continues to meet the December 1973 eligibility criteria. Except for such persons who were grandfathered-in for continued assistance, essential spouses included in assistance grants after December 1973 are not eligible for Medical Assistance. 8.100.6.H. Eligibility for Certain Disabled Widow(er)s 1. Medical Assistance shall be provided retroactive to July 1, 1986, to qualified disabled widow(er)s who lost SSI and/or state supplementation due to the 1983 change in the actuarial reduction formula prescribed in section 134 of P.L. No. 98 21.

In order for these widow(er)s to qualify, these individuals must:

a. have been continuously entitled to Title II benefits since December 1983;

b. have been disabled widow(er)s in January 1984;

c. have established entitlement to Title II benefits prior to age 60;

d. have been eligible for SSI/SSP benefits prior to application of the revised actuarial reduction formula;

e. have subsequently lost eligibility for SSI/SSP as a result of the change in the actuarial table; and f. reapply for assistance prior to July 1, 1987. 8.100.6.I. Eligibility for Disabled Widow(er)s 1. Effective January 1, 1991, Medical Assistance shall be provided to disabled widow(er)s age 50 through 64 who lost SSI and/or OAP due to the receipt of Social Security benefits as a disabled widow(er). The individual shall remain eligible for Medical Assistance until he/she becomes eligible for Part A of Medicare (hospital insurance).

To qualify these individuals must:

a. be a widow(er);

b. have received SSI in the past;

c. be at least 50 years old but not 65 years old;

d. no longer receive SSI payments because of Social Security payments;

e. not have hospital insurance under Medicare; and, f. meet all other Medical Assistance requirements. 8.100.6.J. Disabled Adult Children 1. Medical Assistance shall be provided to an individual aged 18 or older who loses SSI due to the receipt of OASDI drawn from his/her parents' Social Security Number; and:

a. who was determined disabled prior to the age of 22; and b. who is currently receiving OASDI income as a Disabled Adult Child; and c. who would continue to be eligible for SSI if:

i) the current OASDI income of the applicant is disregarded; and ii) the resources are below the applicable limit as listed at 8.100.5.M;

iii) other countable income is below the current years SSI FBR.

Disabled Adult Children are identified by the OASDI Beneficiary Identification Code (BIC) of “C”. 8.100.6.K. Old Age Pension (OAP) Eligibles 1. Individuals that are 65 and over are defined as the OAP-A category. Individuals who attain the age of 60 but not yet 65 are defined as the OAP-B category.
Medical Assistance must be provided to persons receiving OAP-A or OAP-B and SSI (SISC B).
Medical Assistance must be provided to all OAP-A and OAP-B persons who also meet SSI eligibility criteria but are not receiving a money payment (SISC-B).
Medical Assistance must be provided to all OAP-A and OAP-B persons who also meet SSI eligibility criteria except for the level of their income (SISC-B).
Medical Assistance must be provided to persons in a facility eligible for Medical Assistance reimbursement whose income is under 300% of the SSI benefit level and who, but for the level of their income, would be eligible for OAP “A” or OAP “B” and SSI financial assistance. This group includes persons 65 years of age or older receiving active treatment as inpatients in a psychiatric facility eligible for Medical Assistance reimbursement (SISC A). This population is referenced as Psych >65.
The OAP B individual included in AFDC assistance unit shall receive Medical Assistance as a member of the AFDC household (SISC B).
The OAP State Only Medical Assistance Program provides Medical Assistance to OAP-A, OAP-B or OAP Refugees who lost their OAP financial assistance because of a cost of living adjustment other than OASDI. Examples of other sources of income are VA, RRB, PERA, etc. (SISC C).
For the purpose of identifying the proper SISC code for persons receiving assistance under OAP “A” or OAP “B”, if the person:

a. receives an SSI payment (SISC B);

b. does not receive an SSI payment but is receiving assistance under OAP “A”, a second evaluation of resources must be made using the same resource criteria as specified in section 8.100.5.M for those who meet this criteria the SISC code is B for money payment and “disregard” case, A for institutional cases;

c. does not receive an SSI payment and does not otherwise qualify under SISC code B or A as described in item b. above (SISC C). 8.100.6.L. Qualified Medicare Beneficiaries (QMB)

Medical Assistance coverage for QMB members is payment of Medicare part B premiums, co-insurance and deductibles.
In order to be eligible as a Qualified Medicare Beneficiary, the individual must meet the following:

a. is entitled to Part A Medicare; and b. resources may not exceed the standard for an individual or couple who have resources, as described in section 8.100.5.M; and c. has income at or below the percentage of the federal poverty level for the size family as mandated for QMB by federal regulations. Poverty level is established by the Executive Office of Management and Budget.

d. is enrolled in the mandatory SSI program with premium-free Medicare Part A.

For QMB purposes, couples shall have their income compared against the federal poverty level couples income maximum. This procedure shall be applied whether one or both members apply for QMB.
For QMB purposes, income of the applicant and/or the spouse shall be or more individuals have earned income, the income of all the individuals shall be 5. Medicare cost sharing expenses must be provided to qualified Medicare beneficiaries. This limited Medical Assistance package of Medicare cost sharing expenses only includes:

a. payment of Part A Medicare premiums where applicable;

b. payment of Part B Medicare premiums; and c. payment of coinsurance and deductibles for Medicare services whether or not a benefit of Medical Assistance up to the full Medicare rate or reasonable rates as established in the State Plan.

Individuals may be QMB recipients only or the individual may be classified as a dual eligible. A dual eligible is a Medicare recipient who is otherwise eligible for 7. A QMB-only recipient is an individual who is not eligible for other categorical assistance program due to their income and/or resources but who meets the eligibility criteria for QMB described above.
Individuals who apply for QMB assistance have the right to have their eligibility determined under all categories of assistance for which they may qualify.
All other general non-financial requirements or conditions of eligibility must also be met such as age, citizenship, residency requirements as well as reporting and redetermination requirements. These criteria are defined in section 8.100.3 of this volume.
Eligibility for QMB benefits shall be effective the month following the month of determination. Beneficiaries who submit and complete an application within the 45-day standard shall be eligible for benefits no later than the first of the month following the 45th day of application. Administrative delays shall not postpone the effective date of eligibility.
QMB benefits are not retroactive and the three month retroactive Medical Assistance rule does not apply to QMB benefits.
Members who would lose their QMB entitlement due to annual social security COLA will remain eligible for QMB coverage under Medical Assistance, as income disregard cases, until the next year's federal poverty guidelines are published. 8.100.6.M. Specified Low Income Medicare Beneficiaries 1. Medical Assistance coverage for SLMB clients is limited to payment of monthly Medicare Part B (Supplemental Medical Insurance Benefits) premiums.
Effective January 1, 1993, a Specified Low Income Medicare Beneficiary (SLMB) is an individual who:

a. is entitled to Medicare Part A;

b. resources may not exceed the standard for an individual or couple who has resources as described in section 8.100.5.M of this volume.

c. has income at or below a percentage of the federal poverty level for the family size as mandated by federal regulations for SLMB. Income limits have been defined through CY 1995, as follows: CY 1993 and 1994 100- 110% of FPL, CY 1995 100-120% of FPL.

For SLMB purposes, couples shall have their income compared against the federal poverty level couples income maximum. This procedure shall be applied whether one or both members apply for SLMB.
For SLMB purposes, income of the applicant and/or the spouse shall be or more individuals have earned income, the income of all the individuals shall be 5. SLMB eligibility starts on the date of application or up to three month prior to the application date for retroactive Medical Assistance.
Eligibility may be made retroactive up to 90 days, but may not be effective prior to 1/1/93.
Clients who would lose their SLMB entitlement due to annual SSA COLA will remain eligible for SLMB coverage, as income disregard cases, through the month following the month in which the annual federal poverty levels (FPL) update is published. 8.100.6.N. Medicare Qualifying Individuals 1 (QI1)
Medical Assistance coverage is limited to monthly payment of Medicare Part B premiums. Payment of the premium shall be made by the Department on behalf of the individual.
Eligibility for this benefit is limited by the availability of the allocation set by CMS.

Once the state allocation is met, no further benefits under this category shall be paid and a waiting list of eligible individuals shall be maintained.

Eligibility for QI1 benefits shall be effective the month in which application is made and the individual is eligible for benefits. Eligibility may be retroactive up to three months from the date of application, but not prior to January 1, 1998.
In order to qualify as a Medicare Qualifying Individual 1, the individual must meet the following:

a. be entitled to Part A of Medicare, b. income of at least 120%, but less than 135% of the FPL.

c. resources may not exceed the standard as described in section 8.100.5.M, and d. he/she cannot otherwise be eligible for Medical Assistance.

For QI1 purposes, income of the applicant and/or the spouse shall be determined as described under Income Requirements in section 8.100.5. If two or more individuals have earned income, the income of all the individuals shall be added together and the $65 plus one half remainder earned income disregard shall be applied to the total amount of earned income.
Clients who would lose QI-1 entitlement due to annual social security COLA will remain eligible for QI-1 coverage under Medical Assistance, as an income disregard case, until the next year’s federal poverty guidelines are published. 8.100.6.O. Qualified Disabled And Working Individuals 1. Medical Assistance coverage is limited to monthly payment of Medicare Part A premiums, and any other Medicare cost sharing expenses determined necessary by CMS.
Effective July 1, 1990, a Qualified Disabled and Working Individual (QDWI) is an individual who:

a. was a recipient of federal Social Security Disability Insurance (SSDI) benefits, who continues to be disabled but lost SSDI entitlement due to earned income in excess of the Social Security Administration's Substantial Gainful Activity (SGA) threshold, and;

b. has exhausted SSA's allowed extension of “premium free” Medicare Part A coverage under SSDI, and;

c. has resources at or below twice the SSI resource limit as described in

section 8.100.5., and;

d. has income less than 200% of FPL.

For QDWI purposes, income of the applicant and/or the spouse shall be or more individuals have earned income, the income of all the individuals shall be 4. An individual may be eligible under this section only if he/she is not otherwise eligible under another Medical Assistance category of eligibility.
Eligibility for QDWI benefits shall be effective the month of determination of entitlement.
Eligibility may be retroactive only to the date as of which SSA approves an individual's application for coverage as a “Qualified Disabled and Working Individual”. However, eligibility may not begin prior to 07/01/90. 8.100.6.P. Medicaid Buy-In Program for Working Adults with Disabilities.
To be eligible for the Medicaid Buy-In Program for Working Adults with Disabilities:

a. Applicants must be at least age 16.

b. Income must be less than or equal to 450% of FPL after income allocations and disregards. See 8.100.5.F for Income Requirements and 8.100.5.H for Income allocations and disregards. Only the applicant’s income will be considered.

c. Resources are not counted in determining eligibility.

d. Individuals must have a disability as defined by Social Security Administration medical listing or a limited disability as determined by a state contractor.

e. Individuals must be employed. Please see Verification Requirements at 8.100.5.B.1.c.

i) Due to the federal COVID-19 Public Health Emergency, and required by the Federal CARES Act for the Maintenance of Effort (MOE), members who had a loss of employment will remain in the Buy-In program until the end of the federal Public Health Emergency. At the end of the federal Public Health Emergency effective May 11, 2023, members will be redetermined based on their current employment status and be required to be employed to be eligible for the program. New applicants enrolled will still need to meet the work requirement.

f. Individuals will be required to pay monthly premiums on a sliding scale based on income.

i) The amount of premiums cannot exceed 7.5% of the individual’s income.

ii) Premiums are charged beginning the month after determination of eligibility. Any premiums for the months prior to the determination of eligibility will be waived.

iii) Premium amounts are as follows:

There is no monthly premium for individuals with income at or below 40% FPL.
A monthly premium of $25 is applied to individuals with income above 40% of FPL but at or below 133% of FPL.
A monthly premium of $90 is applied to individuals with income above 133% of FPL but at or below 200% of FPL.
A monthly premium of $130 is applied to individuals with income above 200% of FPL but at or below 300% of FPL.
A monthly premium of $200 is applied to individuals with income above 300% of FPL but at or below 450% of FPL.

iv) The premium amounts will be updated at the beginning of each State fiscal year based on the annually revised FPL if the revised FPL would cause the premium amount (based on percentage of income) to increase by $10 or more.

v) A change in a member’s net income may impact the monthly premium amount due. Failure to pay premium payments in full within 60 days from the premium due date will result in the member’s assistance being terminated prospectively. The effective date of the termination will be the last day of the month following the 60 days from the date on which the premium became past due. The Department will waive premiums for the Medicaid Buy-In for Working Adults with Disability Program for member’s who are within their 12 months postpartum period.

Retroactive coverage is available according to 8.100.3.E, however is not available prior to program implementation 3. Individuals have the option to request to be disenrolled if they have been enrolled into the Medicaid Buy-In Program for Working Adults with Disabilities. This is also called “opt out.” 8.100.6.Q. Medicaid Buy-In Program for Children with Disabilities 1. To be eligible for the Medicaid Buy-In Program for Children with Disabilities:

a. Applicants must be age 18 or younger.

b. Household income will be considered and must be less than or equal to 300% of FPL after income disregards. The following rules apply:

i) 8.100.4.E - MAGI Household Requirements ii) 8.100.5.F - Income Requirements iii) 8.100.5.F.6 - Income Exemptions iv) 8.100.5.H. Income Allocations and Disregards c. Resources are not counted in determining eligibility.

d. Individuals must have a disability as defined by Social Security Administration medical listing.

e. Children age 16 through 18 cannot be employed. If employed, children age 16 through 18 will be determined for eligibility through the Medicaid Buy-In Program for Working Adults with Disabilities.

f. Families are required to enroll in medical family coverage offered through an employer-based group health plan if they are eligible and if the employer contributes at least 50% towards the plan premiums.

g. Families will be required to pay monthly premiums on a sliding scale based on household size and income.

i) For families whose income does not exceed 200% of FPL, the amount of premiums and cost-sharing charges cannot exceed 5% of the family’s adjusted gross income. For families whose income exceeds 200% of FPL but does not exceed 300% of FPL, the amount of premiums and cost-sharing charges cannot exceed 7.5% of the family’s adjusted gross income.

ii) Premiums are charged beginning the month after determination of eligibility. Any premiums for the months prior to the determination of eligibility will be waived.

iii) For households with two or more children eligible for the Medicaid Buy-In Program for Children with Disabilities, the total premium shall be the amount due for one eligible child.

iv) Premium amounts are as follows:

There is no monthly premium for households with income at or below 133% of FPL.
A monthly premium of $70 is applied to households with income above 133% of FPL but at or below 185% of FPL.
A monthly premium of $90 is applied to individuals with income above 185% of FPL but at or below 250% of FPL.
A monthly premium of $120 is applied to individuals with income above 250% of FPL but at or below 300% of FPL.

v) The premium amounts will be updated at the beginning of each State fiscal year based on the annually revised FPL if the revised FPL would cause the premium amount (based on percentage of income) to increase by $10 or more.

vi) A change in household net income may impact the monthly premium amount due. Failure to pay premium payments in full within 60 days from the premium due date will result in a member’s assistance being terminated prospectively. The effective date of the termination will be the last day of the month following the 60 days from the date on which the premium became past due. The Department will waive premiums for the Children with Disabilities Program members who are within their 12 months postpartum period.

vii) Due to the federal COVID-19 Public Health Emergency, the Department will waive premiums for the Department’s Children with Disabilities Program during the federal emergency declaration. Effective May 11, 2023 the COVID -19 Public Health Emergency has ended. The Department will continue to waive premiums until the last day of the twelfth month following the end of the COVID - 19 Public Health Emergency. The Department will notify all members as to when required premiums will resume.

Retroactive coverage is available according to 8.100.3.E, however is not available prior to program implementation.
Verification requirements will follow the MAGI Category Verification Requirements found at 8.100.4.B. 4, Individuals have the option to request to be disenrolled if they have been enrolled into the Medicaid Buy-In Program for Children with Disabilities. This is also called “opt out.” 8.100.7 Long-Term Care Medical Assistance Eligibility 8.100.7.A. Persons in Long-Term Care Institutions or Other Residential Placement 1. For Long-Term Care services to be covered in a Long-Term Care institution, a client must be determined eligible under the 300% Institutionalized Special Income category. If the client is already Medicaid eligible, a new application is not required but the client must be determined to meet the eligibility criteria.

For a client entering a Long-Term Care Institution from the community, the Eligibility Site must notify the Single Entry Point/Case Management Agency, upon receipt of the application or client request, to schedule the Long-Term Services and Supports Level of Care Eligibility Determination Screen. This is not applicable to a client being discharged from a hospital, nursing facility or Long- Term Home Health.

For purposes of applying the special income standard for the aged, disabled or blind persons in Long-Term Care Institutions, gross income means income before application of deductions, exemptions or disregards appropriate to the SSI program.

Medical Assistance will be provided beginning the first day of the month following the month during which a child under the age of 18 ceases to live with his or her parent(s). Once determined to meet the institutional requirement, parental income and resources will cease to be deemed available to the child because the child is institutionalized and not living in the parents' home.

Eligibility under the 300% Institutionalized Special Income category will be provided to applicants who:

a. Have attained the age of 65 years or;

b. Have met the requirements according to the definition of disability or blindness applicable to the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI)

c. Have been institutionalized for at least 30 consecutive full days in a Long- Term Care institution. The 30 consecutive full day stay may be a combination of days in a hospital, Long-Term Care institution, or receiving services from a Home and Community Based Services (HCBS) program or Program of All Inclusive Care for the Elderly (PACE).

Supporting documentation must be provided which verifies the 30 consecutive full days. This documentation shall include the Long-Te r m Services and Supports Level of Care Eligibility Determination and/or medical records which must be verified by a physician or case manager.

If a client dies prior to the 30th consecutive full day, the client shall be determined to have met the 30 consecutive full day requirement if:

i) There is a statement from a physician, or case manager that declares if the client had not died, he/she would have been institutionalized for 30 consecutive full days, and;

ii) The statement is verified by supporting documentation from the beginning of the institutionalized period, which is the first 15 days, or prior to the death of the client, whichever is earliest.

iii) Once the 30 consecutive days of institutionalization requirement has been met, Medical Assistance benefits start as of the first day when institutionalization began if all other eligibility requirements were met as of that date.

d. Are in a facility eligible for Medical Assistance Program reimbursement if the individual is in a hospital or Long-Term Care institution; and e. Have gross income that does not exceed 300% of the current individual SSI benefit level or;

Are in a Long-Term Care institution (excluding hospital) whose gross income exceeds the 300% level and who establishes an income trust in accordance with the rules on income trusts in section 8.100.7 of this volume;

i) This special income standard must be applied for:

A person 65 years of age or older, or disabled or blind receiving care in a hospital, nursing facility; or 2) A person who is not SSI eligible needing Long-Term Care from HCBS or PACE; or 3) A person 65 years of age or older receiving active treatment as an inpatient in a psychiatric facility eligible for Medical Assistance reimbursement; and f. Have resources that conform with the regulations regarding resource limits and exemptions set forth in section 8.100.5 of this volume; and g. If married, Income and resources conform to rules set forth at 8.100.7.C and 8.100.7.K; and h. Have not transferred assets without fair consideration on or after the lookback date defined in section 8.100.7.F.2.d. which would incur a penalty period of ineligibility in accordance with the regulations on transfers without fair consideration in section 8.100.7 of this volume; and i. Have submitted trust documents to the Department if the individual or the individual's spouse has transferred assets into a trust or is a beneficiary of trust. The Department shall determine the effect of the trust on Medical Assistance Program eligibility.

j. Have submitted documents verifying that an annuity conforms to the regulations regarding Annuities at 8.100.7.I.

An appeal process is available to children identified by C.R.S. 27-10.3-101 to 108, The Child Mental Health Treatment Act, who are denied residential treatment. The appeal process is outlined in the Income Maintenance Staff Manual of the Department of Human Services (9 CCR 2503-1). A determination made in connection with this appeal shall not be the final agency action with regard to Medical Assistance eligibility 8.100.7.B. Persons Requesting Long-term Care through Home and Community Based Services (HCBS) or the Program of All Inclusive Care for the Elderly (PACE)
HCBS or PACE shall be provided to persons who have been assessed by the Single Entry Point/Case Management Agency to have met the institutional level of care and will remain in the community by receiving HCBS or PACE; and a. are SSI (including 1619b) or OAP Medicaid eligible; or b. are eligible under the Institutionalized 300% Special Income category described at 8.100.7.A; or c. are eligible under the Medicaid Buy-In Program for Working Adults with Disabilities described at 8.100.6.P. For this group, access to HCBS:

i) Is limited to the Elderly, Blind and Disabled (EBD), Community Mental Health Supports (CMHS), Brain Injury (BI), Spinal Cord Injury (SCI), Supported Living Services (SLS), and Developmental Disabilities waivers; and ii) Is contingent on the Department receiving all necessary federal approval for the waiver amendments that extend access to HCBS to the Working Adults with Disabilities population described at 8.100.6.P.

A client who is already Medicaid eligible does not need to submit a new application. The client must request the need for Long-Term Care services and the Eligibility Site must redetermine the client’s eligibility.

a. All individuals applying for or requesting Long-Term Care services must disclose and provide documentation of:

i) any transfer of assets without fair consideration as described at 8.100.7.F; and ii) any interest in an annuity as described at 8.100.7.I; and iii) any interest in a trust as described at 8.100.7.E.

b. Failure to disclose and provide documentation of the assets described at 8.100.7.B.2.a may result in the denial of Long-Term Care services.

c. The requirements at 8.100.7.B.2.a and 8.100.7.B.2.b do not apply to individuals who have been determined eligible under the Medicaid Buy-In Program for Working Adults with Disabilities described at 8.100.6.P.

For individuals served in Alternative Care Facilities (ACF), income in excess of the personal needs allowance and room and board amount for the ACF shall be applied to the Medical Assistance charges for ACF services. The total amount allowed for personal need and room and board cannot exceed the State's Old Age Pension Standard. 8.100.7.C. Treatment of Income and Resources for Married Couples 1. The income of a community spouse is not deemed to the institutionalized spouse in determining eligibility. If both spouses are institutionalized, their individual income is counted in determining their own eligibility. The income of one institutionalized spouse is not deemed to the other institutionalized spouse when determining eligibility.
The income and resources of both spouses are counted in determining eligibility for either or both spouses with the following exceptions:

a. If spouses share the same room in an institution, the income of the individual spouse is counted in determining his or her eligibility, and each spouse is allowed the $2000 limit for resources.

b. Beginning the first month following the month the couple ceases to live together, only the income of the individual spouse is counted in determining his or her eligibility.

c. If one spouse is applying for Long-Term Care in a Long-Term Care institution or Home and Community Based Services (HCBS), refer to the rules on Treatment of Income and Resources for Institutionalized Spouses.

Long term care insurance benefits are not countable as income, but are payable as part of the patient payment to the Long-Term Care institution.
For living expense purposes, income and resources of spouses living in the same household for a full calendar month or more must be considered as available to each other, whether or not they are actually contributed, and must be evaluated in accordance with rules contained in 8.100.7.Q.

Long-Term Care 8.100.7.D. Other Medical Assistance Clients Requesting Long-Term Care in an Institution or through HCBS or PACE Clients who need Long-Term Care services who are eligible for the State Only Health Care Program shall submit an application because they are not already Medicaid eligible. 8.100.7.E Consideration of Trusts in Determining Medical Assistance Eligibility 1. Trusts established before August 11, 1993:

a. Medical Assistance Qualifying Trust (MQT)

i) In the case of a Medical Assistance qualifying trust, as defined in

Section 8.100.7.E.ii, the amount of the trust property that is considered available to the applicant/member who established the trust (or whose spouse established the trust) is the maximum amount that the trustee(s) is permitted under the trust to distribute to the individual assuming the full exercise of discretion by the trustee(s) for the distribution of the maximum amount to the applicant/member. This amount of property is deemed available resources to the individual, whether or not is actually received.

ii) A Medical Assistance qualifying trust is a trust, or similar legal device, established (other than by will) by an individual (or an individual's spouse) under which the individual may be the beneficiary of all or part of the payments from the trust and the distribution of such payments is determined by one or more trustees who are permitted to exercise any discretion with respect to the distribution to the individual.

b. This provision does not apply to any trust or initial decrees established before April 7, 1986, solely for the benefit of a developmentally disabled individual who resides in an Long Term Care Institution for the developmentally disabled.

c. This provision does not apply to individuals who are receiving SSI.

Trusts established on or after July 1, 1994:

Assets include all income and resources of the individual and the individual's spouse, including all income and resources which the individual or the individual's spouse is entitled to but does not receive because of action by any of the following:

a. The individual or the individual's spouse;

b. A person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual’s spouse; or c. Any person court or administrative body acting at the direction of or upon the request of the individual or the individual's spouse.

In determining an individual's eligibility for Medical Assistance, the following regulations apply to a trust established by an individual:

a. An individual shall be considered to have established a trust if assets of the individual were used to form all or part of the corpus of the trust, and if any of the following individuals established the trust, other than by will:

i) The individual or the individual's spouse;

ii) A person, including a court or administrative body, with legal

authority to act in place of, or on the behalf of, the individual or the individual's spouse; or iii) A person, including a court or administrative body acting at the direction or upon the request of the individual or the individual's b. In the case of a trust, the corpus of which includes assets of an individual and the assets of any other person(s), this regulation shall apply to the portion of the trust attributable to the assets of the individual.

c. These regulations apply without regard to the following:

i) The purposes for which a trust is established, ii) Whether the trustees have or exercise any discretion under the trust, iii) Any restrictions on when or whether distributions may be made from the trust, or iv) Any restrictions on the use of distributions from the trust.

Revocable Trusts are considered as follows:

a. The corpus of the trust shall be considered resources available to the individual, b. Payments from the trust to or for the benefit of the individual shall be considered income to the individual, and c. Any other payments from the trust shall be considered assets transferred by the individual for less than fair market value and are subject to a 60 month look back period and a penalty period of ineligibility as set forth in the regulations on transfers without fair consideration in this volume.

Irrevocable Trusts If there are any circumstances under which payments from the trust could be made to or for the benefit of the individual, the following shall apply:

a) The portion of the corpus of the trust, or the income on the corpus, from which payment to the individual could be made, shall be considered as resources available to the individual.

b) Payments from that portion of the corpus, or income to or for the benefit of the individual, shall be considered income to the individual.

c) Payments from that portion of the corpus or income for any other purpose shall be considered as a transfer of assets by the individual for less than fair market value and are subject to a 60 month look back period and a penalty period of ineligibility as set forth in the regulations on transfers without fair consideration in this volume.

d) Any portion of the trust or income on the corpus from which no payment could be made to the individual under any circumstances shall be considered as a transfer of assets for less than fair market value and shall be subject to a 60 month look back period and penalty period of ineligibility as set forth in the regulations on transfers without fair consideration in this volume. The transfer will be effective as of the date of the establishment of the trust, or the date on which payment to the individual from the trust was foreclosed, if later. The value of the trust shall be determined by including the amount of any payments made from such portion of the trust after such date.

The preceding regulations for trusts established on or after July 1, 1994, do not apply to the following:

a. Income Trusts i) A trust consisting only of the individual's pension income, social security income, and other monthly income that is established for the purpose of establishing income eligibility for Long Term Care institution care or Home and Community Based Services (HCBS).

To be valid, the trust must meet the following criteria:

a) The individual's gross monthly income must be above the 300% SSI limit but below the average cost of private Long Term Care institution care in the geographic region in which the individual resides and intends to remain. The Colorado Department of Health Care Policy and Financing shall calculate the average rates for such regions on an annual, calendar-year basis. The geographic regions which are used for calculating the average private pay rate for Long Term Care institution care shall be based on the Bureau of Economic Analysis Regions and consist of the following counties:

REGION I: (Adams, Arapahoe, Boulder, Broomfield, Denver, Jefferson)

REGION II: (Cheyenne, Clear Creek, Douglas, Elbert, Gilpin, Grand, Jackson, Kit Carson, Larimer, Logan, Morgan, Park, Phillips, Sedgwick, Summit, Washington, Weld, Yuma)

REGION III: (Alamosa, Baca, Bent, Chaffee, Conejos, Costilla, Crowley, Custer, El Paso, Fremont, Huerfano, Kiowa, Lake, Las Animas, Lincoln, Mineral, Otero, Prowers, Pueblo, Rio Grande, Saguache, Teller)

REGION IV: (Archuleta, Delta, Dolores, Eagle, Garfield, Gunnison, Hinsdale, La Plata, Mesa, Moffat, Montezuma, Montrose, Ouray, Pitkin, Rio Blanco, Routt, San Juan, San Miguel)

b) For Long Term Care institution members, each month the trustee shall distribute the entire amount of income which is transferred into the trust. An amount not to exceed $20.00 may be retained for trust expenses such as bank charges if such charges are expected to be incurred by the trust.

c) The only deductions from the monthly trust distribution to the Long Term Care institution are the allowable deductions which are permitted for Medical Assistance-eligible persons who do not have income trusts. Allowable deductions include only the following:

i) Personal need allowance ii) Spousal income payments iii) Approved PETI payments d) Any funds remaining after the allowable deductions shall be paid solely to the cost of the Long Term Care institution care in an amount not to exceed the Medical Assistance reimbursement rate. Any excess income which is not distributed shall accumulate in the trust.

e) No other deductions or expenses may be paid from the trust.

Expenses which cannot be paid from the trust include, but are not limited to, trustee fees, attorney fees and costs (including attorney fees and costs incurred in establishing the trust), accountant fees, court fees and costs, fees for guardians ad litem, funeral expenses, past-due medical bills and other debts. Trustee fees which were ordered prior to April 1, 1996 may continue until the trust terminates.

f) For HCBS members, the amount distributed each month shall be limited to the 300% of the SSI limit. Any monthly income above that amount shall remain in the trust. An amount not to exceed $20.00 may be retained for trust expenses such as bank charges if such charges are expected to be incurred by the trust. No other trust expenses or deductions may be paid from the trust. For the purpose of calculating Individual Cost Containment or member payment (PETI), the member's monthly income will be 300% of the SSI limit. Upon termination, the funds which have accumulated in the trust shall be paid to the Department up to the total amount of Medical Assistance paid on behalf of the individual.

g) For a court-approved trust, notice of the time and place of the hearing, with the petition and trust attached, shall be given to the eligibility site and the Department in the manner prescribed by law.

h) The sole beneficiaries of the trust are the individual for whose benefit the trust is established and the Department.

The trust terminates upon the death of the individual or if the trust is not required for Medical Assistance eligibility in Colorado.

i) The trust must provide that upon the death of the individual or termination of the trust, whichever occurs sooner, the Department shall receive all amounts remaining in the trust up to the total amount of Medical Assistance paid on behalf of the individual.

j) The trust must include the name and mailing address of the trustee. The trustee must notify the Department of any trustee address changes or change of trustee(s) within 30 calendar days.

k) The trust must provide that an annual accounting of trust income and expenditures and an annual statement of trust assets shall be submitted to the eligibility site or to the Department upon reasonable request or upon any change of trustee.

l) The amount remaining in the trust and an accounting of the trust shall be due to the Department within three months after the death of the individual or termination of the trust, whichever is sooner. An extension of time may be granted by the Department if a written request is submitted within two months of the termination of the trust.

m) The regulations in this section for income trusts shall also apply to income trusts established after January 1, 1992, under the undue hardship provisions in Section 25.5-6- 102(3), C.R.S. and Section 15-14-412.5, C.R.S.

b. Disability Trusts i) A trust that is established solely for the benefit of a disabled individual under the age of 65, which consists of the assets of the individual, and is established for the purpose or with the effect of establishing or maintaining the individual's resource eligibility for Medical Assistance and which meets the following criteria:

a) The individual for whom the trust is established must meet the disability criteria of Social Security.

b) [Removed and Reserved]

c) The trust is established solely for the benefit of the disabled individual by the individual, the individual’s parent, the individual’s grandparent, the individual’s legal guardian, or by the court.

d) The sole lifetime beneficiaries of the trust are the individual for whose benefit the trust is established, the Colorado Department of Health Care Policy and Financing, and any other state that provides medical assistance to the individual under such state’s Medicaid program.

e) The trust terminates upon the death of the individual or if the trust is no longer required for Medical Assistance eligibility.

i) If the individual becomes ineligible for Medical Assistance in Colorado or any other state due to a change in residency, then the trust shall terminate unless the Department receives proof that: (1) the individual is receiving medical assistance under another state’s Medicaid program; and (2) the trust is required for the individual to receive those medical assistance benefits. The trustee must submit the required proof no later than sixty (60) calendar days from the date the trustee acquires knowledge of the change in residency. An extension of time may be granted upon submission of a written request to the Department by the trustee.

ii) The trustee must provide the Department with notice of the individual’s death, loss of Medicaid eligibility, or change in residency no later than sixty (60) calendar days from the date the trustee acquires knowledge of such event.

f) Any statutory lien pursuant to Section 25.5-4-301(5), C.R.S. must be satisfied prior to funding of the trust and approval of the trust.

g) If the trust is funded with an annuity or other periodic payments, the trust shall be named on the contract or settlement as the remainder beneficiary or the Department and any other state that provided medical assistance to the individual under such state’s Medicaid program may be named as remainder beneficiary up to the amount of Medical Assistance paid on behalf of the individual.

h) The trust shall provide that, upon the death of the beneficiary or termination of the trust, the Department and any other state that provided medical assistance to the individual under such state’s Medicaid program shall receive all amounts remaining in the trust up to the amount of total medical assistance paid on behalf of the individual. If the trust does not have sufficient funds to reimburse each state in full, the amount remaining in the trust shall be distributed based on each state's proportionate share of the total amount of medical assistance benefits paid by all of the states on the individual’s behalf.

i) No expenditures may be made after the death of the beneficiary, except for federal and state taxes. However, prior to the death of the individual beneficiary, trust funds may be used to purchase a burial fund for the beneficiary.

j) The amount remaining in the trust and an accounting of the trust shall be due to the Department within three months after the death of the individual or termination of the trust, whichever is sooner. An extension of time may be granted by the Department if a written request is submitted within two months of the termination of the trust.

k) The trust fund shall not be considered as a countable resource in determining eligibility for Medical Assistance.

l) [Section 8.110.52.B.5.b.i.l expired May 15, 2002.]

m) Distributions from the trust may be made only to or for the benefit of the individual beneficiary. Cash distributions from the trust shall be considered income to the individual.

Distributions for shelter are considered unearned income and are countable toward income eligibility.

n) If exempt resources are purchased with trust funds, those resources continue to be exempt. If non-exempt resources are purchased, those resources are countable toward o) The trust must include the name and mailing address of the trustee. The Department must be notified of any trustee address changes or change of trustee(s) within 30 calendar days.

p) The trust must provide that an accounting of trust income and expenditures and statement of trust assets shall be submitted to the eligibility site and to the Department on an annual basis and upon reasonable request or any change of trustee. Further, the trust must provide that the trustee is required to give the Department notice of any distribution in excess of $5,000 no later than thirty (30) days after such distribution. The Department shall acknowledge receipt within thirty (30) days of receiving the notice.

q) Prior to the establishment or funding of a disability trust, the trust shall be submitted for review to the Department, along with proof that the individual beneficiary is disabled according to Social Security criteria. No disability trust shall be valid unless the Department has reviewed the trust and determined that the trust conforms to the requirements of

Section 15-14-412.8, C.R.S., as amended, and any rules adopted by the Medical Services Board..

c. Pooled Trusts i) A trust consisting of individual accounts established for disabled individuals for the purpose of establishing resource eligibility for Medical Assistance. A valid pooled trust shall meet the following criteria:

a) The individual for whom the trust is established must meet the disability criteria of Social Security.

b) The trust is established and managed by a non-profit association which has been approved by the Internal Revenue Service.

c) A separate account is maintained for each beneficiary; however, the trust pools the accounts for the purposes of investment and management of the funds.

d) The sole lifetime beneficiaries of each trust account are the individual for whom the trust is established and the Department.

e) If the trust is funded with an annuity or other periodic payments, the Department or the pooled trust shall be named as remainder beneficiary.

f) The trust account shall be established by the disabled individual, parent, grandparent, legal guardian, or the court.

g) The only assets used to fund each trust account are (1) the proceeds from any personal injury case brought on behalf of the disabled individual, or (2) retroactive payments of SSI benefits required under Sullivan v. Zebley, 493 U.S. 521 (1990) . (This provision is applicable to pooled trusts established from July 1, 1994 to December 31, 2000.)

h) Any statutory lien pursuant to Section 25.5-4-301(5), C.R.S. must be satisfied prior to funding of the individual's trust account and approval of the joinder agreement.

i) Following the disabled individual's death or termination of the trust account, whichever occurs sooner, to the extent that the remaining funds in the trust account are not retained by the pooled trust, the Department shall receive any amount remaining in the individual's trust account up to the total amount of Medical Assistance paid on behalf of the j) The pooled trust account shall not be considered as a countable resource in determining Medical Assistance k) Distributions from the trust account may be made only to or for the benefit of the individual. Cash distributions to the individual from the trust shall be considered as income to the individual. Distributions for shelter are considered unearned income and are countable toward income eligibility.

l) If exempt resources are purchased with trust funds, those resources continue to be exempt. If non-exempt resources are purchased, those resources are countable toward resource eligibility.

ii) If an institutionalized individual for whom a pooled trust is established is 65 years of age or older, the transfer of assets into the pooled trust creates a rebuttable resumption that the assets were transferred without fair consideration and shall be analyzed in accordance with the rules on transfers without fair consideration in this volume. This

regulation is effective for transfers to pooled trusts after January 1, 2001.

iii) When the individual beneficiary of an income, disability, or pooled trust dies or the trust is terminated, the trustee shall promptly notify the eligibility site and the Department. To the extent required by these rules the trustee shall promptly forward the remainder of the trust property to the Department, up to the amount of Medical Assistance paid on behalf of the individual beneficiary.

d. Third Party Trusts i) Third party trusts are trusts which are established with assets which are contributed by individuals other than the applicant/member or the applicant/member's spouse for the benefit of an applicant/member.

ii) The terms of the trust will determine whether the trust fund is countable as a resource or income for Medical Assistance iii) Trusts which limit distributions to non-support or supplemental needs will not be considered as a countable resource. If distributions are made for income or resources, such distributions are countable as such for eligibility.

iv) If the trust requires income distributions, the amount of the income shall be countable as income in determining eligibility.

v) If the trust requires principal distributions, that amount shall be considered as a countable resource.

vi) If the trustee may exercise discretion in distributing income or resources, the income or resources are not countable in determining eligibility. If distributions are made for income or resources, such distributions are countable as such for eligibility.

e. Federally Approved Trusts i) If an SSI recipient has a trust which has been approved by the Social Security Administration, eligibility for Medical Assistance cannot be delayed or denied. Individuals on SSI are automatically eligible for Medical Assistance despite the existence of a federally approved trust.

ii) If the eligibility site has a copy of a federally approved trust, the eligibility site must send a copy to the Department.

Submission of Trust Documents and Records a. The trustee of a trust which was established by or which benefits a medical assistance applicant /member shall submit trust documents and records to the eligibility site and to the Department.

b. This requirement includes documents and records for income trusts, disability trusts and the joinder agreement for each pooled trust account.

c. The eligibility site shall submit any trust which is submitted with an application or at redetermination to The Department. The eligibility site shall determine Medical Assistance eligibility based on the determination of The Department as to the effect of the trust on eligibility. 8.100.7.F. Transfers of Assets Without Fair Consideration 1. Definitions. The following definitions apply to transfers of assets without fair considerations:

a. “Assets” include all income and resources of the individual and such individual's spouse, including any interest in income or a resource as well as all income or resources which the individual or such individual's spouse is entitled to but does not receive because of action by any of the i) The individual or such individual's spouse, ii) A person, a court, or administrative body with legal authority to act on behalf of the individual or such individual's spouse, or iii) Any person, court or administrative body acting at the direction of or upon the request of the individual or such individual's spouse.

b. “Fair market value” is the value of the asset if sold at the prevailing price at the time it was transferred.

c. “Fair consideration” is the amount the individual receives in exchange for the asset that is transferred, which is equal to or greater than the value of the transferred asset.

d. “Look-back period” means the number of months prior to the month of application for long-term care services that the Department will consider for transfer of assets.

e. “Penalty period” means a period of time for which an applicant or client will not be eligible to receive long-term care services.

f. “Uncompensated value” shall mean the fair market value of an asset at the time of the transfer minus the value of compensation the individual receives in exchange for the asset.

g. “Valuable consideration” shall mean what an individual receives in exchange for his or her right or interest in an asset which has a tangible and/or intrinsic value to the individual that is equivalent to or greater than the value of the transferred asset.

General Provisions If an institutionalized individual or the spouse of such individual disposes of assets without fair consideration on or after the look-back period, the individual shall be subject to a period of ineligibility for Long-Term Care services, including Long-Term Care institution care, Home and Community Based Services (HCBS), and the Program of All Inclusive Care for the Elderly (PACE).

a. For transfers made before February 8, 2006, the look-back period is 36 months prior to the date of application. For transfers made on or after February 8, 2006, the look-back date is 60 months prior to the date of b. An institutionalized individual is one who is institutionalized in a medical facility, a Long-Term Care institution, or applying for or receiving Home and Community Based Services (HCBS) or the Program of All Inclusive Care for the Elderly (PACE).

c. If an institutionalized individual or such individual's spouse transfers assets without fair consideration on or after the look-back period, the transfer shall be evaluated as follows:

i) The fair market value of the transferred asset, less the actual amount received, if any, shall be divided by the average of the regions, defined at 8.100.7.E, monthly private pay cost for Long- Term Care institution care in the state of Colorado at the time of ii) The resulting number is the number of months that the individual shall be ineligible for Medical Assistance. For transfers made before February 8, 2006, the period of ineligibility shall begin with the first day of the month following the month in which the transfer occurred. For transfers made on or after February 8, 2006, the period of ineligibility shall begin on the later of the following dates:

a) The first day of the month following the month in which the transfer occurred or is discovered. For transfers discovered after the date the transfer occurred, the date of transfer shall be the discovery date.

Or;

b) The date on which the individual would initially be eligible for HCBS, PACE or institutional services based on an approved application for such assistance that were it not for the imposition of the penalty period, would be covered by Medical Assistance;

And;

c) Which does not occur during any other period of ineligibility for services by reason of a transfer of assets penalty.

d. The period of ineligibility shall also include partial months, which shall be calculated by multiplying 30 days by the decimal fractional share of the partial month. The result is the number of days of ineligibility. For transfers occurring on or after April 1, 2006, the result shall be rounded up to the nearest whole number.

e. There is no maximum period of ineligibility.

f. For transfers prior to February 8, 2006, the total amount of all of the transfers are added together and the period of ineligibility begins the first day of the month following the month in which the resources are transferred.

i) If the previous penalty period has completely expired, the transfers are not added together.

ii) If the previous penalty period has not completely expired and the first day of the month following the month in which the resources are transferred is part of a prior penalty period, the new penalty period begins the first day after the prior penalty period expires.

g. For transfers on or after February 8, 2006, the total amounts of all of the transfers are added together and the penalty period is assessed as outlined in section 8.100.7.F.2.c-dabove.

i) If the previous penalty period has completely expired, the transfers are not added together.

h. The institutionalized individual may continue to be eligible for Supplemental Security Income (SSI) and basic Medical Assistance services, but shall not be eligible for Medical Assistance for Long-Te r m Care institution services, Home and Community Based Services or the Program of All Inclusive Care for the Elderly due to the transfer without fair i. If a transfer without fair consideration is made during a period of eligibility, a period of ineligibility shall be assessed in the same manner as stated above.

j. Actions that prevent income or resources from being received, or reduce an individual’s ownership, right or interest in an asset such that the individual does not receive valuable consideration as set forth on the following list, which is not exclusive, shall create a rebuttable presumption that the transfer was without fair consideration:

i) Waiving pension income.

ii) Waiving a right to receive an inheritance.

iii) Preventing access to assets to which an individual is entitled by diverting them to a trust or similar device. This is not applicable to valid income trusts, disability trusts and pooled trusts for individuals under the age of 65 years.

iv) Failure of a surviving spouse to elect a share of a spouse's estate or failure to open an estate within 6 months after a spouse’s death.

v) Failure to obtain a family allowance or exempt property allowance from an estate of a deceased spouse or parent. Such allowances are presumed to be available 3 months after death.

vi) Not accepting or accessing a personal injury settlement.

vii) Transferring assets into an irrevocable private annuity which was not purchased from a commercial company.

viii) Transferring assets into an irrevocable entity such as a Family Limited Partnership which eliminates or restricts the individual's access to the assets.

ix) Refusal to take legal action to obtain a court ordered payment that is not being paid, such as child support or alimony, if the benefit outweighs the cost.

x) Failure to exercise rights in a Dissolution of Marriage case, which insure an equitable distribution of marital property and income.

xi) Purchasing a single-premium life insurance policy, endowment policy or similar instrument within the look-back period, which has no cash value, and for which the individual receives no valuable consideration shall be considered an uncompensated transfer.

The total amount of the purchase price shall be considered a 8.100.7.G. Treatment of Certain Assets as Transfers Without Fair Consideration 1. Promissory notes established before April 1, 2006:

a. The fair market value of promissory notes is a countable resource and must be evaluated in accordance with the regulations on consideration of resources in this volume.

b. Promissory notes with one or more of the following provisions, indicating they have little or no market value, shall create a rebuttable presumption of a transfer without fair consideration:

i) An interest rate lower than the prevailing market rate.

ii) A term for repayment longer than the life expectancy of the holder of the note, as determined by the tables at 8.100.7.J.for annuities purchased on or after February 8, 2006.

iii) Low payments.

iv) Cancellation at the death of the note holder.

c. Promissory notes which have been appraised by a note broker as having little or no value shall create a rebuttable presumption of a transfer without fair consideration.

Promissory notes established on or after April 1, 2006 but before March 1, 2007 a. Subject to the look-back date described in section 8.100.7.F.2.b for the

purpose of calculating the penalty period of ineligibility for a transfer without fair consideration, the value of a promissory note, loan or mortgage which does not meet the criteria in section 8.100.5.M.3.n. is the outstanding balance due as of the date of the individual’s application for Medical Assistance for services, described in section 8.100.7.F.2.c.

Promissory notes established on or after March 1, 2007 a. Subject to the look-back date described in section 8.100.7.F.2.b, for the

purpose of calculating the penalty period of ineligibility for a transfer without fair consideration, the value of a promissory note, loan or mortgage which does not meet the criteria in section 8.100.5.M.3.o. is the outstanding balance due as of the date of the individual’s application for Medical Assistance for services, described in section 8.100.7.F.2.c..

Personal care services a. Effective for agreements that were signed and notarized prior to March 1, 2007, family members who provide assistance or services are presumed to do so for love and affection, and compensation for past assistance or services shall create a rebuttable presumption of a transfer without fair consideration unless the compensation is in accordance with the following:

i) A written agreement must be executed prior to the delivery of services.

ii) The agreement must be signed by the applicant, or a legally authorized representative, such as agent under a power of attorney, guardian, or conservator. If the agreement is signed by a representative, that representative may not be a beneficiary of the agreement.

iii) The agreement must be dated and the signature must be notarized;

iv) Compensation for services rendered must be comparable to what is received in the open market.

b. Effective for agreements that are signed and notarized on or after March 1, 2007, compensation under personal service agreements will be deemed to be a transfer without fair consideration unless the following requirements are met:

i) A written agreement was executed prior to the delivery of services;

a) The agreement must be signed by the applicant, or a legally authorized representative, such as agent under a power of attorney, guardian, or conservator. If the agreement is signed by a representative, that representative may not be a beneficiary of the agreement; and b) The legally authorized representative, agent, guardian, conservator, or other representative of the applicant’s estate may not be a beneficiary of a care agreement; and c) The agreement specifies the type, frequency and time to be spent providing the services agreed to in exchange for the payment or transferred item; and d) The agreement provides for payment of services on a regular basis, no less frequently than monthly, while the services are being provided; and ii) Compensation for services rendered must be comparable to what is received in the open market. The burden is on the applicant to prove that the compensation is reasonable and comparable; and iii) A record or log is provided which details the actual services rendered. The services cannot be services that duplicate services that another party is being paid to provide or which another party is responsible to provide.

c. Payment for services, which were rendered previously and for which no compensation was made, shall be considered as a transfer without fair d. Assets transferred in exchange for a contract for personal services for future assistance after the date of application are considered available resources.

e. A care agreement must be entered into, signed, and notarized prior to providing any services for which a beneficiary will be compensated.

Transfers of real property into joint tenancy without fair consideration a. If real property is transferred into joint tenancy with right of survivorship with one or more joint tenants, the amount transferred depends on the number of joint tenants to whom the property is transferred. The following are examples:

i) If the transfer is to one joint tenant, the amount transferred is equal to one-half of the value of the property at the time of the transfer.

ii) If the transfer is to two joint tenants, the amount transferred is equal to two-thirds of the value.

iii) If the transfer is to three joint tenants, the amount transferred is equal to three-fourths of the value of the property at the time of the transfer.

b. If the transfer is completed with two deeds or transactions, the first of which transfers a fractional share of the property into tenancy in common, and the second into joint tenancy, the amount transferred shall be determined in the same manner as set forth above.

No period of ineligibility will be imposed if the individual transferred the assets under any of following circumstances:

a. The asset transferred was a home and title to the home was transferred i) The spouse of such individual;

ii) A child of such individual who is either 1) Under the age of 21 years, or 2) Is blind or totally and permanently disabled as determined by the Social Security Administration.

iii) A brother or sister 1) Who has an equity interest in the home and 2) Who was residing in such individual's home for at least one year immediately before the date that the individual becomes institutionalized.

iv) A son or a daughter of such individual 1) Who was residing in the home for a period of at least two years immediately before the date the individual becomes institutionalized and 2) Who provided care to such individual by objective evidence, that permitted such individual to reside at home rather than in an institution.

Documentation shall be submitted proving that the son or daughter's sole residence was the home of the parent. The parent's attending physician(s) or professional health provider(s) during the past two years must substantiate in writing that the care was provided, and that the care prevented the parent from requiring placement in a Long- Term Care institution.

b. The assets were transferred:

i) To the individual's spouse or to another for the sole benefit of the individual's spouse.

ii) From the individual's spouse to another for the sole benefit of the individual's spouse.

iii) To a trust which is established solely for benefit of the individual's child who is determined to be blind or totally disabled by the Social Security Administration or to that child directly for the sole benefit of the child.

iv) To a trust established solely for the benefit of an individual under 65 years of age who is determined to be blind or totally disabled by the Social Security Administration.

c. Definition of the term “for the sole benefit of,” as used in the preceding exceptions to the transfer penalty rules: i). A transfer or a trust is considered to be for the sole benefit of the spouse, blind or disabled child, or a disabled individual if the transfer is arranged in such a way that no individual or entity except the spouse, blind or disabled child, or disabled individual can benefit from the assets transferred in any way, whether at the time of the transfer or at any time in the future. ii). To insure that the asset transferred is for the sole benefit of the spouse, blind or disabled child or disabled individual, the following criteria must be met:

The transfer must be accomplished by a written instrument which legally binds the parties to a specified course of action and sets forth:

a) The conditions under which the transfer was made, b) A statement as to whom can benefit from the transfer.

The written instrument must provide for the spending of funds or use of the transferred assets for the benefit of the individual on a basis that is actuarially sound based on the life expectancy of the individual.
Disability trusts and income trusts, which designate the Colorado Department of Health Care Policy and Financing as the remainder beneficiary up to the amount of Medical Assistance paid on behalf of the individual, are exempt from this requirement.
A community spouse to whom a Community Spouse Resource Allowance has been transferred does not have to provide a written document or comply with the requirement that the transfer is actuarially sound. However, the Community Spouse Resource Allowance must be for the sole benefit of the community spouse to whom it is transferred. Upon the death of the community spouse, those resources shall be made available to the surviving spouse, at least up to the amount of the elective share of the augmented estate, the family allowance and the exempt property allowance.

There is a rebuttable presumption the transfer without fair consideration was made for purposes of Medical Assistance eligibility or avoiding the medical assistance estate recovery program.

a. The presumption that an asset was transferred to establish or maintain Medicaid eligibility or to avoid the medical assistance estate recovery program is rebutted only if the individual or individual’s spouse demonstrates by providing convincing evidence that the asset was transferred exclusively for some other purpose and the reason for the transfer did not include Medical Assistance eligibility or avoidance of medical assistance estate recovery..

b. A subjective statement of intent or ignorance of the transfer penalty or verbal assurances that the individual was not considering Medical Assistance eligibility when the transfer was made are not sufficient.

c. There is a rebuttable presumption that transfers without fair consideration were made for the purpose of Medical Assistance eligibility in the following cases:

i) In any case in which the individual's assets and the assets of the individual's spouse remaining after the transfer total an amount insufficient to meet all living expenses and medical expenses reasonably expected to be incurred by the individual or the individual's spouse in the sixty (60) months following the transfer.

Medical expenses include the cost of Long-Term Care unless the future necessity of such care could have been absolutely precluded because of the particular circumstances.

ii) In any case where:

the transfer was made on behalf of the individual or the individual's spouse;
the transfer was made by:

a) the individual or individual’s spouse b) a guardian, c) a conservator, or d) agent under a power of attorney; and 3) the transfer was made to:

a) anyone related to the individual or individual’s spouse by birth, adoption or marriage, other than between the individual and the individual’s spouse; or to b) anyone related to the guardian, conservator, or agent under a power of attorney by birth, adoption or marriage.

d. Convincing evidence may include, but is not limited to, verification which establishes:

i) That at the time of the transfer the individual could not have anticipated needing long term Medical Assistance due to the existence of other circumstances which would have precluded the need.

ii) Other assets were available at the time of the transfer to meet current and future needs of the individual, including the cost of Long-Term Care institution or other institutionalized care for a period of sixty (60) months.

iii) The specific purpose for which the assets were transferred and the reason the transfer was necessary and the reason there was no alternative but to transfer the assets without fair consideration.

Apportionment of penalty period between spouses a. If a transfer results in a period of ineligibility for an individual, and the individual's spouse becomes institutionalized and is otherwise eligible for Medical Assistance, the period of ineligibility shall be apportioned equally between the spouses.

b. If one spouse dies or is no longer institutionalized, any months remaining in the period of ineligibility shall be assigned to the spouse who remains institutionalized.

If the individual or the individual's spouse has transferred assets into a trust or is a beneficiary of a trust, the trust document shall be submitted to the Colorado Department of Health Care Policy and Financing to determine the effect of the trust on Medical Assistance eligibility.
Notice a. The Colorado Department of Health Care Policy and Financing is an interested person according to 15-14-406, C.R.S. or a successor statute.

b. As an interested party, the department shall be given notice of a hearing in cases in which Medical Assistance planning or Medical Assistance eligibility is set forth in the petition as a factor for requesting court authority to transfer property.

Undue Hardship a. The period of ineligibility resulting from the imposition of the transfer or the trust provisions may be waived if denial of eligibility would create an undue hardship for an individual who is otherwise eligible. Undue hardship can be established if application of the transfer penalty would:

i) deprive the individual of medical care such that the individual’s health or life would be endangered; or ii) deprive the individual of food, clothing, shelter or other necessities of life.

b. Undue hardship shall not exist when the application of the trust or transfer rules merely causes the individual inconvenience or when such application might restrict his or her lifestyle but would not put him or her at risk of serious deprivation.

c. Notice of an undue hardship exception shall be given to the applicant or client. The Eligibility Site shall make a determination on the request within 15 working days from when the request is received. The Eligibility Site shall issue a notice of action on the determination of hardship. An adverse determination may be appealed in accordance with the appeal process as described at Section 8.057 of this volume.

d. The facility in which an institutionalized individual is residing may file an undue hardship waiver application on behalf of the individual with the individual's or his or her personal representative's consent. Where the individual is unable to give consent and where the personal representative of the individual has a conflict of interest concerning the particular circumstance giving rise to the period of ineligibility, the facility may request an undue hardship on behalf of the individual. An example of such a conflict of interest would be a situation where the personal representative who is also an agent under a power of attorney transfers property to himself or herself. The facility shall submit the undue hardship request to the Eligibility Site and give sufficient detail of the circumstance surrounding the conflict of interest and the information required below to the Eligibility Site. These provisions are not intended to change the Department’s requirements under Section 8.057 of the Department’s regulations as to who has standing to file an appeal.

e. An individual or representative may request that the Eligibility Site waive a transfer penalty on the basis of undue hardship. The request shall be made in writing to the applicant’s or client’s Eligibility Site case worker.

The individual making the request has the burden of proof and must provide clear and convincing evidence to substantiate the circumstances surrounding the transfer, attempts to recover the assets, and the impact of the denial of Medicaid payments for Long-Term Care services. The request and documentation shall include all of the following:

i) the reason(s) for the transfer including the individual’s participation in the transfer or grant of legal authority to another that gave rise to the transfer, and the relationship between the transferor and transferee;

ii) evidence to prove that the assets have been irretrievably lost and that all reasonable attempts made to recover the asset(s), including any legal actions and the results of the attempts, including but not limited to a request for an adult protection investigation (such as in a case of financial exploitation), filing a police report, or filing a civil action have been exhausted or have been or are being pursued; and, iii) documentation such as a notice of discharge or pending discharge from the facility and a physician’s statement detailing how the inability to receive nursing facility or community based services would result in the individual’s inability to obtain life-sustaining medical care or that the individual would not be able to obtain food, clothing or shelter.

f. To the extent that the transferred assets are recovered pursuant to the attempts in (e)(ii) above, the individual shall reimburse Medicaid for the funds expended as a result of an approved undue hardship request.

g. If the transferee and the transferor of the assets for which the transfer penalty is being imposed are related parties there shall be a rebuttable presumption that the transferred assets are not irretrievably lost as required under (e)(ii) above. Related parties are described in Section 8.100.7.G.7.c.ii of these regulations.

No period of ineligibility shall be assessed in any of the following circumstances:

a. Convincing and objective evidence is provided that the individual intended to dispose of the resources either at fair market value or for other fair b. Convincing and objective evidence is presented proving that the resources were transferred exclusively for a purpose other than to qualify or remain eligible for Medical Assistance.

c. All of the resources transferred without fair consideration have been returned to the individual.

d. For assets transferred before February 8, 2006, the assets were transferred more than 36 months prior to the date of application.

e. For assets transferred before February 8, 2006, the penalty period has expired based on the following formula: The fair market value of the transferred asset is divided by the average cost of Long Term Care institution care in the state at the time of application and the resulting number of months of ineligibility has ended prior to the date of application. 8.100.7.H. Life Estates 1. Definitions a. “Fair Market Value” means the amount for which a property or interest in a property could reasonably be expected to sell on the open market.

b. “Life Estate.” A life estate conveys upon a grantee certain rights in property measured by the life of the life estate holder or of some other person. The owner of a life estate has the right to possess the property, the right to use the property, the right to obtain profits from the property, and the right to sell the life estate interest in the property. The establishment of a life estate on a property results in the creation of two interests: a life estate interest and a remainder interest.

c. “Remainder Interest” means an interest in property created at the time a life estate is established which gives the holder of the interest the right to ownership of the property upon the death of the life estate holder. An individual holding a remainder interest is free to sell his or her interest in the property unless the sale is restricted by the terms of the instrument which established the remainder interest.

General Provisions a. Life Estates Established before July 1, 1995 i) Transfer without fair consideration Treatment 1) The establishment of a life estate before July 1, 1995 by an individual or individual’s spouse shall not be considered a ii) Resource Treatment 1) A life estate owned by an individual or individual’s spouse that was established on exempt property shall be considered to be an exempt resource.

A life estate owned by an individual or individual’s spouse that was established on countable property shall be considered a countable resource.

i) The value of the life estate shall be determined by using the methodology described at 8.100.7.H.3.

A remainder interest held by an individual or individual’s spouse on exempt property shall be considered an exempt resource.
A remainder interest held by an individual or individual’s spouse on countable property shall be considered a countable resource i) The value of the remainder interest shall be determined by using the methodology described at 8.100.7.H.4.a.

b. Life Estates Established on or after July 1, 1995 i) Transfer without fair consideration Treatment 1) The establishment of a life estate on or after July 1, 1995 on property owned by an individual or individual’s spouse shall be considered a transfer without fair consideration if the life estate was established within the look-back period described at 8.100.7.F.2.b.

a) For the purpose of determining the transfer without fair consideration penalty period, the amount of the transfer shall be based on the value of the remainder interest, as calculated using the methodology described at 8.100.7.H.4.a.

The purchase of a life estate interest in a home not owned by an individual or individual’s spouse on or after April 1, 2006 within the look-back period described at 8.100.7.F.2.b. shall be considered a transfer without fair consideration unless the purchaser lives in the home for a period of at least twelve (12) consecutive months after the date of the purchase.

a) For the purpose of determining the transfer without fair consideration penalty period, the amount of the transfer shall be the entire amount used to purchase the life estate.

b) If the payment for the life estate exceeds the value of the life estate, as calculated using the methodology described at 8.100.7.H.3, then the difference between the amount paid and the value of the life estate shall be considered to be a transfer without fair ii) Resource Treatment 1) A life estate owned by an individual or individual’s spouse that was established on exempt property shall be considered an exempt resource.

A life estate owned by an individual or individual’s spouse that was established on countable property shall be considered a countable resource.

a) The value of the life estate shall be determined by using the methodology described at 8.100.7.H.3.a.

A remainder interest held by an individual or individual’s spouse on exempt property shall be considered an exempt resource.
A remainder interest held by an individual or individual’s spouse on countable property shall be considered a countable resource a) The value of the remainder interest shall be determined by using the methodology described at 8.100.7.H.4.

Determining the Value of a Life Estate a. The value of a life estate interest is calculated using the following method:

i) Determine the fair market value of the property on which the life estate was established. The fair market value shall be obtained by using the most recent actual value reported by the county assessor or from the most recent property assessment notice. If the actual value is not shown on the property assessment notice, the assessed value shall be divided by the appropriate property assessment rate to obtain the market value.

ii) Multiply the fair market value of the property by the “Life Estate” factor in Column 1 from the Life Estate Table at 8.100.7.H.5, in this section, that corresponds to the life estate holder’s age as of his or her last birthday. The result is the value of the life estate interest.

b. If a life estate was established on property held by spouses in joint tenancy, then the age of the youngest individual shall be used to calculate the value of the life estate.

Determining the Value of a Remainder Interest a. The value of a remainder interest is calculated using the following method:

i) Determine the fair market value of the property on which the remainder interest was established. The fair market value shall be obtained by using the most recent actual value reported by the county assessor or from the most recent property assessment notice. If the market value is not shown on the property assessment notice, the assessed value shall be divided by the appropriate property assessment rate to obtain the market value.

ii) Multiply the fair market value of the property by the “Remainder” factor in Column 2 from the Life Estate Table at 8.100.7.H.5, in this section, that corresponds to the life estate holder’s age as of his or her last birthday. The result is the value of the remainder interest.

b. If a life estate was established on property held by spouses in joint tenancy, then the age of the youngest individual shall be used to calculate the value of the remainder interest.

Life Estate Table This rule incorporates by reference the Social Security life estate and remainder interest table effective April 1999 to the present. The incorporation of the table excludes later amendments, or editions of, the referenced material.

The Social Security life estate and remainder interest tables are available at http://policy.ssa.gov/poms.nsf/lnx/0501140120 Pursuant to § 24-4-103 (12.5), C.R.S., the Department maintains copies of the incorporated text in its entirety, available for public inspection during regular 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated materials 8.100.7.I. Annuities 1. DEFINITIONS a. “Annuity” means a contract between an individual and a commercial company in which the individual invests funds and in return receives installments for life or for a specified number of years.

b. “Annuitant” means an individual who is entitled to receive payments from an annuity.

c. “Annuitization Period” means the period of time during which an annuity makes payments to an annuitant.

d. “Annuitized” means an annuity that has become irrevocable and is making payments to an annuitant.

e. “Assignable” means an annuity that can have its owner and/or annuitant changed.

f. “Balloon Payment” means a lump sum equal to the initial annuity premium less any distributions paid out before the end of an annuitization period.

g. “Beneficiary” means an individual or individuals entitled to receive any remaining payments from an annuity upon the death of the annuitant.

h. “Department” means the Department of Health Care Policy and Financing, its successor(s), or its designee(s).

i. “Irrevocable” means an annuity that cannot be canceled, revoked, terminated, or surrendered under any circumstances.

j. “Non-assignable” means an annuity that cannot have its owner and/or annuitant changed under any circumstances.

k. “Owner” means the person who may exercise the rights provided in an annuity contract during the life of the annuitant. An owner can generally name himself or herself or another person as the annuitant.

l. “Revocable” means an annuity that can be canceled, revoked, terminated, or surrendered.

m. “Transaction” means:

i) The purchase of an annuity;

ii) The addition of principal to an annuity;

iii) Elective withdrawals from an annuity;

iv) Requests to change the distributions from an annuity;

v) Elections to annuitize an annuity contract; or vi) Any other action taken by an individual that changes the course of payments made by an annuity or the treatment of income or principal of an annuity.

Annuities purchased on or before June 30, 1995 a. A revocable or irrevocable annuity established on or before June 30, 1995 is not a countable resource if it is annuitized and regular returns are being received by the annuitant.

i) Payments from the annuity to the individual or individual’s spouse are income in the month received.

b. A revocable or irrevocable annuity established on or before June 30, 1995 is a countable resource if it has not been annuitized.

Annuities Established on or after July 1, 1995 but before February 8, 2006 a. The purchase of an annuity shall be considered to be a transfer without fair consideration unless the following criteria are met:

i) The annuity is purchased from a life insurance company or other commercial company that sells annuities as part of its normal course of business;

ii) The annuity is annuitized for the individual or individual’s spouse;

iii) The annuity is purchased on the life of the individual or individual’s spouse; and iv) The annuity provides payments for a period not exceeding the annuitant’s projected life expectancy based on life expectancy tables described at 8.100.7.J.

b. To determine if a transfer without fair consideration has occurred in the purchase of an annuity, the Eligibility Site shall:

i) Determine the date on which the annuity was purchased;

ii) Determine the amount of money used to purchase the annuity and the length of the annuitization period;

iii) Determine the age of the annuitant at the time the annuity was purchased; and iv) Determine the life expectancy of the annuitant at the time the annuity was purchased using the appropriate life expectancy table described at 8.100.7.J.

If the length of the annuitization period exceeds the annuitant’s life expectancy, then a transfer without fair consideration exists for the portion of the annuitization period that exceeds the annuitant’s life expectancy.
If the total value of the annuity’s payments during the annuitization period is less than the original purchase price of the annuity, then the difference shall be considered to be a 3) If the total value of the annuity’s payments during the annuitization period is equal to or greater than the original purchase price of the annuity, then the purchase of the annuity shall not be considered to be a transfer without fair consideration. However, any payments made by the annuity shall be considered to be countable income in the month received.
If the annuity was purchased more than 36 months before the date of application for Medicaid, then there is no transfer without fair consideration penalty period. However, any payments made by the annuity shall be considered to be countable income in the month received.

Annuities Established on or after April 1, 1998 but before February 8, 2006 a. The Eligibility Site shall determine the Minimum Monthly Maintenance Needs Allowance (MMMNA) of the community spouse, if applicable.

i) If the monthly payment amount provided by the annuity to the community spouse exceeds the MMMNA, then the amount of the annuity which causes the monthly annuity payment to exceed the MMMNA shall be considered to be a transfer without fair consideration in determining the institutionalized spouse’s eligibility. This applies only to the extent that the transferred amount causes the Community Spouse Resource Allowance to exceed the maximum.

b. The Eligibility Site shall determine if the Individual is receiving substantially equal installments from the annuity for the annuitization period of the annuity.

i) If the annuity is not paid in substantially equal installments, then the original purchase price of the annuity shall be considered to be a c. If the annuity was purchased more than 36 months before the date of application for Medicaid, then there is no transfer without fair consideration penalty period.

i) Any payments made by the annuity shall be considered to be countable income in the month received.

Annuities Purchased on or after February 8, 2006 a. As a condition of Medicaid eligibility, at the time of application or redetermination, an applicant or his or her spouse for Medicaid Long-Te r m Care services shall disclose any interest that the Medicaid applicant or his or her spouse has in an annuity.

i) A complete copy of the annuity contract, including the most recent beneficiary designation, shall be provided to the eligibility site.

b. By providing Medicaid Long-Term Care services, the Department shall be a remainder beneficiary of any annuity in which an individual or individual’s spouse has an interest. The purchase of the annuity shall not be considered to be a transfer without fair consideration if:

i) The Department is named as the remainder beneficiary in the first position for the total amount of medical assistance paid on behalf of the individual; or ii) The Department is named as the remainder beneficiary in the next position after the community spouse or minor or disabled child.

iii) This provision shall not apply to annuities that are revocable and/or assignable.

c. The Eligibility Site shall notify the issuer of the annuity that the Department is a preferred remainder beneficiary in the annuity for medical assistance provided to the institutionalized individual. This notice shall include a statement requiring the issuer to notify the Eligibility Site of any changes in the amount of income or principal that is being withdrawn from the annuity or any other transactions, as defined at 8.100.7.I.1., regardless of when the annuity was purchased.

d. If the Department is not named on the annuity as a remainder beneficiary, then the value of funds used to purchase the annuity shall be deemed a transfer without fair consideration and shall be subject to the penalty period provisions described at 8.100.7.F.

i) This provision shall not apply to annuities that are revocable and/or assignable.

e. Revocable Annuities i) A revocable annuity is a countable resource. The value of the annuity is the total value of the annuity principal plus any accumulated interest.

a) If the annuity includes a surrender charge or other financial penalty (other than tax withholding or a tax penalty) for withdrawing funds from the annuity, then the value of the annuity is the net amount the individual would receive upon full surrender of the annuity.

ii) Payments from a revocable annuity are not countable as income.

f. Irrevocable Assignable Annuities i) An irrevocable assignable annuity is a countable resource. The value of the annuity is presumed to be the total value of the annuity principal plus any accumulated interest.

a) An individual or individual’s spouse can rebut the presumption by providing documented offers from at least three companies who are active in the market for buying and selling annuities an annuity income streams. The value of the annuity shall then be the highest of the offers.

b) Any payments from an irrevocable assignable annuity that is considered to be a countable resource are not considered to be countable income.

ii) An individual or individual’s spouse can rebut the presumption that an irrevocable assignable annuity is not a countable resource by providing documented offers from at least three companies who are active in the market for buying and selling annuities and annuity income streams stating their unwillingness or inability to purchase the annuity or annuity income stream.

a) Any payments from an irrevocable assignable annuity that is not considered to be a countable resource are considered to be countable income in the month received.

g. Irrevocable Non-Assignable Annuities i) An irrevocable non-assignable annuity is not considered to be a countable resource.

ii) Payments from an irrevocable non-assignable annuity are considered countable income in the month received.

iii) An irrevocable non-assignable annuity purchased by or for the benefit of a community spouse shall not be considered to be a transfer without fair consideration if:

The Department is named as the remainder beneficiary in the first position for the total amount of medical assistance paid on behalf of the institutionalized individual; or 2) The Department is named as the remainder beneficiary in the second position after the community spouse or minor or disabled child and is named in the first position if such spouse or a representative of such child disposes of any such remainder without fair consideration.

iv) An irrevocable non-assignable annuity purchased by or for the benefit of an institutionalized individual shall not be considered to be a transfer without fair consideration if:

The Department is named as the remainder beneficiary in the first position for the total amount of medical assistance paid on behalf of the institutionalized individual; or 2) The Department is named as the remainder beneficiary in the second position after the community spouse or minor or disabled child and is named in the first position if such spouse or a representative of such child disposes of any such remainder without fair consideration.

v) In addition to the requirements listed at 8.100.7.I.5.g.iv) for naming the Department as remainder beneficiary, an irrevocable nonassignable annuity purchased by or for the benefit of an institutionalized individual shall not be considered to be a transfer without fair consideration if the annuity meets any one of the following conditions:

The annuity is considered either:

a) An Individual Retirement Annuity as described in

Section 408(b) of the Internal Revenue Code of 1986;

b) A deemed Individual Retirement Account under a qualified employer plan described in Section 408(q) of the Internal Revenue Code of 1986; or 2) The annuity is purchased with proceeds from one of the a) An Individual Retirement Account as described in

Section 408(a) of the Internal Revenue Code of 1986;

b) An account established by an employer or association of employers as described in Section 408(c) of the Internal Revenue Code of 1986; or c) A simple retirement account as described in Section 408(p) of the Internal Revenue Code of 1986; or d) A simplified employee pension plan as described in

Section 408(k) of the Internal Revenue Code of 1986;

e) A Roth IRA as described in Section 408A of the Internal Revenue Code of 1986; or 3) The annuity meets all of the following requirements:

a) The annuity is irrevocable and non-assignable; and b) The annuity is actuarially sound based on the life expectancy tables described at 8.100.7.J.; and c) The annuity provides for payments in equal amounts during the term of the annuity with no deferral and no balloon payments made.

vi) If an irrevocable non-assignable annuity is considered to be a transfer without fair consideration, then, for the purpose of calculating the transfer without fair consideration penalty period, the value that was transferred shall be the amount of funds used to purchase the annuity.

h. Annuity Transactions i) If an Individual or individual’s spouse undertakes any transaction, as defined at 8.100.7.I.1. which has the effect of changing the course of payments to be made by an annuity or the treatment of income or principal of the annuity, such a transaction shall be deemed to be a transfer without fair consideration, regardless of when the annuity was originally purchased. For the purpose of calculating the transfer without fair consideration penalty period, the value that was transferred shall be the amount used to purchase the annuity.

a) Routine changes such as a notification of an address change or death or divorce of a remainder beneficiary are excluded from treatment as a transfer without fair b) Changes which occur based on the terms of the annuity which existed before February 8, 2006 and which do not require a decision, election, or action to take effect are excluded from treatment as a transfer without fair c) Changes which are beyond the control of the individual, such as a change in law, a change in the policies of the annuity issuer, or a change in terms based on other factors, such as the annuity issuer’s financial condition, are excluded from treatment as a transfer without fair consideration. 8.100.7.J. Life Expectancy Tables This rule incorporates by reference the Social Security Office of the Chief Actuary Period Life Table 2011 for both males and females. The incorporation of the table excludes later amendments, or editions of, the referenced material.

The Social Security Office of the Chief Actuary Period Life Table 2011 is available at www.ssa.gov/oact/STATS/table4c6.html.

Pursuant to § 24-4-103 (12.5), C.R.S., the Department maintains copies of the incorporated text in its entirety, available for public inspection during regular 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated materials 8.100.7.K. Spousal Protection - Treatment of Income and Resources for Institutionalized Spouses 1. The spousal protection regulations apply to married couples where one spouse is institutionalized or likely to be institutionalized for at least 30 consecutive days and the other spouse remains in the community. Being a community spouse does not prohibit Medicaid eligibility if all criteria are met. The community spouse resource allowance does not supersede the Medicaid eligibility criteria.

For purposes of spousal protection, an institutionalized spouse is an individual who:

a. Begins a stay in a medical institution or nursing facility on or after September 30, 1989, or b. Is first enrolled as a Medical Assistance client in the Program of All Inclusive Care for the Elderly (PACE) on or after October 10, 1997, or c. Receives Home and Community Based Services on or after July 1, 1999;

d. Is married to a spouse who is not in a medical institution or nursing facility; but does not include any such individual who is not likely to meet the requirements of subparagraphs 8.100.7.K.2.a thru c for at least 30 consecutive days.

A community spouse is defined as the spouse of an institutionalized spouse. 8.100.7.L. Assessment and Documentation of The Couple's Resources An assessment of the total value of the couple’s resources shall be completed at the time of initial Medical Assistance application or when requested by either spouse of a married couple. All non-exempt resources owned by a married couple are counted, whether owned jointly or individually. There are no exceptions for legal separation, pre-nuptial, or post-nuptial agreements. Once the applicant is approved, the Community Spouses’ resources are not reviewed again unless the Community Spouse applies for Medical Assistance. 8.100.7.M. Calculation of the Community Spouse Resource Allowance 1. A Community Spouse Resource Allowance (CSRA) shall be allocated based on the total resources owned by the couple as of the time of Medical Assistance application. The CSRA is established at intake only, and; once approved the community spouse’s resources are not considered again until the community spouse applies for Medical Assistance. This is true even if the community spouse becomes institutionalized but does not apply for Medical Assistance. In calculating the amount of the CSRA, resources shall not be attributed to the community spouse based upon state laws relating to community property or the division of marital property.

For persons whose Medical Assistance application is for an individual who meets the definition of an institutionalized spouse, the CSRA is the largest of the following amounts:

a. The total resources of the couple but no more than the current maximum allowance which, changes each year beginning January 1st.; or b. The increased CSRA calculated pursuant to section 8.100.7.S; or c. The amount a court has ordered the institutionalized spouse to transfer to the community spouse for monthly support of the community spouse or a dependent family member.

The resources allotted to the community spouse as the CSRA shall be transferred into the name of the community spouse and shall not be considered available to the institutionalized spouse. After the transfer of the CSRA to the community spouse, the income from these resources shall be attributed to the 3. The transfer of the CSRA shall be completed as soon as possible, but no later than the next redetermination when the community spouse becomes institutionalizes; whichever is earlier. If the transfer is not completed within this time period, the resources shall be attributed to the institutionalized spouse and shall affect his/her Medical Assistance eligibility. Verification of the transfer of assets to the community spouse shall be provided to the eligibility site.

The institutionalized spouse may transfer the resources allotted to the community spouse as the CSRA to another person for the sole benefit of the community 4. If the community spouse is in control of resources attributed to the institutionalized spouse, but fails to make such resources available for his/her cost of care, this fact shall not make the institutionalized spouse ineligible for Medical Assistance, where:

a. The institutionalized spouse has assigned The Department any rights to support from the community spouse; or b. The institutionalized spouse lacks the ability to execute an assignment due to physical or mental impairment but The Department has the right to bring a support proceeding against the community spouse without such assignment; or c. The eligibility site determines that the denial of eligibility would work an undue hardship upon the institutionalized spouse. For the purposes of this subparagraph, undue hardship means that an institutionalized spouse, who meets all the Medical Assistance eligibility criteria except for resource eligibility, has no alternative living arrangement other than the medical institution or Long Term Care institution. 8.100.7.N. Treatment of the Home and Other Exempt Resources The CSRA shall not include the value of exempt resources including the home. It is not necessary for the home to be transferred to the community spouse. The rules regarding countable and exempt resources can be found in the section 8.100.5. However, for Spousal Protection there is no limit to the value of household goods and personal effects and one automobile. 8.100.7.O. Determination of the Institutionalized Spouse’s Income and Resource Eligibility 1. The institutionalized spouse is resource eligible for Medical Assistance when the total resources owned by the couple are at or below the amount of the Community Spouse Resource Allowance plus the Medical Assistance resource allowance for an individual of $2,000.

The eligibility site shall determine whether the institutionalized spouse is income eligible for Medical Assistance. The institutionalized spouse shall be income eligible if his/her gross income is at or below the Medical Assistance income limit for recipients of long-term care. If an income trust is used the trust must be established before the MIA is calculated. 8.100.7.P. Attribution of Income During any month in which a spouse is institutionalized, the income of the community spouse shall not be deemed available to the institutionalized spouse except as follows:
If payment of income from resources is made solely in the name of either the institutionalized spouse or the community spouse, the income shall be considered available only to the named spouse.
If payment of income from resources is made in the names of both the institutionalized spouse and the community spouse, one-half of the income shall be considered available to each spouse.
If payment of income is made in the names of the institutionalized spouse or the community spouse, or both, and to another person or persons, the income shall be considered available to each spouse in proportion to the spouse’s interest.
The above regulations of attribution of income are superseded if the institutionalized spouse can establish by a preponderance of the evidence that the ownership interests in the income are other than that provided in the regulations. 8.100.7.Q. Calculating the Community Spouse’s Monthly Income Needs 1. The community spouse's total minimum monthly needs shall be determined as a. The current minimum monthly maintenance needs allowance (MMMNA), which is equal to 150% of the federal poverty level for a family of two and is adjusted in July of each year;

b. An excess shelter allowance, in cases where the community spouse's expenses for shelter exceed 30% of the MMMNA. The excess shelter allowance is computed by adding (a) and (b) together:

i) The community spouse’s expenses for rent or mortgage payment including principal and interest, taxes and insurance, and, in the case of a condominium or cooperative, any required maintenance fee, for the community spouse’s principal residence; and ii) The larger of the following amounts: the standard utility allowance used by Colorado under U.S.C. 2014(e) of Title 7; or the community spouse’s actual, verified, utility expenses. A utility allowance shall not be allowed if the utility expenses are included in the rent or maintenance charge, which is paid by the community iii) The excess shelter allowance is the amount, if any, that exceeds 30% of the MMMNA.

An additional amount may be approved for the following expenses:

a. Medical expenses of the community spouse or dependent family member for necessary medical or remedial care. Each medical or remedial care expense claimed for deduction must be documented in a manner that describes the service, the date of the service, the amount of the cost incurred, and the name of the service provider. An expense may be deducted only if it is:

i) Provided by a medical practitioner licensed to furnish the care;

ii) Not subject to payment by any third party, including Medical Assistance and Medicare;

b. The cost of Medicare, Long Term Care insurance, and health insurance premiums. A health insurance premium may be allowed in the month the premium is paid or may be prorated and allowed for the months the premium covers. This allowance does not include payments made for coverage which is:

i) Limited to disability or income protection coverage;

ii) Automobile medical payment coverage;

iii) Supplemental to liability insurance;

iv) Designed solely to provide payments on a per diem basis, daily indemnity or non-expense-incurred basis; or v) Credit life and/or accident and health insurance.

If either spouse establishes that the community spouse needs income above the level provided by the minimum monthly maintenance needs allowance due to exceptional circumstances, which result in significant financial duress, such as loss of home and possessions due to fire, flood, or tornado, an additional amount may be substituted for the MMMNA if established through a fair hearing.
The total that results from adding the current MMMNA and the excess shelter allowance shall not exceed the current maximum MMMNA which is $2,175.00 for the year 2001 and is adjusted by the Health Care Financing Administration in January of each year. 8.100.7.R. Calculating the Amount of Income to be Contributed by the Institutionalized Spouse for the Community Spouse's Monthly Needs 1. The Monthly Income Allowance (MIA) is the amount of money necessary to raise the community spouse's income to the level of his/her monthly needs, and shall be obtained from the monthly income of the institutionalized spouse. For individuals who become institutionalized on or after February 8, 2006, all income of the institutionalized spouse that could be made available to the community spouse must be considered to have been made available to the community spouse before an MIA is allocated to the community spouse.
The MIA shall be the amount by which the community spouse's minimum monthly needs, which is the MMMNA, exceed his/her income from sources other than the institutionalized spouse. The community spouse’s income shall be calculated by using the gross income less mandatory deduct ions for FICA and Medicare tax.
If a court has entered an order against the institutionalized spouse for monthly support of the community spouse, the MIA shall not be less than the monthly amount ordered by the court.
The eligibility site shall make adjustments to the MMMNA and/or the MIA on a monthly basis for any continuing change in circumstances that exceeds $50 a month. Continuing changes of less than $50 in a month, and any infrequent or irregular changes, shall be considered at redetermination. 8.100.7.S. Increasing the Community Spouse Resource Allowance 1. The CSRA shall be increased above the maximum amount if additional resources are needed to raise the community spouse's monthly income to the level of the Minimum Monthly Maintenance Needs Allowance (MMMNA). In making this determination the items listed below are calculated in the following order:

a. The community spouse's MMMNA;

b. The community spouse’s own income; and c. The Monthly Income Allowance (MIA) contribution that the community spouse is eligible to receive from the institutionalized spouse.

d. If the community spouse’s own income, and the Monthly Income Allowance contribution from the institutionalized spouse’s income is less than the Minimum Monthly Maintenance Needs Allowance, additional available resources shall be shifted to the community spouse to bring his/her income up to the level of the MMMNA. The additional resources necessary to raise the community spouse’s monthly income to the level of the MMMNA shall be based upon the cost of a single-premium lifetime annuity with monthly payments equal to the difference between the MMMNA and the community spouse’s income. The following steps shall be followed to determine the amount of resources to be shifted:

i) The applicant shall obtain three estimates of the cost of an annuity that would generate enough income to make up the difference between the MMMNA and the combined community spouse’s income as described above.

ii) The amount of the lowest estimate shall be used as the amount of resources to increase the CSRA.

iii) The applicant shall not be required to purchase the annuity in order to have the CSRA increased.

e. The CSRA shall not be increased if the institutionalized spouse refuses to make the monthly income allowance (MIA) available to the community 8.100.7.T. Deductions from Monthly Income of the Institutionalized Spouse 1. During each month after the institutionalized spouse becomes Medical Assistance eligible, deductions shall be made from the institutionalized spouse's monthly income in the following order.

a. A personal needs allowance or the client maintenance allowance as allowed by program eligibility.

b. A Monthly Income Allowance (MIA) for the community spouse, but only to the extent that income of the institutionalized spouse is actually made available to, or for the benefit of, the community spouse;

c. A family allowance for each dependent family member who lives with the i) The allowance for each dependent family member shall be equal to one third of the amount of the MMMNA and shall be reduced by the monthly income of that family member.

ii) Family member means dependent children (minor or adult), dependent parents or dependent siblings of either spouse that are residing with the community spouse and can be claimed by either the institutionalized or community spouse as a dependent for federal income tax purposes.

d. Allowable deductions identified in section 8.100.7.V.

e. If the institutionalized spouse fails to make his/her income available to the community spouse or eligible dependent family members in accordance with these regulations, that income shall be applied to the cost of care for the institutionalized spouse.

f. No other deductions shall be allowed. 8.100.7.U. Right to Appeal 1. Both spouses shall be informed of the following:

a. The amount and method by which the eligibility site calculated the community spouse resource allowance (CSRA), community spouse monthly income allowance (MIA), and any family allowance;

b. The spouses' right to a fair hearing concerning these calculations;

c. The eligibility site conclusions with respect to the spouses' ownership and availability of income and resources, and the spouses' right to a fair hearing concerning these conclusions.

If either spouse establishes that the community spouse needs income above the level provided by the minimum monthly maintenance needs allowance due to exceptional circumstances, which result in significant financial duress, such as loss of home and possessions due to fire, flood, or tornado, an additional amount may be substituted for the MMMNA if established through a fair hearing.
Appeals from decisions made by the eligibility site shall be governed by the provisions under Recipient Appeals Protocols/Process at 8.058. 8.100.7.V. Long-Term Care Institution Recipient Income 1. Determination of Income and Communication between the Long-Term Care institution and the Eligibility Site Using the AP-5615 Form for Patient Payment a. Sections I, II and IV of the AP-5615 form are to be completed by the Long- Term Care institution for all admissions, readmissions, transfers to and from another payer source, including private pay and Medicare, discharges, deaths, changes in income and/or patient payment, medical leaves of absence and non-medical/programmatic leave in excess of 42 days combined per calendar year.

b. The initial determination of resident income for patient payment shall be made by the Eligibility Site. The Eligibility Site shall notify the Long-Te r m Care institution of current resident income.

c. On receipt of AP-5615 form, the Eligibility Site will, within five working days:

i) For an admission, a readmission or a transfer from/to private pay, Medicare, or another payer source:

Verify and correct, if necessary, data entered by the Long- Term Care institution.
List and/or verify the resident's monthly income adjustments and/or Long-Term Care Insurance benefit payments; and compute patient payment. Provide the completed AP-5615 to the Long-Term Care institution.
Correct the automated system to indicate the Long-Te r m Care institution name and provider number and to reflect the current distribution of income. Submit the AP-5615 form to the Department.

d. For change in patient payment with respect to changes in resident income:

i) Verify changes in resident income, and correct if necessary. All such corrections must be initialed, ii) Compute patient payment and provide the completed AP-5615 to the Long-Term Care institution.

e. For change in patient payment with respect to the post-eligibility treatment of income, the Eligibility Site shall:

i) Review the AP-5615 form for Medicare part B premium deduction allowances for the first two months of admission.

ii) If client is already on the Medicare Buy-In program for Medicare

part B, do not adjust patient payment on AP-5615 form for the Medicare premium deduction. If client is not on the Buy-In program, adjust AP-5615 form for the Medicare premium deduction for the first two months of Long-Term Care institution iii) If the client has a Medicare D premium, the Eligibility Site shall use the amount as an income adjustment/deduction in the patient payment calculation and complete the AP-5615 form.

f. For resident leave of absence:

i) Non-Medical/Programmatic Leave. When combined nonmedical/programmatic days in excess of 42 days are reported, verify adherence to the restrictions and conditions of section 8.482.44.

ii) Medical Leave/Hospitalization. Verify that the patient payment is apportioned correctly between the nursing facility and the hospital so that no Medicaid payment is requested for the period. See also

section 8.482.43.

iii) The nursing facility may wait until the end of the month to complete the AP-5615 form for an ongoing hospitalization.

g. For change in payer status:

i) If Medicare or insurance is a primary payer during the month, verify the nursing facility’s calculation of the patient payment.

ii) Complete and provide the AP-5615 to the nursing facility.

h. For discharge or death of resident:

i) Verify the date of death or discharge, and verify the correct patient payment including the resident's monthly income for the discharged month, and the amount calculated by per diem. All corrections must be initialed.

ii) Note if the resident entered another Long-Term Care institution and, if so, enter the name of the new Long-Term Care institution in the system.

iii) In the event the resident may return to the same facility, the AP- 5615 form may be completed at the end of the month for discharges due to hospitalization.

i. For discontinuation of Long-Term Care eligibility:

i) Initiate and send an AP-5615 form to the Long-Term Care institution within 5 working days of the date of determination that the client’s eligibility will be discontinued. Indicate the date the discontinuation will be effective.

j. Failure to provide a correct and timely AP-5615 to the Long-Term Care institution may result in the refusal of the Department to reimburse such Long-Term Care institution care. The AP-5615 form is required in order for a Prior Authorization Request (PAR) to be issued for Long-Term Care institution claim reimbursement.

k. General Instructions:

i) The AP-5615 form must be verified and a signed AP-5615 form returned to the Long-Term Care institution.

ii) The AP-5615 form must be signed and dated by the director of the Eligibility Site or by his/her designee.

iii) AP-5615 forms may be initiated by either the Long-Term Care institution or Eligibility Site. If the Eligibility Site is aware of information requiring a change in financial arrangements of a resident, and a new AP-5615 form is not forthcoming from the Long-Term Care institution, the Eligibility Site may initiate the revision to the AP-5615 form. In such case, one copy of the AP- 5615 form showing the changes will be sent to the Long-Te r m Care institution.

l. The Department may deduct excess payments from the Eligibility Site administrative reimbursement as stated in the Colorado Department of Human Services Finance Staff Manual, Volume 5 if the Eligibility Site fails i) Perform the duties as detailed in this section; or ii) Adhere to the limitations on a reduced patient payment; as detailed in section 8.100.7.V.4; or iii) Notify the Long-Term Care institution within 5 working days of any changes in resident income, provided the Long-Term Care institution is not authorized to receive the resident's income; and excessive Medicaid funds are paid to the Long-Term Care institution as a result of this negligence.

Collection of Patient Payment a. It shall be the responsibility of the Long-Term Care institution to collect from the client, or from the client's family, conservator or administrator, the patient payment, which is to be applied to the cost of client care. The Department is not responsible for any deficiency in patient payment accounts, due to failure of the Long-Term Care institution to collect such income.

b. If, however, the Long-Term Care institution is unable to collect such funds, through refusal of the resident or the resident's family, conservator, administrator or responsible party to release such income, the Long-Te r m Care institution shall immediately notify the Eligibility Site.

c. When notified by the Long-Term Care institution of the refusal of the client or the client's family, conservator administrator or responsible party to pay the patient payment due, the Eligibility Site shall immediately contact the refusing party. If, after such contact, the party still refuses to release such income, the action shall be deemed a failure to cooperate, and the Eligibility Site shall proceed to discontinue Medicaid benefits for the resident.

Calculation of Patient Payment a. Specific instructions for computing the patient payment amount are contained in this volume under The “Status of Long-Term Care institution Care” Form, AP-5615 b. Once an applicant for Nursing Facility Medical Assistance has been determined eligible for Medical Assistance, the Eligibility Site shall determine the patient payment due to the Nursing Facility which is to be applied to the Medicaid reimbursement for the cost of care. That patient payment is calculated by:

i) Determining all applicable income of the recipient ii) Deducting all applicable allowable monthly income adjustments, which include:

Personal Needs Allowance 2) If applicable, Monthly Income Allowance for the community 3) If applicable, Family Dependent Allowance 4) If applicable, Home Maintenance Allowance 5) If applicable, Trustee/Maintenance Fees: actual fees, with a maximum of $20 per month 6) If applicable, Mandatory Income Tax Withheld 7) Mandatory garnishments repaying Federal assistance overpayment 8) Medical or remedial care expenses that are not subject to payment by a third party:

a) Medicare Part B Premium expenses, if applicable, are deductible only for the first and second month in the Nursing Facility.

b) Medicare Part D Premium expenses, if applicable, are ongoing deductions.

c) Other medical and remedial expenses covered under the Nursing Facility PETI (NF PETI) program are not deductible. NF PETI-approved expenses are allowed only for residents with a patient payment, but do not change the patient payment amount. For NF PETI, see the Section 8.482.33 in this volume “Post Eligibility Treatment of Income”.

c. Long-Term Care Insurance Long-Term Care insurance payments are not counted as income for eligibility purposes. However, they are income available for a patient payment. The patient payment shall include the client’s income after the allowable deductions and any Long-Term Care insurance payments for the month. In the event that the patient payment is greater than the cost of care, the Long-Term Care insurance payment shall be applied before the client’s income.

i) If Long-Term Care insurance is received for the month, and:

If, after all deductions, the client has income available for a patient payment, add this to the amount of the Long-Te r m Care insurance to determine the total patient payment.

a) If the total amount is greater that the allowable cost of care, the Long-Term Care insurance is applied before the client’s income, or; b If after all deductions, the client does not have income available for the patient payment, only the Long-Te r m Care insurance payment is used.

d. Personal Needs Allowances i) Non-Veteran related personal needs allowance 1) Prior to January 1, 2015 the personal needs allowance base amount is $50 per month.

Effective January 1, 2015 the personal needs allowance base amount is $75 per month and will be adjusted annually at the same rate as the statewide average of the nursing facility per diem rate net of patient payment pursuant to C.R.S. § 25.5-6-202(9)(b)(I). Each yearly adjustment will set a new base amount.

a) The first annual rate adjustment to the new $75 base amount will occur on January 1, 2015.

ii) Veterans-related personal needs allowance Effective 07/01/91, the personal needs allowance shall be $90 per month for a veteran in a Long-Term Care institution who has no spouse or dependent child and who receives a non-service connected disability pension from the U.S. Veterans Administration.

The personal needs allowance shall also be $90 per month for the widow(er) of a veteran with no dependent children.

Public Law requires that a veteran, without a spouse or dependent child, who enters a Long-Term Care institution have their veteran’s pension reduced to $90 which is to be reserved for their personal needs. This reduction in pension is not applicable to veteran’s who reside in a State Veteran’s Nursing facility. If a veteran, who does not reside in a State Veteran’s Nursing facility, receives a pension reduction of $90 he/she is allowed to apply this $90 to his/her personal needs allowance. It is not considered income toward the patient payment. The same regulation applies to a widow of a veteran without any dependent children.
To verify if those veterans residing in State Veteran’s Nursing facilities are receiving a non-service connected pension you may request their award letter from the Department of Veterans Affairs or call the Department of Veterans Affairs and verify through contact. If they are receiving any amount in a non-service connected pension they are entitled to a $90 personal needs allowance so long as they do not have a spouse or dependent child. The same regulation applies to a widow of a veteran without any dependent children.

iii) For aged, disabled, or blind Long-Term Care institution recipients engaged in income-producing activities, an additional amount of $65 per month plus one-half of the remaining gross income may be retained by the individual.

iv) Effective September 15, 1994, aged, disabled, or blind Long-Te r m Care institution residents, HCBS or PACE recipients with mandatory withholdings from earned or unearned income to cover federal state, and local taxes may have an additional amount included as a deduction from the patient payment. The patient payment deduction must be for a specific accounting period when the taxes are owed and expected to be withheld from income or paid by the individual in the accounting period. The Eligibility Site must verify that the taxes were withheld. If the taxes are not paid, the Eligibility Site must establish a recovery. The deduction is also applicable for any Federal pensions with mandated tax withholdings from unearned income despite the individual earner being institutionalized. All other pensions will discontinue the tax withholding once notified that the recipient is receiving institutionalized care through Medicaid, thus signifying that the withholding was not mandatory. This deduction does not apply to individuals who have elected to have taxes withheld from their earnings as a means to receiving a greater tax refund.

e. The reserve specified in section 8.100.7.V.3.d.iii. of this volume shall apply to Long-Term Care institution residents who are engaged in incomeproducing activities on a regular basis. Types of income-producing activities include:

i) work in a sheltered workshop or work activity center;

ii) “protected employment” which means the employer gives special privileges to the individual;

iii) an activity that produced income in connection with a course of vocational rehabilitation;

iv) employment training sessions;

v) activities within the facility such as crafts products and facility employment.

f. In determining the personal needs reserve amount for Long-Term Care institution residents engaged in income-producing activities:

i) The personal needs allowance is reserved from earned income only when the person has insufficient unearned income to meet this need;

ii) In determining countable earned income of a Long-Term Care institution resident, the following rules shall apply:

$65 shall be subtracted from the gross earned income.
The result shall be divided in half.
The remaining income is the countable earned income and shall be considered in determining the patient payment.

iii) When the personal needs allowance is reserved from unearned income, the additional reserve is computed based on the total gross earned income.

g. Other Deductions Reserved from Recipient's Income:

i) In the case of a married, long-term care recipient who is institutionalized in a Long-Term Care institution and who has a spouse (and, in some cases, other dependent family members) living in the community, there are “spousal protection” rules which permit the contribution of the institutionalized spouse's income toward their living expenses. See section 8.100.7.K.

ii) For a Long-Term Care institution recipient with no family at home, an amount in addition to the personal needs allowance may be reserved for maintenance of the recipient's home for a temporary period, not to exceed 6 months, if a physician has certified that the person is likely to return to his/her home within that period.

This additional reserve from recipient income is referred to as Home Maintenance Allowance and the amount of the deduction must be based on actual and verified shelter expenses such as mortgage payments, taxes, utilities to prevent freeze, etc.

The Home Maintenance Allowance:

Prior to July 1, 2018 shall not exceed the total of the current shelter and utilities components of the applicable standard of assistance (OAP for aged recipients; AND/SSI-CS or AB/SSI-CS for disabled or blind recipients).
Beginning July 1, 2018 a) The Home Maintenance Allowance shall not exceed the Home Maintenance Allowance Maximum described in this section.

Claimable utility costs will be limited to the lessor of the following amounts:

The standard utility allowance used by Colorado under 7 U.S.C. 2014(e) (2018), which is hereby incorporated by reference.

The incorporation of 7 U.S.C. 2014(e) (2018) excludes later amendments to, or editions of, the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver CO 80203. Certified copies of incorporated materials are provided at cost upon request.

Or;

The individual’s actual, verified, utility expenses.

b) The Maximum Home Maintenance Allowance is The Individual Needs Standard minus 105% Federal Poverty Limit (FPL) for a household of 1, rounded to the nearest whole dollar, and is determined as (1) The Department will calculate the Individual Needs Standard by dividing the Federal Minimum Monthly Maintenance Needs Allowance maximum by the Federal Minimum Monthly Maintenance Needs Allowance (MMMNA), described at 8.100.7.Q, which is in place on January 1st of each calendar year.

The result of this division will be multiplied by 150% of FPL for a household of 1.

(2) The Home Maintenance Maximum is determined by subtracting 150% FPL for a household of 1 from the Individual Needs Standard and adding 30% of 150% FPL for a household of 1. The result will be rounded to the nearest whole dollar.

h. The necessity for the deduction from a recipient's income specified in

section 8.100.7.V.3 shall be fully explained in the case record. Such additional reserve amount must be entered on the eligibility reporting form.

i. As of July 1, 1988, an SSI cash recipient may continue to receive SSI benefits when he/she is expected to be institutionalized for three months or less. This provision is intended to allow temporarily institutionalized recipients to pay the necessary expenses to maintain the principal place of residence.

i) Payments made under this continued benefit provision are not considered over-payments of SSI benefits if the recipient's stay is more than 90 days.

ii) The amount of Supplemental Security Income (SSI) benefit paid to an institutionalized individual is deducted from gross income when computing the patient payment.

j. When a nursing facility resident’s SSI is reduced due to institutionalization, the difference between the reduced SSI payment and the personal needs allowance amount shall be provided through the Adult Financial program so that the resident receives the full personal needs allowance.

Reduction of the Patient Payment a. Patient payment may be reduced only under the following conditions:

i) A resident's income is equal to or less than the personal needs allowance and there is no long term care insurance payment, in which case the patient payment is zero; or ii) A resident's income is equal to or less than the sum of all allowable and appropriate deductions, and there is no long term care insurance payment; or iii) A resident is admitted to the Long Term Care institution from his/her home and the resident's funds are committed elsewhere for that month; or iv) The resident is admitted from his/her home, where his/her funds were previously committed, to the hospital, and subsequently to the Long Term Care institution, in the same calendar month; or v) The resident is discharged to his/her home, and the Eligibility Site determines that the income is necessary for living expenses; or vi) The resident is admitted from another Long Term Care institution or from private pay within the facility and has committed the entire patient payment for the month for payment of care already provided in the month of admission.

vii) Medicare assesses a co-insurance payment for a QMB recipient; the recipient’s patient payment cannot be used for payment of Medicare co-insurance.

b. Patient payment may not be waived in the following instances:

i) Transfers between nursing facilities, except that the patient payment for the receiving facility may be waived if the patient payment has already been committed to the former nursing facility; or ii) Discharges from nursing facility to a hospital or other medical institution when Medicaid is paying for services in the medical institution; or iii) Changes from private pay within the facility and the patient payment is not already committed for care provided under private pay status; or iv) The death of the resident.

c. The Eligibility Site shall verify and approve partial month patient payments due to transfers, discharges or death when calculated by the nursing facility based upon the nursing facility’s per diem rate.

d. The amount of SSI benefits received by a person who is institutionalized is not considered when calculating patient payment.

Responsibilities of the Eligibility Site Regarding the Personal Needs Fund a. It shall be the responsibility of the Eligibility Site to explain to the resident the various options for handling the personal needs monies, as well as the resident's rights to such funds. The resident has the option to allow the Long Term Care institution to hold such funds in trust.

b. It shall be the responsibility of the Eligibility Site to assure that the Long Term Care institution properly transfers or disposes of the resident's personal needs funds within 30 days of discharge from the Long Term Care institution, or transfer to another Long Term Care institution.

c. The Eligibility Site shall notify the State Department if they become aware that a Long Term Care institution has retained personal needs funds more than 30 days after the death of a resident.

For rules regarding post eligibility treatment of income, see the section in this volume titled “Post Eligibility Treatment of Income”

8.125 PROVIDER SCREENING

8.125.1 DEFINITIONS.

Managed Care Entity defined at 42 CFR § 455.101, means managed care organizations (MCOs, PIHPs, PAHPs, PCCMs, and HIOs.

Ownership interest defined at 42 CFR § 455.101, means the possession of equity in the capital, the stock, or the profits of the disclosing entity.

Person with an ownership or control interest defined at 42 CFR § 455.101, means a person or corporation that- (a) Has an ownership interest totaling 5 percent or more in a disclosing entity;

(b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;

(d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;

(e) Is an officer or director of a disclosing entity that is organized as a corporation; or (f) Is a partner in a disclosing entity that is organized as a partnership.

Enrollment is defined as the process by which an individual or entity not currently enrolled as a Colorado Medicaid provider submits a provider application, undergoes any applicable screening, pays an application fee, as appropriate for the provider type, and is approved by the Department for participation in the Medicaid program. Entities that have never previously enrolled as Medicaid providers or whose enrollment was previously terminated and are not currently enrolled are required to enroll. The date of enrollment shall be considered the date that is communicated to the provider in communication from the Department or its fiscal agent verifying the provider’s enrollment in Medicaid.

Revalidation is defined as the process by which an individual or entity actively enrolled as a Colorado Medicaid provider resubmits a provider application, undergoes a statedefined screening process, pays an application fee, as appropriate for the provider type, and is approved by the Department to continue participation in the Medicaid program.

Disclosing Entity, defined at 42 CFR § 455.101, means a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent.

Other Disclosing Entity,defined at 42 CFR § 455.101, means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or XX of the Act. This includes:

(a) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII);

(b) Any medicare intermediary or carrier; and (c) Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of health-related services for which it claims payment under any plan or program established under title V or title XX of the Act.

8.125.2 PROVIDERS DESIGNATED AS LIMITED CATEGORICAL RISK AND

NEW PROVIDER TYPES 8.125.2.A. Except as provided for in Section 8.125.2.B, provider types not designated as moderate or high categorical risk at Sections 8.125.3 or 8.125.4 shall be considered limited risk. 8.125.2.B. The risk category for each provider type designated by the Centers for Medicare and Medicaid Services (CMS) shall be the risk category for purposes of this rule regardless of whether a provider type may be listed in Sections 8.125.3 or 8.125.4.

8.125.3 PROVIDERS DESIGNATED AS MODERATE CATEGORICAL RISK 8.125.3.A. Emergency Transportation including ambulance service suppliers 8.125.3.B. Enrolling Opioid Treatment Provider that has been fully and continuously certified by Substance Abuse and Mental Health Services Administration (SAMHSA) since October 23, 2018, and revalidating Opioid Treatment Providers. 8.125.3.C. Community Mental Health Center 8.125.3.D. Independent Laboratory 8.125.3.E. Comprehensive Outpatient Rehabilitation Facility 8.125.3.F. Comprehensive Safety Net Provider 8.125.3.G. Physical Therapists, both individuals and group practices 8.125.3.H. X-Ray Facilities 8.125.3.I. Revalidating Doulas 8.125.3.J. Revalidating Community Health Workers/Community Health Representatives 8.125.3.K. Revalidating Home Health agencies 8.125.3.L. Revalidating Hospice 8.125.3.M. Revalidating Durable Medical equipment suppliers, including revalidating pharmacies that supply Durable Medical Equipment 8.125.3.N. Revalidating Lactation Consultant 8.125.3.O. Revalidating Lactation Counselor or Educator 8.125.3.P. Revalidating Lactation / Doula Professional Group 8.125.3.Q. Revalidating Personal Care Agencies under the state plan 8.125.3.R. Revalidating Skilled Nursing Facilities 8.125.3.S. Providers of the following services for Home and Community-Based Services (HCBS) waiver members:

Acupuncture 2. Alternative Care Facility 3. Adult Day Services 4. Assistive Technology, if the provider is revalidating 5. Behavioral Programing 6. Behavioral Services 7. Benefits Planning 8. Children’s Habilitation Residential Program (CHRP)
Chiropractic 10. Community Connector 11. Community Mental Health Services 12. Complementary and Integrative Health 13. Day Habilitation 14. Day Treatment 15. Expressive Therapy 16. Home Delivered Meals 17. Home Modifications/Adaptations/Accessibility 18. Independent Living Skills Training 19. In-Home Support Services, if the provider is revalidating 20. Life Skills Training 21. Massage Therapy 22. Mental Health Transitional Living Homes 23. Mentorship 24. Non-Medical Transportation 25. Palliative/Supportive Care 26. Peer Mentorship 27. Personal Care/Homemaker Services, if the provider is revalidating 28. Personal Emergency Response System/Medication Reminder/Electronic Monitoring 29. Pre-Tenancy Support Money Follows the Person (MFP)
Prevocational Services 31. Professional Services 32. Remote Supports 33. Residential Habilitation Services 34. Respite 35. Specialized Medical Equipment and Supplies, if the provider is revalidating 36. Substance Abuse Counseling 37. Supported Employment 38. Supported Living Program 39. Therapy and Counseling 40. Transition Setup 41. Transitional Living Program 42. Youth Day Services 8.125.3.T. Medicare Only Providers 1. Independent Diagnostic Testing Facility 2. Revalidating Medicare Diabetes Prevention Program Supplier 3. Newly enrolling Opioid Treatment Program that has been fully and Administration (SAMHSA) since October 24, 2018.
Revalidating Opioid Treatment Program 8.125.4 PROVIDERS DESIGNATED AS HIGH CATEGORICAL RISK 8.125.4.A. Enrolling Durable Medical Equipment (DME) Suppliers 8.125.4.B. Enrolling Doulas 8.125.4.C. Enrolling Home Health Agencies 8.125.4.D. Enrolling Hospices 8.125.4.E. Enrolling Lactation Consultant 8.125.4.F. Enrolling Lactation Counselor or Educator 8.125.4.G Enrolling Lactation / Doula Professional Group 8.125.4.H. Enrolling Opioid Treatment Provider that has not been fully and Administration (SAMHSA) since October 23, 2018. 8.125.4.I. Enrolling Personal Care Agencies providing services under the state plan 8.125.4.J. Enrolling Skilled Nursing Facilities 8.125.4.K. Enrolling Community Health Workers/Community Health Representatives 8.125.4.L. Enrolling providers of the following services for Home and Community- Based Services (HCBS) waiver members:
Assistive Technology 2. Personal Care/Homemaker Services 3. Specialized Medical Equipment and Supplies 4. In-Home Support Services 8.125.4.M. Non-Emergent Medical Transportation 8.125.4.N. Medicare Only Providers 1. Enrolling Medicare Diabetes Prevention Program Supplier 2. Enrolling Opioid Treatment Program that has not been fully and Administration (SAMHSA) since October 24, 2018. 8.125.4.O. Enrolling and revalidating providers for which the Department has suspended payments during an investigation of a credible allegation of fraud, for the duration of the suspension of payments. 8.125.4.P. Enrolling and revalidating providers which have a delinquent debt owed to the State arising out of Medicare, Colorado Medical Assistance or other programs administered by the Department, not including providers which are current under a settlement or repayment agreement with the State. 8.125.4.Q. Providers that were excluded by the United States Department of Health and Human Services (HHS) Office of Inspector General or had their provider agreement terminated for cause by the Department, its contractors or agents or another State's Medicaid program at any time within the previous 10 years. 8.125.4.R. Providers applying for enrollment within six (6) months from the time that the Department or the Centers for Medicare and Medicaid Services (CMS) lifts a temporary enrollment moratorium on the provider’s enrollment type.

8.125.5 PROVIDERS WITH MULTIPLE RISK LEVELS 8.125.5.A Providers shall be screened at the highest applicable risk level for which a provider meets the criteria. Providers shall only pay one application fee per location.

8.125.6 PROVIDERS WITH MULTIPLE LOCATIONS 8.125.6.A. Providers must enroll separately each location from which they provide services. Only claims for services provided at locations that are enrolled are eligible for reimbursement. 8.125.6.B. Each provider site will be screened separately and must pay a separate application fee. Providers shall only pay one application fee per location.

8.125.7 ENROLLMENT AND SCREENING OF PROVIDERS 8.125.7.A. All enrolling and revalidating providers must be screened in accordance with requirements appropriate to their categorical risk level. 8.125.7.B. Notwithstanding any other provision of the Colorado Code of Regulations, providers who provide services to Medicaid members as part of a managed care entity’s provider network who would have to enroll in order to participate in feefor-service Medicaid must enroll with the Department and be screened as Medicaid providers. 8.125.7.C. Nothing in Section 8.125.7.B shall require a provider who provides services to Medicaid members as part of a managed care entity’s provider network to participate in fee-for-service Medicaid. 8.125.7.D. All physicians or other professionals who order, prescribe, or refer services or items for Medicaid members, whether as part of fee-for-service Medicaid or as part of a managed care entity’s provider network under either the state plan, the Children’s Health Insurance Program, or a waiver, must be enrolled in order for claims submitted for those ordered, referred, or prescribed services or items to be reimbursed or accepted for the calculation of managed care rates by the Department. 8.125.7.E. The Department may exempt certain providers from all or part of the screening requirements when certain providers have been screened, approved and enrolled or revalidated:

By Medicare, or 2. By another state’s Medicaid program within the last 5 years, provided the Department has determined that the state in which the provider was enrolled or revalidated has screening requirements at least as comprehensive and stringent as those for Colorado Medicaid. 8.125.7.F. The Department may deny a Provider’s enrollment or terminate a Provider agreement for failure to comply with screening requirements. 8.125.7.G. The Department may terminate a Provider agreement or deny the Provider's enrollment if the Centers for Medicare and Medicaid Services (CMS) or the Department determines that the provider has falsified any information provided on the application or cannot verify the identity of any provider applicant.

8.125.8 NATIONAL PROVIDER IDENTIFIER FOR ORDERING, PRESCRIBING,

REFERRING 8.125.8.A. As a condition of reimbursement, any claim submitted for a service or item that was ordered, referred, or prescribed for a Medicaid member must contain the National Provider Identifier (NPI) of the ordering, prescribing or referring physician or other professional.

8.125.9 VERIFICATION OF PROVIDER LICENSES 8.125.9.A. If a provider is required to possess a license or certification in order to provide services or supplies in the State of Colorado, then that provider must be so licensed as a condition of enrollment as a Medicaid provider. 8.125.9.B. Required licenses must be kept current and active without any current limitations throughout the term of the agreement.

8.125.10 REVALIDATION 8.125.10.A. Actively enrolled providers must complete all requirements for revalidation at least every 5 years as established by the Department, or upon request from the Department for an off-cycle review. 8.125.10.B. The date of revalidation shall be considered the date that the provider’s application was initially approved plus 5 years, or by an off-cycle request from the Department. 8.125.10.C. If a provider fails to comply with any requirement for revalidation by the deadlines established by Sections 8.125.10.A. or 8.125.10.B., the provider agreement may be terminated. In the event that the provider agreement is terminated pursuant to this section, any claims for dates of service submitted after deadlines established by Sections 8.125.10.A. or 8.125.10.B., are not reimbursable beginning on the day after the date indicated by Section 8.125.10.B.

8.125.11 SITE VISITS 8.125.11.A. All providers designated as “moderate” or “high” categorical risks to the Medicaid program must consent to and pass a site visit before they may be enrolled or re-validated as Colorado Medicaid providers. The purpose of the site visit is to verify that the information submitted to the state department is accurate and to determine compliance with federal and state enrollment requirements. 8.125.11.B. All enrolled providers who are designated as “moderate” or “high” categorical risks must consent to and pass an additional site visit after enrollment or revalidation. The purpose of the site visit is to verify that the information submitted to the state department is accurate and to determine compliance with federal and state enrollment requirements. Post-enrollment or post-revalidation site visits may occur anytime during the five-year period after enrollment or revalidation. 8.125.11.C. All providers enrolled in the Colorado Medicaid program must permit the Centers for Medicare and Medicaid Services (CMS), its agents, its designated contractors, the State Attorney General’s Medicaid Fraud Control Unit or the Department to conduct unannounced on-site inspections of any and all provider locations 8.125.11.D. All site visits shall verify the following information:

Basic Information including business name, address, phone number, onsite contact person, National Provider Identifier (NPI) number and Employer Identification Number, business license, provider type, owner’s name(s), and owner’s interest in other medical businesses.
Location including appropriate signage, utilities that are turned on, the presence of furniture and applicable equipment, and disability access where applicable and where clients are served at the business location.
Employees with relevant training, designated employees who are trained to handle Medicaid billing, where applicable, and resources the provider uses to train employees in Medicaid billing where applicable.
Appropriate inventory necessary to provide services for specific provider type.
Other information as designated by the Department. 8.125.11.E. The Department shall give the provider a report detailing the discrepancies or insufficiencies in the information disclosed by the provider and the criteria the provider failed to meet during the site visit. 8.125.11.F. Providers that are found in full compliance shall be recommended for approval of enrollment or revalidation, subject to other enrollment or revalidation requirements. 8.125.11.G. Providers who meet the vast majority of criteria in Section 8.125.11.D but have small number of minor discrepancies or insufficiencies shall have 60 days from the date of the issuance of the report in Section 8.125.11.E to submit documentation to the Department attesting that the provider has corrected the issues identified during the site visit.
If the provider submits attestation within the 60 day timeframe and has met requirements, then the provider shall be recommended for enrollment or revalidation, subject to the verification of other enrollment or revalidation requirements.
If the provider fails to submit the attestation in Section 8.125.11.G.1 within the 60 day deadline, the Department may deny the provider’s application for enrollment or revalidation.
If the provider submits an attestation within 60 days indicating that the provider is not fully compliant with criteria in Section 8.125.11.D, then the Department may, a. For existing providers, suspend the provider, until the provider demonstrates compliance in a subsequent site visit, conducted at the provider’s expense; or b. For new providers, deny the application and require the provider to restart the enrollment process. 8.125.11.H. When site visits reveal major discrepancies or insufficiencies in the information provided in the enrollment application or a majority of the criteria described in Section 8.125.11.D are not met, the Department shall allow for an additional site visit for the provider.
Additional site visits shall be conducted at the provider’s expense.
The provider shall have 14 days from the date of the issuance of the report listed in Section 8.125.11.E above to request an additional site visit.
The Department shall deny or terminate enrollment or revalidation of any provider subject to Section 8.125.11.G who does not request an additional site visit within 14 days.
If the Department determines that a provider is not in full compliance upon the additional site visit:

a. for a revalidating provider, the Department shall immediately suspend the provider until a subsequent site visit demonstrates provider is in compliance.

b. for an enrolling provider, deny the application and require the provider to restart the enrollment process. 8.125.11.I. The Department shall deny or terminate enrollment or revalidation of any provider who refuses to allow a site visit, unless the Department determines the provider or the provider’s staff refused the on-site inspection in error. The provider must provide credible evidence to the Department that it refused the onsite inspection in error within in 7 days of the date of the issuance of the report in

Section 8.125.11.E. Any provider who does not provide credible evidence to the Department that it refused the on-site inspection in error shall be denied or terminated from enrollment or revalidation. 8.125.11.J. The Department shall deny an application or terminate a provider’s enrollment when an on-site inspection provides credible evidence that the provider has committed Medicaid fraud. 8.125.11.K. The Department shall refer providers in Section 8.125.11.J to the State Attorney General.

8.125.12 CRIMINAL BACKGROUND CHECKS AND FINGERPRINTING 8.125.12.A. As a condition of provider enrollment, any person with an ownership or control interest in a provider designated as “high” categorical risk to the Medicaid program, must consent to criminal background checks and submit a set of fingerprints, in a form and manner to be determined by the Department. 8.125.12.B. Any provider, and any person with an ownership or control interest in the provider, must consent to criminal background checks and submit a set of fingerprints, in a form and manner designated by the Department, within 30 days upon request from the Centers for Medicare and Medicaid Services (CMS), the Department, the Department’s agents, or the Department’s designated contractors.

8.125.13 APPLICATION FEE 8.125.13.A. Except when exempted in Sections 8.125.13.C and 8.125.13.D, enrolling and re-validating providers must submit an application fee or a formal request for a hardship exemption with their application. 8.125.13.B. The amount of the application fee is the amount calculated by the Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR § 424.514(d). 42 CFR § 424.514(d) (2024) is hereby incorporated by reference.

The incorporation of 42 CFR § 424.514(d)(2024) excludes later amendment to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17 Avenue, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart- P/section-424.514. 8.125.13.C. Application fees shall apply to all providers except:

Individual practitioners 2. Providers who have enrolled or re-validated in Medicare and paid an application fee 3. Providers who have enrolled or re-validated in another State’s Medicaid or Children’s Health Insurance Program and paid an application fee provided that the Department has determined that the screening procedures in the state in which the provider is enrolled are at least as comprehensive and stringent as the screening procedures required for enrollment in Colorado Medicaid. 8.125.13.D. The Department may exempt a provider, or group of providers, from paying the applicable application fee, through a hardship exemption request or categorical fee waiver, if:
The Department determines that requiring a provider to pay an application fee would negatively impact access to care for Medicaid clients, and 2. The Department receives approval from the Centers for Medicare and Medicaid Services to exempt the application fee. 8.125.13.E. A provider may not be enrolled or revalidated unless the provider has either paid any applicable application fee or obtained an exemption described at

Section 8.125.13.D. 8.125.13.F. The application fee is non-refundable, except if submitted with one of the 1. A request for hardship exemption described at Section 8.125.13.D, that is subsequently approved;

An application that is rejected prior to initiation of screening processes;
An application that is subsequently denied as a result of the imposition of a temporary moratorium as described at Section 8.125.14.

8.125.14 TEMPORARY MORATORIA 8.125.14.A. In consultation with the Centers for Medicare and Medicaid Services (CMS) and the United States Department of Health and Human Services (HHS), the Department may impose temporary moratoria on the enrollment of new providers or provider types, or impose numerical caps or other limits on providers that the Department and the Secretary of HHS identify as being a significant potential risk for fraud, waste, or abuse, unless the Department determines that such an action would adversely impact Medicaid members’ access to medical 8.125.14.B. Before imposing any moratoria, caps, or other limits on provider enrollment, the Department shall notify the Secretary of the United States Department of Health and Human Services (HHS) in writing and include all details of the moratoria. 8.125.14.C. The Department shall obtain the Secretary of the United States Department of Health and Human Services (HHS) concurrence with imposition of the moratoria, caps, or other limits on provider enrollment, before such limits shall take effect.

8.125.15 DISCLOSURES BY MEDICAID PROVIDERS, MANAGED CARE

ENTITIES, MEDICARE PROVIDERS AND FISCAL AGENTS 8.125.15.A. All providers, disclosing entities, fiscal agents, and managed care entities must provide the following federally required disclosures to the Department:

The name and address of any entity (individual or corporation) with an ownership or control interest in the disclosing entity, fiscal agent, or managed care entity having direct or indirect ownership of 5 percent or more. The address for corporate entities must include, as applicable, primary business address, every business location, and P.O. Box address.
For individuals: Date of birth and Social Security number 3. For business entities: Other tax identification number for any entity with an ownership or control interest in the disclosing entity (or fiscal agent or managed care entity) or in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a 5 percent or more interest.
Whether the entity (individual or corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or managed care entity) is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling; or whether the entity (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a 5 percent or more interest is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling.
The name of any other disclosing entity (or fiscal agent or managed care entity) in which an owner of the disclosing entity (or fiscal agent or managed care entity) has an ownership or control interest.
The name, address, date of birth, and Social Security Number of any managing employee of the disclosing entity (or fiscal agent or managed care entity).
The identity of any person who has an ownership or control interest in the provider, or is an agent or managing employee of the provider who has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, Children’s Health Insurance Program or the Title XX services since the inception of these programs.
Full and complete information about the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12 month period ending on the date of the request; and any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request.
Full and complete identifying information about any and all affiliations that a provider or any of its owning or managing employees or organizations has or, within the previous 5 years, had with a currently or formerly enrolled Medicare, Medicaid, or Children’s Health Insurance Program provider or supplier that has a disclosable event as defined at 42 C.F.R. § 455.101 (2024). 42 C.F.R. § 455.101 is hereby incorporated by reference.

The incorporation of 42 C.F.R. § 455.101 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.ecfr.gov. Full and complete identifying information includes:

a. Legal name as reported to the Internal Revenue Service or the Social Security Administration b. “Doing business as” name (if applicable)

c. Tax identification number d. National Provider Identifier (NPI)

e. Reason for disclosing the affiliated provider or supplier f. Specific data regarding the affiliation relationship, including:

i. Length of relationship ii. Type of relationship iii. Degree of affiliation g. Reason for termination, if the affiliation has ended 8.125.15.B. Disclosures from any provider or disclosing entity are due at any of the following times:

Upon the provider or disclosing entity submitting the provider application.
Upon the provider or disclosing entity executing the provider agreement.
Upon request of the Department during revalidation.
Within 35 days after any change in ownership of the disclosing entity. 8.125.15.C. Disclosures from fiscal agents are due at any of the following times:
Upon the fiscal agent submitting its proposal in accordance with the State's procurement process.
Upon the fiscal agent executing a contract with the State.
Upon renewal or extension of the contract.
Within 35 days after any change in ownership of the fiscal agent. 8.125.15.D. Disclosures from managed care entities are due at any of the following times:
Upon the managed care entity submitting its proposal in accordance with the State's procurement process.
Upon the managed care entity executing a contract with the State.
Upon renewal or extension of the contract.
Within 35 days after any change in ownership of the managed care entity. 8.125.15.E. The Department will not reimburse any claim from any provider or entity or make any payment to an entity that fails to disclose ownership or control information as required by 42 CFR § 455.104. 42 CFR § 455.104 (2024) is hereby incorporated by reference. The incorporation of 42 CFR § 455.104 (2024) excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17 Avenue, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at https://www.ecfr.gov/current/title-42/chapter- IV/subchapter-C/part-455/subpart-B/section-455.104. The Department will not reimburse any claim from any provider or entity or make any payment to an entity that fails to disclose information related to business transactions as required by 42 CFR § 455.105 beginning on the day following the date the information was due and ending on the day before the date on which the information was supplied. 42 CFR § 455.105 (2024) is hereby incorporated by reference. The incorporation of 42 CFR § 455.105 (2024) excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17 Avenue, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart- B/section-455.105. Any payment made to a provider or entity that is not reimbursable in accordance with this section shall be considered an overpayment. 8.125.15.F. The Department may terminate the agreement of any provider or entity or deny enrollment of any provider that fails to disclose information when requested or required by 42 CFR § 455.100-106. 42 CFR § 455.100-106 (2024) is hereby incorporated by reference. The incorporation of 42 CFR § 455.100-106 (2024) excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17 Avenue, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at https://www.ecfr.gov/current/title-42/chapter- IV/subchapter-C/part-455/subpart-B/section-455.106.

8.126 COLORADO NPI RULE 8.126.1 Definitions A. Billing Provider Field means the data field on a Claim that reflects the Health Care Provider to which the payer issues payment.

B. Campus means the physical area immediately adjacent to the Hospital’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis by the Centers of Medicare and Medicaid Services to be part of the provider's campus.

C. Claim means a request for payment for the delivery of medical care, services, or goods authorized under the Medical Assistance Program, submitted to the Department through its fiscal agent by a Health Care Provider. Claim includes the transmission of encounter information for the purpose of reporting the delivery of medical care, services, or goods.

D. Health Care Provider means any person or organization that furnishes, bills for, or is paid for medical care, services, or goods to one or more Medical Assistance Program members.

A Health Care Provider includes an Organization Health Care Provider,

Subpart of an Organization Health Care Provider, Off Campus Location, and a Site of an Organization Health Care Provider.

Unless specified otherwise in Subsection 8.126.1, a Health Care Provider may include a Health Care Provider located outside the state of Colorado (out-of-state provider) that is licensed and/or certified pursuant to their state laws.

E. Hospital means an Organization Health Care Provider that is enrolled in the Medical Assistance Program under the Provider Type of “Hospital - General” as defined in this Subsection 8.126.1.

F. Medical Assistance Program means the programs authorized under Articles 4, 5, 6, 8, and 10 of Title 25.5.

G. National Provider Identifier (NPI) means the standard, unique health identifier for Health Care Providers or Organization Health Care Providers that is used by the National Plan and Provider Enumeration System (NPPES) in accordance with 45 C.F.R. sec. 162.406. 45 CFR sec. 162.406 (2024) is hereby incorporated by reference. The incorporation of 45 CFR sec. 162.406 (2024) excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E.

Avenue, Denver, CO 80203, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at https://www.ecfr.gov/current/title- 45/subtitle-A/subchapter-C/part-162/subpart-D/section-162.406.

H. Off-Campus Location means a facility that:

Has operations that are directly or indirectly owned or controlled by, in whole or in part, or affiliated with, a Hospital, regardless of whether the operations are under the same governing body as the Hospital;
Is not on the Hospital’s Campus;
Provides services that are organizationally and functionally integrated with the Hospital;
Is an outpatient facility providing preventive, diagnostic, treatment, or emergency services; and 5. Is identified on the Hospital’s State License Addendum issued by the Colorado Department of Public Health and Environment or, for Hospitals licensed outside of Colorado, documentation demonstrating direct or indirect ownership or control of the Off-Campus Location.

I. Organization Health Care Provider means a Health Care Provider that is not an J. Provider Type means a classification of Health Care Provider or Organization Health Care Provider to which the payer issues payment for services provided to individuals enrolled in the Medical Assistance Program, according to the Provider Type license, accreditation, certification, and/or service provided. The Provider Types recognized by the Department are as follows:

Administrative Services Organization (ASO) is an entity that has entered into a valid, active contract to provide ASO services with the Colorado Department of Health Care Policy and Financing.
Adult Mental Health Residential means a facility licensed as a Behavioral Health Entity (BHE) by the Behavioral Health Administration (BHA) with an Adult Mental Health Transitional Living, Level 2 sub-endorsement.
Ambulatory Surgical Center (ASC) means a health care entity that is:

a. Licensed by the Colorado Department of Public Health and Environment as an Ambulatory Surgical Center; and b. Certified by the Centers for Medicare and Medicaid Services to participate in the Medicare program as an Ambulatory Surgical Center.

Audiologist means an individual licensed as an audiologist by the Division of Professions and Occupations within the Colorado Department of Regulatory Agencies.
Behavioral Health Crisis Line means services provided by a call center that has proof of Crisis Line contract(s) with the Behavioral Health Administration (BHA).
Behavioral Health Crisis Services means an agency that is licensed by the Behavioral Health Administration (BHA) to provide crisis services with at least one affiliated licensed practitioner.
Behavioral Health Group means any behavioral health group practice enrolled in the Colorado Medical Assistance Program that has at least one affiliated licensed practitioner.
Behavioral Health Secure Transportation means services provided by an agency that is licensed by a Board of County Commissioners license for secure transportation services for each county of operation and has a Board of County Commissioners vehicle permit for each vehicle.
Behavioral Therapy Clinic means any group practice that has at least one affiliated Behavioral Therapy Individual. The affiliated Behavioral Therapy Individual must be enrolled in the Colorado Medical Assistance Program.
Behavioral Therapy Individual means an individual that:

a. Is nationally certified as a Board-Certified Behavioral Analyst (BCBA); or b. Meets one of the following:

(1) Has a doctoral degree with a specialty in psychiatry, medicine, or clinical psychology and is actively licensed by the State Board of Examiners; and has completed 400 hours of training; and/or has direct supervised experience in behavioral therapies that are consistent with best practice and research on effectiveness for people with autism or other developmental disabilities; or (2) Has a doctoral degree in one of the behavioral or health sciences; and has completed 800 hours of specific training; and/or has experience in behavioral therapies that are consistent with best practice and research on effectiveness for people with autism or other developmental disabilities; or (3) Is nationally certified as a Board-Certified Behavioral Analyst (BCBA); or (4) Has a master’s degree or higher in behavioral or health sciences; and is a licensed teacher with an endorsement of school psychologist; or is a licensed teacher with an endorsement of special education or early childhood special education; or is credentialed as a related services provider (Physical Therapist, Occupational Therapist, or Speech Therapist); and has completed 1,000 hours of direct supervised training or has experience in behavioral therapies that are consistent with best practice and research on effectiveness for people with autism or other developmental disabilities.

Birthing Center means a health care entity licensed as a Birth Center by the Colorado Department of Public Health and Environment. Out-of-state providers are not eligible for enrollment.
Case Management Agency (CMA) means a public or private not-for-profit or for-profit agency that meets all applicable state and federal requirements and is certified by the Department to provide case management services for Home and Community Based Services waivers.
Certified Midwife (CM) means an individual who is:

a. Licensed as a certified midwife by the State Board of Nursing within b. Included within the advanced practice registry as a Certified Midwife (CM) with certification from the American Midwifery Certification Board (AMCB) and a graduate-level education program accredited by the Accreditation Commission for Midwifery Education (ACME).

Certified Registered Nurse Anesthetist (CRNA) means an individual who is:

a. Licensed as a registered nurse by the State Board of Nursing within b. Included within the advanced practice registry as a Certified Registered Nurse Anesthetist (CRNA).

Chiropractor-Qualified Medicare Beneficiary (Chiropractor-QMB) means Chiropractors who are certified as a Qualified Medicare Beneficiary (QMB)

Benefits Only providers through the Centers for Medicare and Medicaid Services and participate as providers in the QMB Program.

Chiropractor means an individual licensed as a chiropractor by the Board of Chiropractic Examiners within the Colorado Department of Regulatory 17. Clinic – Dental means any group practice that has at least one affiliated, licensed dentist or dental hygienist.

a. The affiliated dentist or dental hygienist must be enrolled in the Colorado Medical Assistance Program; and b. A dental practice or clinic must be owned by a licensed dentist except if the dental practice or clinic is a non-profit organization defined as a community health center (also known as a Federally Qualified Health Center or FQHC) or having 50% or more patients determined as low income, or a political subdivision (i.e. city, county, state, etc.); and c. A dental hygiene practice or clinic must be owned by a licensed dentist or licensed dental hygienist except if the dental hygiene practice or clinic is a non-profit organization defined as a community health center (also known as a Federally Qualified Health Center or FQHC) or having 50% or more patients determined as low income, or a political subdivision (i.e. city, county, state, etc.)

Clinic – Practitioner means any group practice that has at least one affiliated, licensed physician, osteopath, optometrist, or podiatrist. The affiliated practitioner must be enrolled in the Colorado Medical Assistance 19. Community Clinic means a health care entity that is:

a. Licensed as a Community Clinic or Freestanding Emergency Department (FSED) by the Colorado Department of Public Health and Environment;

b. Certified by the Centers for Medicare and Medicaid Services to participate in the Medicare program; and c. Owned by a Medicare participating hospital.

Community Health Worker/Community Health Representative means a frontline public health worker who serves as a liaison between health-care providers or social service providers and community members in order to facilitate access to physical, behavioral, or dental health-related services, or services to address social determinants of health, and who improves the quality and cultural responsiveness of health-related service delivery.

Community Health Worker is meant to be an umbrella term for individuals who meet this definition but may go by many names, such as health promoters, community outreach workers, promotores de salud, health navigators, and patient navigators.

Community Mental Health Center (CMHC) means an entity licensed by the Behavioral Health Administration (BHA) as a Behavioral Health Entity (BHE) that has program approval to operate as a CMHC from the BHA.

a. If the Community Mental Health Center (CMHC) delivers substance use disorder services, it shall have an endorsement on its Behavioral Health Entity (BHE) license from the Behavioral Health Administration (BHA) for those services.

Community Support Services Provider means an agency that provides community support services and has at least one affiliated licensed practitioner enrolled in the Colorado Medical Assistance Program.

a. Any agency providing peer services must be licensed by the Behavioral Health Administration (BHA) as a Recovery Support Services Organization.

b. Any agency that provides supportive housing must have a Colorado Department of Local Affairs (DOLA) Division of Housing (DOH)

Memorandum with certification number and approval as a Supportive Housing Provider.

Comprehensive Safety Net Provider means an agency that is licensed by the Behavioral Health Administration (BHA) as a Behavioral Health Entity and has a BHA approval letter as a Comprehensive Provider.
Dental Hygienist means an individual who is licensed as a Dental Hygienist by the Colorado Dental Board within the Colorado Department 25. Dental Therapist means an individual licensed pursuant to § 12-220- 407.2, C.R.S. to carry out all the duties of a dental hygienist and in collaboration with a licensed dentist to provide direct restorations in primary and permanent teeth, extraction of primary teeth and periodontally diseased permanent teeth, perform brush biopsies, place temporary and preformed crowns, repair defective prosthetics, reimplant and stabilize teeth, remove sutures, dispense and administer nonnarcotic analgesics, anti-inflammatories, and antibiotics.
Dentist means an individual who is licensed as a Dentist by the Colorado Dental Board within the Colorado Department of Regulatory Agencies.
Developmental Evaluation Clinic: A clinic approved by the Colorado Department of Public Health and Environment to diagnose and evaluate a child's development in various areas, such as cognitive, motor, language, social-emotional, and adaptive skills.
Dialysis Treatment Clinic [Formerly Known as Dialysis Center] means a health care entity that is:

a. Licensed as a Dialysis Treatment Clinic pursuant to § 25-3-101, C.R.S; and b. Certified by Centers for Medicare and Medicaid Services to participate in the Medicare program as an End-Stage Renal Dialysis Facility (ESRD).

Direct Entry or Certified Professional Midwife means an individual who is:

a. Registered/Licensed as either a direct-entry midwife (DEM) or certified profession midwife (CPM) by the Colorado Department of Regulatory Agencies, pursuant to §§ 12-225-101-109, C.R.S; and b. Includes being overseen by the Director of the Division of Professions and Occupations in the Department of Regulatory Agencies; and for registration/licensing and approval by the Director;

c. Certified Professional Midwives (CPM) are accredited by the Midwifery Education Accreditation Council (MEAC) following completion of an accredited education program in midwifery; or, d. Direct-Entry Midwives/Certified Professional Midwives (DEM/CPM) may utilize apprenticeship programs, followed by their skills, knowledge and education (identified by the National American Registry of Midwives (NARM)) being verified by a qualified preceptor, if they have not completed a Midwifery Education Accreditation Council (MEAC) accredited educational program in midwifery.

Doula is a trained non-medical professional that provides continuous physical, emotional and informational support to birthing individuals before, during and after childbirth.
Federally Qualified Health Center (FQHC) means a health care entity that has been awarded a Section 330 Grant from the Health Resources and Services Administration. A health care entity that has been designated as a “look-alike” is also eligible to be enrolled as an FQHC.
Foreign Teaching Physician means an individual who is licensed as a distinguished foreign teaching physician by the Colorado Medical Board within the Colorado Department of Regulatory Agencies.
Home and Community Based Services (HCBS) means Health First Colorado (Colorado’s Medicaid Program)’s community-based care alternatives to institutional, Long-Term care. Providers enrolling as an HCBS provider shall meet all applicable state and federal requirements to provide HCBS by waiver and specialty type.
Home Health Agency means a health care entity that:

a. Has a Class A Home Care Agency license from the Colorado b. Is certified by the Centers for Medicare and Medicaid Services to participate in the Medicare program as Home Health Agency.

Hospice means a health care entity that is:

a. Licensed as a Hospice by the Colorado Department of Public Health and Environment; and b. Certified by the Centers for Medicare and Medicaid Services to participate in the Medicare program as a Hospice.

Hospital – General means a health care entity that is:

a. Licensed as a General Hospital by the Colorado Department of b. Certified by the Centers for Medicare and Medicaid Services to participate in the Medicare program as a Hospital.

Hospital – Psychiatric [Formerly Known as Hospital - Mental] means a health care entity that is:

a. Licensed as a Psychiatric Hospital by the Colorado Department of b. Certified by the Centers for Medicare and Medicaid Services to participate in the Medicare program as a Psychiatric Hospital.

Independent Laboratory means a laboratory that:

a. Has a current and valid Clinical Laboratory Improvement Amendments (CLIA) certification 39. Indian Health Service – Federally Qualified Health Center (FQHC) means a health care entity that:

a. Is treated by the Centers for Medicare and Medicaid Services as a comprehensive Federally funded health center; and b. Includes an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act or by an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act for the provision of primary health services.

Indian Health Service – Pharmacy means a health care entity that has evidence of participation in the Indian Health Service.
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) [Formerly Known as Nursing Facility – ICF/IID] means a health care entity that is:

a. Licensed as an Intermediate Care Facility for Individuals with Intellectual Disabilities through the Colorado Department of Public Health and Environment 42. Lactation Consultant means an International Board Certified Lactation Consultant (IBCLC) with current certification by the International Board of Lactation Consultant Examiners (IBLCE).

Lactation Counselor/Educator means a health care professional certified as either:

a. A Certified Lactation Counselor (CLC) with current certification by the Academy of Lactation Policy and Practice, Inc. (ALPP); or b. A Certified Lactation Educator (CLE) with current certification by the Childbirth and Postpartum Professional Association (CAPPA).

Lactation/Doula Professional Group means any group practice consisting of any of the following professionals who are enrolled with the Department as approved providers:

a. International Board Certified Lactation Consultant;

b. Doula 45. Licensed Behavioral Health Clinician means an individual that is licensed by the Colorado Department of Regulatory Agencies as either:

a. A Licensed Clinical Social Worker;

b. A Licensed Professional Counselor;

c. A Licensed Marriage and Family Therapist; or d. A Licensed Addiction Counselor.

Licensed Psychologist means an individual who is licensed as a psychologist by the State Board of Psychologist Examiners within the Colorado Department of Regulatory Agencies.
Managed Care Entity [Formerly Known as Health Maintenance Organization (HMO)] means an entity that has a valid and comprehensive or all-inclusive risk contract with the Colorado Department of Health Care Policy and Financing.
Medicare Only Providers means a provider enrolled in the Medical Assistance Program for purposes of Medicare cost-sharing only, pursuant to 42 CFR §455.410(d). 42 CFR §455.410(d) (2024) is hereby incorporated by reference. The incorporation of 42 CFR §455.410(d) excludes later amendments to, or editions of the referenced material.

Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at https://www.ecfr.gov/current/title-42/chapter-IV/subchapter- C/part-455/subpart-E/section-455.410.

Non-Physician Practitioner Group means any group practice consisting of any of the following:

a. Licensed Nurse Practitioners;

b. Licensed Audiologists;

c. Licensed Occupational Therapists;

d. Licensed Behavioral Health Clinicians;

e. Licensed Psychologists;

f. Licensed Speech Therapists g. Licensed Physical Therapists h. Licensed Nurse Midwives; and/or i. Certified Registered Nurse Anesthetists 50. Non-Physician Practitioner Individual means a registered nurse, which means an individual licensed as a Registered Nurse by the State Board of Nursing within the Colorado Department of Regulatory Agencies.

Nurse Midwife means an individual who is:

a. Licensed as a registered nurse by the State Board of Nursing within b. Included within the advanced practice registry as a Nurse Midwife with certification from the American Midwifery Certification Board (AMCB) and a graduate-level education program accredited by the Accreditation Commission for Midwifery Education (ACME).

Nurse Practitioner means an individual who is:

a. Licensed as a registered nurse by the State Board of Nursing within b. Included within the advanced practice registry as a Nurse Practitioner.

Nursing Facility means a health care entity that is:

a. Licensed as a Nursing Care Facility through the Colorado b. Certified by the Centers for Medicare and Medicaid Services or the Colorado Department of Health Care Policy and Financing to participate in the Medicaid program as a Skilled Nursing Care Facility.

Occupational Therapist means an individual who is licensed as an Occupational Therapist by the Director of the Division of Professions and Occupations within the Colorado Department of Regulatory Agencies.
Optical Outlet means a health care supplier that is qualified to make and supply eyeglasses and contact lenses for the correction of vision. If, in the performance of its duties, the Optical Outlet requires laboratory services, the laboratory is required to have a current and valid Clinical Laboratory Improvement Amendments (CLIA) certification.
Optometrist means an individual who is licensed as an Optometrist by the State Board of Optometry within the Colorado Department of Regulatory 57. Osteopath means an individual who holds a degree of “doctor of osteopathy,” and who is licensed as a physician by the Colorado Medical Board within the Colorado Department of Regulatory Agencies.
Personal Care Agency means a health care entity that has a Class A or Class B Home Care Agency license from the Colorado Department of Public Health and Environment.
Pharmacist means an individual who is licensed as a Pharmacist by the State Board of Pharmacy within the Colorado Department of Regulatory 60. Pharmacy means a pharmacy, pharmacy outlet, or prescription drug outlet registered by the Board of Pharmacy within the Colorado Department of Regulatory Agencies.
Physical Therapist means an individual who is licensed as a Physical Therapist by the Physical Therapy Board within the Colorado Department 62. Physician means an individual who is licensed as a physician by the Colorado Medical Board within the Colorado Department of Regulatory 63. Physician Assistant means an individual who is licensed as a physician assistant by the Colorado Medical Board within the Colorado Department 64. Podiatrist means an individual licensed as a podiatrist by the Colorado Podiatry Board within the Colorado Department of Regulatory Agencies.
Psychiatric Residential Treatment Facility (PRTF) means a health care entity that:

a. Is licensed by the Colorado Department of Human Services as a Residential Child Care Facility and a Psychiatric Residential Treatment Facility (PRTF); and b. Is certified as a qualified residential provider by the Department of c. Is accredited by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children; and d. Has provided an attestation to the Department that the Psychiatric Residential Treatment Facility (PRTF) is in compliance with the conditions of participation as required by Colorado Department of Human Services and the Centers for Medicare and Medicaid Services.

Qualified Residential Treatment Program (QRTP) means a facility that has:

a. A time-limited child care License from Department of Early Childhood, Division of Early Learning Licensing and Administration indicating Service Type as: Qualified Residential Treatment Program.

b. Received accreditation by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or Council on Accreditation of Services for Families and Children; and c. For facilities enrolling with Health First Colorado (Residential Child Care Facility (RCCF) & Qualified Residential Treatment Program (QRTP)), a completed attestation form.

Regional Accountable Entity (RAE) means an entity that has entered into a valid, existing contract with the Colorado Department of Health Care Policy and Financing to be a Regional Accountable Entity.
Rehabilitation Agency means a group practice that requires at least one affiliated and licensed professional enrolled in the Colorado Medical Assistance Program.
Residential Child Care Facility (RCCF) means a health care entity that is:

a. Designated by the Colorado Department of Human Services to provide Medicaid-reimbursable mental health services as a Residential Child Care Facility (RCCF); and b. Licensed by Colorado Department of Human Services as a Residential Child Care Facility (RCCF).

Rural Health Clinic (RHC) means a clinic that is certified by the Centers for Medicare and Medicaid Services as a Rural Health Clinic.
School Health Services means a school district or Board of Cooperative Educational Services that has a valid, active contract with the Colorado Department of Health Care Policy and Financing to participate in the Colorado School Health Services Program.

a. The Site at which an Organization Health Care Provider delivers medical care, services, or goods authorized under the Medical Assistance Program enrolled under the Provider Type of School Health Services is a school district.

School Speech Therapist means an individual with a Colorado Department of Education (CDE) Special Services License with a Speech Therapist Endorsement.
Speech Therapist is an individual certified as a Speech Language Pathologist by the Director of the Divisions of Professions and Occupations within the Colorado Department of Regulatory Agencies.
Substance Use Disorder (SUD) continuum means all levels of SUD services as defined by American Society of Addiction Medicine criteria.

SUD services are grouped into outpatient, high intensity outpatient, residential and inpatient hospital levels of care.

Supply means a Durable Medical Equipment, Prosthetic, Orthotic and Supplies (DMEPOS) provider that meets one or both of the following definitions::

a. Complex Rehabilitation Technology (CRT) Supplier means a health care supplier that meets all the requirements of Section 8.590.5.D, and that:

(1) Has a Sales Tax Certificate or Tax-Exempt Certificate;

(2) Has Complex Rehabilitation Technology (CRT) Professional Certification; and (3) Is accredited by the Centers for Medicare and Medicaid Services to provide Durable Medical Equipment, Prosthetic, Orthotic and Supplies (DMEPOS) and Complex Rehabilitation Technology (CRT).

b. Durable Medical Equipment (DME) means a health care supplier that meets the requirements of Sections 8.590.5.A and B, and that:

(1) Has a Sales Tax Certificate or Tax-Exempt Certificate; and (2) Is accredited by the Centers for Medicare and Medicaid Services to provide Durable Medical Equipment, Prosthetic, Orthotic and Supplies (DMEPOS).

Transportation means a provider that meets one or both of the following definitions:

a. Emergency Medical Transportation (EMT) [Formerly Known as Emergency Medical Transportation and Air Ambulance] means providers that:

(1) Meet all provider screening requirements in Section 8.125.

(2) Comply with commercial liability insurance requirements.

(3) Maintain the appropriate licensure for:

(a) Ground ambulance license as required by Colorado (b) Air ambulance license as required by Colorado Department of Public Health and Environment.

(4) License, operate, and equip ground and air ambulances in accordance with federal and state regulations.

b. Non-Emergent Medical Transportation (NEMT) means a provider that:

(1) Has a Public Utilities Commission (PUC) common carrier certificate as a taxicab; or (2) Has a ground ambulance license as required by Department of Public Health and Environment; or (3) Has an Air Ambulance license as required by Colorado Department of Public Health and Environment; or (4) Is exempt from licensure requirements in accordance with the Public Utilities Commission (PUC).

X-Ray Facility means an imaging center that:

a. Has an X-Ray Facility and Machine Registration Report certified by the Colorado Department of Public Health and Environment; and b. Is certified by the Centers for Medicare and Medicaid Services to participate in Medicare as an X-Ray facility.

K. Service Facility Location Field means the physical location specifically where services were rendered as identified on the Claim.

L. Site means the physical location by street address, including suite number, where goods and/or services are provided. The term Site when involving a Health Care Provider that voluntarily contracts with a Regional Accountable Entity (RAE) as a Primary Care Medical Provider (PCMP) to participate in the Department’s Accountable Care Collaborative (ACC) as a medical home, also includes the following requirements:

Primary Care Medical Provider (PCMP) services must be identifiable from other goods and/or services, including services provided by specialists provided by the Health Care Provider in the same physical location through a separate and unique National Provider Identifier (NPI).
Primary Care Medical Provider (PCMP) services provided at a Campus or Off-Campus Location must be identifiable from other goods and/or services, including services provided by specialists, provided by the Health Care Provider on the same Campus or Off-Campus Location through a separate and unique National Provider Identifier (NPI).

M. Subpart means a component or separate physical location of an Organization Health Care Provider that may be separately licensed or certified.

N. The definitions in Subsection 8.126.1 apply only to Section 8.126. 8.126.2 Enrollment of Health Care Providers A. Health Care Providers must enroll in the Medical Assistance Program through the Department’s Fiscal Agent, if they:

deliver medical care, services, or goods authorized under the Medical Assistance Program; and 2. are required to submit a Claim. 8.126.3 Health Care Provider Requirements to Obtain and Use a National Provider Identifier (NPI)

A. A Health Care Provider that is required or eligible to obtain a National Provider Identifier (NPI) pursuant to 45 C.F.R. § 162.410 must:

Enroll with a unique National Provider Identifier (NPI) that identifies the Health Care Provider that delivers medical care, services, or goods authorized under the Medical Assistance Program; and 2. Utilize the Health Care Provider’s unique National Provider Identifier (NPI) for all Claims.

a. A Health Care Provider that is not enrolled as of January 1, 2020, must submit every Claim using the unique National Provider Identifier (NPI) used for enrollment that identifies both the Provider Type and Site effective for date-of-services on or after January 1, 2020.

b. All Off Campus Locations must submit every Claim using the unique National Provider Identifier (NPI) used for enrollment that identifies both the Provider Type and Site effective for date-ofservices on or after January 1, 2020.

c. All Health Care Providers must submit every Claim using the unique National Provider Identifier (NPI) used for enrollment that identifies both the Provider Type and Site effective for date-ofservices on or after January 1, 2021.

d. On every Claim, including Coordination of Benefits Agreement (COBA) automatic crossover Claims, the Organization Health Care Provider shall use the Service Facility Location Field to represent the most specific Site with a National Provider Identifier (NPI) where the services are rendered unless the Billing Provider Field represents the most specific Site with an NPI where the services are rendered. 8.126.4 Organization Health Care Provider Requirements to Obtain and Use a National Provider Identifier (NPI)

A. Each Organization Health Care Provider and each Subpart of an Organization Health Care Provider that is required or eligible to obtain an NPI pursuant to 45 C.F.R. § 162.410 must enroll using a unique National Provider Identifier (NPI).

Each Organization Health Care Provider must enroll using its unique National Provider Identifier (NPI) for each Site at which the Organization Health Care Provider delivers medical care, services, or goods authorized under the Medical Assistance Program.

a. A Hospital must enroll in the Medical Assistance Program with a unique National Provider Identifier (NPI) for:

(1) Its Campus; and (2) Each Off-Campus Location.

Each Organization Health Care Provider must enroll in the Medical Assistance Program using a unique National Provider Identifier (NPI) for each Provider Type at each Site from which the Organization Health Care Provider delivers medical care, services, or goods authorized under the a. A Hospital must enroll with a unique National Provider Identifier (NPI) for each Provider Type at each Site at its Campus and at each Off-Campus Location at which it delivers medical care, services, or goods authorized under the Medical Assistance 3. An Organization Health Care Provider that is a School Health Services provider type must enroll once per School District and not each individual Site. 8.126.5 Health Care Provider Requirements Not Eligible to Receive a National Provider Identifier (NPI)

A. A Health Care Provider that is not eligible pursuant to 45 C.F.R. § 162.410 to receive a National Provider Identifier (NPI) shall:

Enroll without submitting a National Provider Identifier (NPI). The Health Care Provider must obtain a unique identification number assigned by the Department through its Fiscal Agent, that identifies both the unique Provider Type at each Site at which the Health Care Provider delivers medical care, services or goods authorized under the Medical Assistance Program; and 2. Use the unique identification number assigned by the Department through its Fiscal Agent on every Claim.

a. A Health Care Provider that is not eligible to obtain a National Provider Identifier (NPI) that is not enrolled as of January 1, 2020, must submit every Claim using the unique identification number used for enrollment that identifies both the Provider Type and Site, effective January 1, 2020.

b. All Health Care Providers that are not eligible to obtain a National Provider Identifier (NPI) must submit every Claim using the unique identification number used for enrollment that identifies both the Provider Type and Site, effective January 1, 2021. 8.126.6 New Providers as of January 1, 2020 A. A Health Care Provider that is not enrolled as of January 1, 2020, shall not apply to be enrolled to deliver medical care, services, or goods authorized under the Medical Assistance Program unless the Health Care Provider complies with

Section 8.126. 8.126.7 Existing Providers as of January 1, 2021 A. A Health Care Provider that is enrolled as of January 1, 2021, shall not apply to have their enrollment revalidated to deliver medical care, services, or goods authorized under the Medical Assistance Program, as required under 42 C.F.R. § 455.414, unless the Health Care Provider complies with Section 8.126.

8.130 PROVIDER PARTICIPATION

Providers will not discriminate on the basis of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or disability.

8.130.1 DEFINITIONS

A. “Advanced Directive” means a written instruction, such as a Living Will or Durable Power of Attorney for health care, recognized under state law, whether statutory or as recognized by the courts of the state, that relates to the provision of medical care when the individual is incapacitated.

B. "Agent" means any person who has been delegated the authority to obligate or act on behalf of a Provider.

C. “Change of Information” means any change in information contained in the Provider’s current enrollment record with the Department, including, but not limited to, any change to a person or entity who holds a direct or indirect ownership interest in the Provider exceeding five percent and any change to the Provider’s licensure, certification registration status, accreditation, bankruptcy status, address (including any change to location(s) where good and services are rendered), contact person, telephone number, email address, or criminal conviction disclosures within the scope of 42 CFR § 455.106.

D “Change of Ownership” means that a Provider has been issued a new tax identification number.

E. “Colorado Department of Health Care Policy and Financing” or “Department” means the Colorado State governmental agency responsible for the administration of the Medical Assistance Program, , Child Health Plan Plus, the old age pension health and medical care program, and the supplemental old age pension health and medical care program pursuant to Title XIX of the Social Security Act and Title 25.5 of the Colorado Revised Statutes.

F. “Inactivation” means a Provider’s billing privileges have been stopped but can be restored upon resolution of the basis of inactivation.

G. “Provider” means any person, public or private institution, agency, or business concern enrolled under the state Medical Assistance Program to provide medical care, services, or goods, and holding, where applicable, a current valid license or certificate to provide such services or to dispense such goods.

H. “Requesting Agency” means the US Department of Health and Human Services or its designees, the Department or its designees, the Colorado Department of Human Services or its designees, or the Medicaid Fraud Control Unit or its designees, acting through their representatives who have written or other authorization to act on behalf of these agencies.

8.130.2 MAINTENANCE OF RECORDS

A. Each Provider shall:

Maintain legible, complete, and accurate records necessary to establish that conditions of payment for Medical Assistance Program covered goods and services have been met, and to fully disclose the basis for the type, frequency, extent, duration, and delivery of goods and/or services provided to Medical Assistance Program members, including but not limited to:

a. Billings, b. Prior authorization requests, c. All medical records, service reports, and orders prescribing treatment plans, d. Records of goods prescribed, ordered for, or furnished to, members, and unaltered copies of original invoices for such items, e. Records of all payments received from the Medical Assistance Program, and f. Records required elsewhere in Section 8.000 et seq.

The records shall be created at the time the goods or services are provided.

B. Records of Providers shall include employment records, including but not limited to shift schedules, payroll records, and time-cards of employees.

C. Providers who issue prescriptions shall keep in the patient's record, the date of each prescription and the name, strength, and quantity of the item prescribed.

D. Records must be maintained for seven (7) years unless an additional retention period is required elsewhere in Section 8.000 et seq., or in an individual Provider participation agreement.

E. Each Provider shall retain any other records created in the regular operation of business that relate to the type and extent of goods and/or services provided (for example, superbills). All records must be legible, verifiable, and must comply with generally accepted accounting principles, auditing standards, and all applicable state and federal laws, rules, and regulations.

F. Each entry in a medical record must be signed and dated by the individual providing the medical service or good. Stamped signatures are not acceptable.

G. Providers utilizing electronic record-keeping may apply computerized signatures and dates to a medical record if their record-keeping systems guarantee the following security measures:

Restrict application of an electronic signature to the specific individual identified by the signature. System security must prevent one person from signing another person's name.
Prevent alterations to authenticated (signed and dated) records. If the Provider chooses to supplement a previous entry, the system must only allow a new entry that explains the supplement. The Provider must not be allowed to change the initial entry.
Printed or displayed electronic records must note that signatures and dates have been applied electronically.

H. At the discretion of the Requesting Agency, record verification may include, but will not be limited to, interviews with Providers, employees of Providers, billing services that bill on behalf of Providers, and any member of a corporate structure that includes the Provider as a member.

8.130.3 ADVANCE DIRECTIVES

A. Providers shall provide adult Medical Assistance Program members with written information about the individual's rights under state law to accept or refuse medical treatment, the right to formulate advance directives, and the Providers' policies regarding the implementation of such rights as follows:

Hospitals, at the time of the individual's admission as an inpatient.
Nursing facilities, at the time of the individual's admission as a resident.
Providers of home health care or personal care services, in advance of the individual coming under the care of the Provider.
Hospice programs, at the time of initial receipt of hospice care by the individual from the program.
Health maintenance organizations, at the time of enrollment of the individual with the organization.

B. The Provider shall maintain written policies and procedures with respect to all adult individuals receiving medical or personal care by or through the Provider, which shall include:

Documentation in the individual's medical records indicating whether the individual has executed an advance directive.
Documentation that the individual will not be discriminated against, nor will the provision of care be conditioned on whether he/she has executed an advance directive.
Documentation ensuring compliance with requirements of state law respecting advanced directives.
Documentation in the individual's medical record substantiating the Provider's reason(s) for non-compliance with an advance directive based on conscience or professional ethics.

C. Providers shall provide education for staff and the patient/member community on issues concerning advance directives.

8.130.35 SCREENING FOR EXCLUDED EMPLOYEES AND CONTRACTORS

A. As a condition of enrollment and participation in the Medical Assistance Program, each Provider shall comply with the following requirements for screening for employees and contractors who have been excluded from participation in Medicaid and Medicare by the US Department of Health & Human Services Office of Inspector General:

Each Provider shall utilize the US Department of Health & Human Services Office of Inspector General’s List of Excluded Individuals/Entities (www.oig.hhs.gov) to determine if a prospective employee or newly signed contractor has been excluded from participation in a Medical Assistance a. Such screening should be performed within five (5) business days of the date on which the new employee was hired or new contract was signed.
Each Provider shall screen its employees and contractors against the List of Excluded Individuals/Entities at least monthly to capture any exclusions or reinstatements that have occurred since the last search of the database.
If a Provider determines that an employee or contractor of the Provider has been excluded, then the Provider shall report this to the Department within five (5) business days of the date of discovery.
Each screening must be documented in a manner that can be provided to the Department upon request.

B. Except as otherwise provided in federal law, if the Medical Assistance Program pays for any goods or services furnished, ordered, or prescribed by an excluded individual or entity that is employed by or has contracted with a Provider, such payment shall constitute an overpayment and shall be subject to overpayment recovery, pursuant to Section 8.076. Such Provider may also be subject to sanctions by the Department, including the termination of the Provider agreement, as described at 8.076.5., if the Provider knew or should have known of the exclusion. The Provider may also be subject to civil and monetary penalties imposed by the US Department of Health and Human Services.

To the extent that such amount can be traced, the amount of the overpayment shall include any funds expended by the Medical Assistance Program to pay the excluded individual’s or contractor’s salary, expenses, or fringe benefits.

C. Subject to federal law and the Department’s discretion, failure of a Provider to comply with the screening requirements listed at Section 8.130.35.A. may constitute good cause sufficient to justify termination of the Provider agreement, as described at 8.076.5.

8.130.40 PROVIDER EMPLOYEE OR CONTRACTOR LICENSE VERIFICATION

A. As a condition of participation in the Medical Assistance program, any Provider who provides or who has employees or contractors who provide services or supplies must ensure that, at the time services or supplies are provided, the Provider, the employee, or the contractor possesses the license, certification, or credential that is required in the State of Colorado to provide such services or supplies.

8.130.45 REPORTING CHANGES

A. Within thirty-five (35) calendar days, Provider shall update the provider portal of the Department’s Medicaid Management Information System (MMIS) with any Change of Information or Change in Ownership.

B. Failure by the Provider to notify the Department of any Change of Information or Change in Ownership in accordance with section 8.130.45.A.:

May result in the denial, suspension, inactivation, or termination of the Provider agreement or contract.
Does not exempt a Medical Assistance Program Provider from compliance with 10 CCR 2505-3 and 10 CCR 2505-10.

8.130.50 REQUIREMENT TO VERIFY ENROLLMENT OF MEMBER AT TIME OF

SERVICE

A. A Provider shall verify and document that the member is enrolled in the applicable Medical Assistance Program at the time the service is rendered.

B. A Provider shall verify that payments received are for medically necessary goods and services that were actually rendered, and that claims and encounters submitted for payment are true and correct.

8.130.60 PROVIDERS ARE RESPONSIBLE FOR ALL CLAIMS SUBMITTED

A. A Provider shall accept full legal responsibility for all claims submitted under the Provider’s Medical Assistance Program ID number to the Medical Assistance Program, whether submitted by the Provider or submitted on the Provider’s behalf.

A Provider shall comply with all federal and state civil and criminal statutes, regulations, and rules relating to the delivery of goods and services to eligible individuals, and to the submission of claims for such goods and services. A Provider’s non-compliance may result in no payment for goods and services rendered.

B. A Provider shall furnish to the Department its National Provider Identifier (NPI) (if eligible for an NPI) and include the NPI on all claims submitted pursuant to Sections 8.125.8 and 8.126.3.

C. A Provider shall request payment only for those goods and services which are medically necessary, as such term is defined in Section 8.076.1.8. and in any other subsection of these rules defining medical necessity, and which are rendered personally by the Provider or rendered by qualified personnel under the Provider’s direct and personal supervision.

A Provider shall submit claims only for those goods and services provided by health care personnel who meet the professional qualifications established by the State.
Any misrepresentation or falsification of a claim submitted by a Provider, or on a Provider’s behalf, may subject the Provider to fines and/or imprisonment under state or federal law.

D. If at any time the Department determines that a Provider has failed to maintain compliance with any state or federal laws, rules, or regulations, the Provider may be suspended from participation in the Medical Assistance Program, and may be subject to administrative actions authorized by federal or state law or regulation, criminal investigation, and/or prosecution.

8.130.70 COMPLIANCE WITH GUIDANCE

A. Providers must comply with all state and federal statutes, rules, regulations, and guidance.

B. Guidance includes, but is not limited to:

Department Billing Manual 2. Department Provider Bulletins 3. Department Memo Series 4. Uniform Service Coding Standards 5. Current Procedural Terminology (CPT) code set 6. Current Healthcare Common Procedure Coding System (HCPCS)
Current International Classification of Diseases (ICD))

C. Failure to comply may subject the Provider to authorized administrative actions, civil investigation, and criminal investigation.

8.130.80 INACTIVATING PROVIDER AGREEMENTS

A. A Provider may have its Provider Participation Agreement inactivated and will no longer be able to bill for goods and services if any of the following occur:

The Provider’s license, certification, or accreditation has expired or is subject to conditions or restrictions.
The Provider has failed to complete Provider revalidation.
The Provider is no longer eligible to participate as a Medical Assistance Program Provider or breaches the Provider agreement.
There is a Change of Ownership.
The Provider’s business closes, or the business is nonoperational.
The Provider is deceased or retired.
The Provider is inactive and has not submitted any claims activity for 24 months.

B. The Provider will be sent written notice thirty (30) days prior to the inactivation, unless otherwise required by federal or state statute, regulation, or rule.

The notice will detail the reason for the inactivation.
The notice will give the Provider the opportunity to dispute the inactivation.

C. If the Provider elects to dispute the inactivation, the Department must receive the Provider’s written request to dispute the inactivation within thirty (30) calendar days of the date of the inactivation notice.

D. The Department will review the request and issue a determination on the inactivation which will include the Provider’s right to file an appeal in accordance with Section 8.050.

E. The effective date of the inactivation may be backdated to the date of the occurrence described in Section 8.130.80.A.

8.170 STATE IDENTIFICATION NUMBER .10 As medical assistance is administered on an individual recipient basis, rather than on a household basis, the individual recipient is uniquely identified. A state assigned number is used for this purpose. This state identification number consists of an alpha (letter) prefix, followed by a six-digit number. When an individual is approved for medical assistance, the state identification number is assigned. This number is transmitted to the county department via the automated system. .20 The State Identification Number is the only numeric designation medical assistance providers will have, other than the name, to identify individuals. This number is required to be entered on all billing transactions.

In order to carry out this responsibility for facilitating provision of medical benefits to recipients, to properly respond to inquiries from providers, to secure benefits of medical resources other than Medicaid (see 8.061 et seq.), and for other administrative purposes, county departments are to maintain cross reference files of household and medical identification numbers.

8.180 MEDICAL IDENTIFICATION CARDS AND DURATION OF ELIGIBILITY

8.181 IDENTIFICATION .10 The state department will issue identification cards directly to clients who are eligible for benefits under a medical assistance program. .20 The providers of benefits in the Department's medical assistance programs are instructed to use the identifying information to access an automated eligibility database to obtain the client's current or previous eligibility for medical assistance for a given date of service.

8.182 MEDICAL IDENTIFICATION CARD

Each eligible client shall have a medical identification card issued from the state department's office to obtain medical services.

8.183 INSTRUCTIONS FOR HANDLING UNDELIVERED MEDICAL IDENTIFICATION

CARDS

The Post Office returns all undelivered Medical Identification Cards to the county departments when recipients are deceased, no longer at that address, etc. The following steps will be taken to assure delivery of cards to the recipient.

A. If the address shown in the envelope window is incorrect or no longer valid, the county departments are not to make the address change for remailing on the returned envelope. Counties are to open the envelope, paste a white sticker over the incorrect address, type in the correct address, use a separate envelope with the corrected address, insert the Medical Identification Card Mailer, and remail the card and its carrier to the client's new (correct) address. (This includes out-of-state moves if the client remains eligible.)

B. Counties shall immediately correct the address on the automated system.

C. If the recipient is deceased, the county shall destroy the identification card and make appropriate change in the eligibility system.

8.190 ACUTE MEDICAL BENEFITS DETERMINATION 8.190.1 A client or provider may request a coverage determination for new acute medical benefits or services by submitting a written request to the Department. 8.190.1.A. Written requests shall include documentation on all the following criteria regarding the benefit or service:

Prescribed by a doctor of medicine or osteopathy, or an optometrist, dentist or podiatrist acting within the scope of their respective licenses;
A reasonable, appropriate and effective method for meeting the medical need;
The expected use is in accordance with current medical standards or practices;
Proven cost effective method of treatment;
Does not result in an unsafe environment or situation;
Not experimental, investigational and is accepted by the medical community as standard practice;
Primary purpose is not to enhance personal comfort or convenience; and 8. Considered to be medically necessary for the diagnosis. 8.190.2 The requestor shall be notified in writing of the Department's decision regarding coverage.

Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.200 MEDICAL ASSISTANCE - SECTION 8.200 Physician Services, Dental, Vision Services, Medicaid Managed Care Program, EPSDT {#sec-10-ccr-2505-10-8.200 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.200}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE – SECTION 8.200 PHYSICIAN SERVICES, DENTAL, VISION SERVICES, MEDICAID MANAGED CARE PROGRAM, EPSDT 10 CCR 2505-10 8.200 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

8.200 PHYSICIAN SERVICES 8.200.1.A Definitions 1. Advanced Practice Nurse means a provider that meets the requirements to practice advanced practice nursing as defined in Article 255 of Title 12 of the Colorado Revised Statutes. In Colorado an Advanced Practice Nurse may have prescriptive authority.

Certified Family Planning Clinic means a family planning clinic certified by the Colorado Department of Public Health and Environment, accredited by a national family planning organization and staffed by medical professionals licensed to practice in the State of Colorado, including but not limited to, doctors of medicine, doctors of osteopathy, physicians’ assistants, and advanced practice nurses.
Direct Supervision means the supervising provider shall be on-site during the rendering of services and immediately available to give assistance and direction throughout the performance of the service.
General Supervision means the supervising provider may not be on-site during the rendering of services, but is immediately available via telephonic or other electronic means to give assistance and direction throughout the performance of the service. Health Education Services means the provision of counseling, referral, instruction, suggestions, and support to maintain or improve health.
Licensed Psychologist means a provider that meets the requirements to practice psychology as defined in Part 3 of Article 245 of Title 12 of the Colorado Revised Statutes.
Medical Necessity is defined in Section 8.076.1.8. 8.200.2 Providers 8.200.2.A. A doctor of medicine or a doctor of osteopathy may order and provide all medical care goods and services within the scope of their license that are covered benefits of the Colorado Medical Assistance Program.
A provider of covered dental care surgery may be enrolled as either a dentist or oral surgeon, but not as both. A dentist may order and provide covered dental care. 8.200.2.B. Physician services that may be provided by non-physician providers without a physician order.
Advanced Practice Nurses may provide and order covered goods and services in accordance with the scope of practice as described in the Colorado Department of Regulatory Agencies rules without a physician order.
Licensed Psychologists may provide and order covered mental health goods and services in accordance with the scope of practice as described in the Colorado Department of Regulatory Agencies rules without a physician order.

a. Services ordered by a Licensed Psychologist but rendered by a non-licensed mental health provider must be signed and dated by the Licensed Psychologist contemporaneously with the rendering of the service by a non-licensed mental health provider.

Optometrists may provide covered optometric goods and services within their scope of practice as described by the Colorado Department of Regulatory Agencies rules without a physician order.
Podiatrists may provide covered foot care services within their scope of practice as described by the Colorado Department of Regulatory Agencies rules without a physician order.
Licensed dental hygienists may provide unsupervised covered dental hygiene services in accordance with the scope of practice for dental hygienists as described in the Colorado Department of Regulatory Agencies rules without a physician order.
Licensed pharmacists may provide covered services, in accordance with the scope of practice for pharmacists as described by the Colorado Department of Regulatory Agencies rules, without a physician order. 8.200.2.C. Physician services that may be provided by a non-physician provider when ordered by a provider acting under the authority described in Sections 8.200.2.A. and 8.200.2.B.
Registered occupational therapists, licensed physical therapists, licensed audiologists, certified speech-language pathologists, and licensed physician assistants may provide services ordered by a physician.

a. Services must be rendered and supervised in accordance with the scope of practice for the non-physician provider described in the Colorado Department of Regulatory Agencies rules. 8.200.2.D. Physician services that may be provided by a non-physician provider when supervised by an enrolled provider.

With the exception of the non-physician providers described in Sections 8.200.2.A. through 8.200.2.C. and 8.200.2.D.1., a non-physician provider may provide covered goods and services only under the Direct Supervision of an enrolled provider who has the authority to supervise those services, according to the Colorado Department of Regulatory Agencies rules. If Colorado Department of Regulatory Agencies rules do not designate who has the authority to supervise, the non-physician provider must provide services under the Direct Supervision of an enrolled physician, with exception of doulas and Lactation Consultants (IBCLCs).

a. Registered Nurses (RNs) are authorized to provide delegated medical services within their scope of practice as described in § 12- 255-104 (10)-(11), C.R.S. under General Supervision.

b. Non-physician providers are authorized to provide Health Education Services under General Supervision of a provider who has the

authority to supervise them in accordance with Colorado Department of Regulatory Agencies rules. Community Health Workers (CHWs)/Community Health Representatives (CHRs) are authorized to provide health education services without supervision.

c. Physical therapy assistants, occupational therapy assistants, and speech language pathology clinical fellows are authorized to provide services within their scope of practice, and under the General Supervision of an enrolled provider who has the authority to supervise them, in accordance with Colorado Department of Regulatory Agencies rules.

d. Speech language pathology assistants are authorized to provide services within their scope of practice only under the Direct Supervision of a licensed speech language pathologist who has the

authority to supervise them, in accordance with Colorado Department of Regulatory Agencies rules.

e. Certified Midwives (CMs) and Certified Professional Midwives/Direct Entry Midwives (CPMs/DEMs) registered with DORA are authorized to provide home births without Direct Supervision. 8.200.2.E. Licensure and required certification for all physician services providers must be in accordance with their specific specialty practice act and with current state licensure statutes and regulations. 8.200.2.F Requirements for outpatient physical therapy, occupational therapy, audiology and speech-language pathology services.

Plan of Care a. A Physician (MD/DO), Advanced Practice Nurse (APN), or Physician Assistant (PA) who has knowledge of the case does not need to sign the certification of the Plan of Care if:

i. A physical therapist, occupational therapist, or speechlanguage pathologist established the Plan of Care; and ii. The member’s Physician (MD/DO), Advanced Practice Nurse (APN), Physician Assistant (PA) issued an order or referral maintained in the member’s medical record; and iii. The therapist has documented evidence that the Plan of Care has been delivered to the Physician (MD/DO), Advanced Practice Nurse (APN), or Physician Assistant (PA) within 30 days of completion of the initial evaluation.

8.200.3. BENEFITS 8.200.3.A Physician services are reimbursable when the services are a benefit of Medicaid and meet the criteria of Medical Necessity as defined in Sections 8.076.1.8 and 8.280.4.E.2., and are provided by the appropriate provider specialty.

Physician services in dental care are a benefit when provided for surgery related to the jaw or any structure contiguous to the jaw or reduction of fraction of the jaw or facial bones. Service includes dental splints or other devices.
Outpatient mental health services are provided as described in Section 8.205.
Physical examinations are a benefit when they meet the following criteria:

a. Physical examinations are a benefit for preventive service, diagnosis and evaluation of disease or early and periodic screening, diagnosis and treatment for members under the age of 21 as described in Section 8.280.

b. Physical examination as a preventive service for adults is a benefit limited to one per state fiscal year.

Physician services for the provision of immunizations are a benefit.

Vaccines provided to enrolled children that are eligible for the Vaccines for Children program shall be obtained through the Colorado Department of Public Health and Environment. Immunization services are provided in accordance with Section 8.815.

Physician services for laboratory testing described in Section 8.660, are a benefit.
Occupational and physical therapy services are benefits.
Family planning services described in Section 8.730 are benefits. 8.200.3.B Physician services may be provided as telemedicine in accordance with

Section 8.095. 8.200.3.C Services and goods generally excluded from coverage are identified in

Section 8.011.11. 8.200.3.D Physician Services Note: 8.200.3.D.1 Podiatry Services was moved to §8.810 01/2015.

Speech – Language and Hearing Services a. ELIGIBLE PROVIDERS i. Eligible providers include individual practitioners and those employed by home care agencies, children’s developmental service agencies, health departments, federally qualified health centers (FQHC), clinics, or hospital outpatient ii. Otolaryngologists, speech-language pathologists (speech therapists), and audiologists shall have a current and active license or registration and be current, active and unrestricted to practice.

iii. Providers shall be enrolled as a Health First Colorado provider in order to be eligible to bill for procedures, products and services in treating a Health First Colorado member.

iv. Rendering Providers include:

Otolaryngologist 2. Speech-language pathologist 3. Speech-language pathology assistant 4. Clinical fellow 5. Audiologist b. PROVIDER AGENCY REQUIREMENTS i. Providers of in-home health who employ therapists or audiologists shall apply for licensing through the Colorado Department of Public Health and Environment (CDPHE) as a home care agency.
This rule does not apply to providers delivering Early Intervention Services under an Individual Family Service Plan (IFSP) and billing through contracts with the Community Centered Boards.

c. ELIGIBLE PLACES OF SERVICE i. Eligible Places of Service shall include:

Office 2. Home 3. School A. Therapies provided as part of a member’s school requirement are not separately reimbursable. These services are paid for by the school district which is reimbursed by the Department. Providers may not submit claims for therapy services performed as part of a member’s school requirement.
FQHC
Outpatient Hospital 6. Community Based Organization 7. Telemedicine in accordance with Section 8.095.

d. ELIGIBLE MEMBERS i. All Health First Colorado members are eligible for habilitative services deemed medically necessary.

e. COVERED SERVICES i. Newborn Screening 1. Screening shall include a comprehensive health assessment performed soon after birth or as early as possible in a child’s life and repeated at periodic intervals of time as recommended by the Colorado Early & Periodic Screening & Diagnostic and Treatment (EPSDT) periodicity schedules.

ii. Early Language Intervention 1. Early language intervention for children 0 through three with a hearing loss may be provided by audiologists, speech therapists, or Colorado Home Intervention Program (CHIP) providers.

iii. Audiology Services 1. Audiological benefits include identification, diagnostic evaluation and treatment for members 20 and under with hearing loss, neurologic, dizziness/vertigo, or balance disorders. Conditions treated may be either congenital or acquired.

Assessment – Service may include testing or clinical observation or both, as appropriate for chronological or developmental age, for one or more of the following areas, and must yield a written evaluation report.

a. Auditory sensitivity (including pure tone air and bone conduction, speech detection and speech reception thresholds).

b. Auditory discrimination in quiet and noise.

c. Impedance audiometry (tympanometry and acoustic reflex testing).

d. Hearing aid evaluation (amplification selection and verification).

e. Central auditory function.

f. Evoked otoacoustic emissions.

g. Brainstem auditory evoked response.

h. Assessment of functional communicative skills to enhance the activities of daily living.

i. Assessment for cochlear implants (for members age 20 and under).

j. Hearing screening.

k. Assessment of facial nerve function.

l. Assessment of balance function.

m. Evaluation of dizziness/vertigo.

Treatment – Service may include one or more of the following, as appropriate:

a. Auditory training.

b. Speech reading.

c. Augmentative and alternative communication training including training on how to use cochlear implants.

d. Purchase, maintenance, repairs and accessories for approved devices.

e. Selection, testing and fitting of hearing aids for members 20 and under with bilateral or unilateral hearing loss; and auditory training in the use of hearing aids.

f. Purchase and training on Department approved assistive technologies.

g. Balance or vestibular therapy.

iv. Cochlear Implants 1. Bilateral and unilateral cochlear implants are covered for members aged 20 years and under in accordance with Section 8.280. The following prior authorization criteria must be met:

a. The proposed use of the device must be in accordance with FDA guidelines applicable to the member’s age.

b. Bilateral and unilateral hearing loss with unaided pure tone average thresholds of 60 dB or greater.

c. Minimal speech perception may be measured using recorded standardized stimuli-speech discrimination scores of 50-60% or below with optimal amplification at 1000, 2000, and 4000 Hz.

d. Family support and motivation to participate in a post-cochlear aural, auditory, and speechlanguage rehabilitation program.

e. Assessment by an audiologist and otolaryngologist experienced in cochlear implants.

f. No medical contraindications.

g. Up-to-date-immunization status as determined by the Advisory Committee on Immunization Practices (ACIP).

h. Replacement of an existing cochlear implant for all ages is a benefit when the currently used internal or external component is no longer functioning and cannot be repaired. For members age 20 and younger, please see 8.280 for additional guidance.

v. Speech-language Services 1. Assessment – Service may include testing and/or clinical observation, as appropriate for chronological or developmental age, for one or more of the following areas, and must yield a written evaluation report:

a. Expressive language.

b. Receptive language.

c. Cognition.

d. Augmentative and alternative communication.

e. Voice disorder.

f. Resonance patterns.

g. Articulation/phonological development.

h. Pragmatic language.

i. Fluency.

j. Feeding and swallowing.

k. Hearing status based on pass/fail criteria.

l. Motor speech.

m. Aural rehabilitation (defined by provider’s scope of practice.

Treatment – Service may include one or more of the following, as appropriate:

a. Articulation/phonological therapy.

b. Language therapy including expressive, receptive, and pragmatic language.

c. Augmentative and alternative communication therapy.

d. Auditory processing/discrimination therapy e. Fluency therapy.

f. Voice therapy.

g. Oral motor therapy.

h. Swallowing therapy.

i. Speech reading.

j. Cognitive treatment.

k. Necessary supplies and equipment.

l. Aural rehabilitation (defined by provider’s scope of practice).

f. DOCUMENTATION i. General Requirements for Member’s Record of Service:

Rendering providers shall document all evaluations, re-evaluations, services provided, member progress, attendance records, and discharge plans. All documentation must be kept in the member’s records along with a copy of the referral or prescribing provider’s order.
Documentation shall support both the medical necessity of services and the need for the level of skill provided.
Rendering providers shall copy the member’s prescribing provider and medical home/primary care provider on all relevant records.

ii. Documentation shall include all of the following:

The member’s name and date of birth.
The date and type of service provided to the member.
A description of each service provided during the encounter including procedure codes and time spent on each.
The total duration of the encounter.
The name(s) and title(s) of the person(s) providing each service and the name and title of the therapist supervising or directing the services.

iii. Documentation categories 1. Provider shall keep documentation for the following episodes of care: Initial Evaluation, Re-evaluation, Visit/Encounter Notes, and Discharge Summary.

Written documentation of the Initial Evaluation shall include the following:

a. The reason for the referral and reference source.

b. Diagnoses pertinent to the reason for referral, including:

i. Date of onset;

ii. Any cognitive, emotional, or physical loss necessitating referral, and the date of onset, if different from the onset of the relevant diagnoses;

iii. Current functional limitation or disability as a result of the above loss, and the onset of the disability;

iv. Pre-morbid functional status, including any pre-existing loss or disabilities;

v. Review of available test results;

vi. Review of previous therapies/interventions for the presenting diagnoses, and the functional changes (or lack thereof) as a result of previous therapies or interventions.

c. Assessment: Include a summary of the member’s impairments, and functional limitations and disabilities, based on a synthesis of all findings gathered from the evaluation. Highlight pertinent factors which influence the treatment diagnosis and prognosis, and discuss the inter-relationship between the diagnoses and disabilities for which the referral was made must be discussed.

d. Plan of Care: A detailed Plan of Care must include the following:

i. Specific treatment goals for the entire episode of care which are functionallybased and objectively measured.

e. Proposed interventions/treatments to be provided during the episode of care.

f. Proposed duration and frequency of each service to be provided.

g. Estimated duration of episode of care.

The therapist’s Plan of Care must be reviewed, revised if necessary, and signed, as medically necessary by the member’s Physician, or other licensed practitioner of the healing arts within the practitioner’s scope of practice under state law at least once every 90 days. The Plan of Care must not cover more than a 90-day period or the time frame documented in the Individual Family Service Plan (IFSP). Early intervention services authorized through a member’s IFSP qualify as being medically necessary, as set forth at § 26.5-3-402(9), C.R.S. .
A Plan of Care must be certified. Certification is the Physician’s, Physician’s Assistant or Advanced Practice Nurse’s approval of the Plan of Care.

Certification requires a dated signature on the Plan of Care or some other document that indicates approval of the Plan of Care unless the steps under 8.200.2.F.1 are followed. If the service is a Medicare covered service and is provided to a recipient who is eligible for Medicare, the Plan of Care must be reviewed at the intervals required by Medicare.

Re-evaluation. A re-evaluation must be done whenever there is an unanticipated change in the member’s status, a failure to respond to interventions as expected or there is a need for a new Plan of Care based on new problems and goals that require significant changes to the Plan of Care. The documentation for a re-evaluation need not be as comprehensive as the initial evaluation, but must include at least the following: Reason for reevaluation; member’s health and functional status reflecting any changes; findings from any repeated or new examination elements; and, changes to Plan of Care.

iv. Visit/Encounter Notes 1. Written documentation of each encounter must be in the member’s record of service. These visit notes document the implementation of the Plan of Care established by the therapist at the initial evaluation.

Each visit note must include the following:

a. The total duration of the encounter.

b. The type and scope of treatment provided, including procedure codes and modifiers used.

c. The time spent providing each service. The number of units billed/requested must match the documentation.

d. Identification of the short-term or long-term goals being addressed during the encounter.

In addition to the above required information, the visit note must include the following elements:

a. A subjective element which includes the reason for the visit, the member or caregiver’s report of current status relative to treatment goals, and any changes in member’s status since the last visit;

b. An objective element which includes the practitioner’s findings, including abnormal and pertinent normal findings from any procedures or tests performed;

c. An assessment component which includes the practitioner’s assessment of the member’s response to interventions provided, specific progress made toward treatment goals, and any factors affecting the intervention or progression of goals; and d. A plan component which states the plan for next visit(s).

v. Discharge Summary 1. At the conclusion of therapy services, a discharge summary must be included in the documentation of the final visit in an episode of care. This may include the following:

a. Highlights of a member’s progress or lack of progress towards treatment goals.

b. Summary of the outcome of services provided during the episode of care.

g. NON-COVERED SERVICES AND GENERAL LIMITATIONS i. Health First Colorado does not cover items and services which generally enhance the personal comfort of the eligible person but are not necessary in the diagnosis of, do not contribute meaningfully to the treatment of an illness or injury, or the functioning of a malformed body member.

ii. Services provided without a referral from a Physician or other licensed practitioner of the healing arts within the practitioner’s scope of practice under state law are not covered, unless they are covered by an IFSP.

iii. Treatment of speech and language delays not associated with an acquired or chronic medical condition, neurological disorder, acute illness, injury, or congenital defect are not covered, unless they are covered by an IFSP.

iv. Any service that is not determined by the provider to be medically necessary according to the definition of medical necessity in Section 8.076.1.8.

v. Hearing aids for adults are not a covered service.

vi. Hearing exams and evaluations are a benefit for adults only when a concurrent medical condition exists.

viii. Initial placement of cochlear implants for adults is not covered.

ix. The upgrading of a cochlear implant system or component (e.g., upgrading processor from body worn to behind the ear, upgrading from single to multi-channel electrodes) of an existing properly functioning cochlear implant is not covered.

x. Services not documented in the member’s Plan of Care are not covered.

xi. Services specified in a Plan of Care that is not reviewed and revised as medically necessary by the member’s attending Physician or by an IFSP are not covered.

xii. Services that are not designed to improve or maintain the functional status of a recipient with a physical loss or a cognitive or psychological deficit are not covered.

xiii. A rehabilitative and therapeutic service that is denied Medicare payment because of the provider’s failure to comply with Medicare requirements is not covered.

xiv. Vocational or educational services, including functional evaluations, except as provided under IEP-related services are not covered.

xv. Services provided by unsupervised therapy assistants as defined by the American Speech-Language Hearing Association (ASHA) are not covered.

xvi. Treatment for dysfunction that is self-correcting (for example, natural dysfluency or developmental articulation errors) is not covered.

xvii. Psychosocial services are not covered. xviii. Costs associated with record keeping documentation and travel time are not covered.

xix. Training or consultation provided by an audiologist to an agency, facility, or other institution is not covered.

xx. Therapy that replicates services that are provided concurrently by another type of therapy is not covered.

Particularly, occupational therapy which should provide different treatment goals, plans, and therapeutic modalities from speech therapy.

8.200.4 CERTIFIED FAMILY PLANNING CLINICS 8.200.4.A Laboratories at Certified Family Planning Clinics providing services must meet all Clinical Laboratory Improvement Amendment requirements. 8.200.4.B Services at a Certified Family Planning Clinic shall be rendered under the General Supervision of a physician. General Supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. 8.200.4.C The Certified Family Planning Clinic shall contact the client’s Primary Care Provider or Primary Care Medical Provider or managed care organization, if applicable, prior to rendering services that require a referral.

8.200.5 REIMBURSEMENT 8.200.5.A The amount of reimbursement for physician services is the lower of the 1. Submitted charges; or 2. Fee schedule as determined by the Department of Health Care Policy and Financing which may be a manual pricing. 8.200.5.B Reimbursement for services may be made directly to Advanced Practice Nurses, registered occupational therapists, licensed physical therapists, licensed audiologists, certified speech-language pathologists, and licensed psychologists unless the non-physician practitioner is acting within the scope of his/her contract with a physician or public or private institution or employment as a salaried employee of a physician or public or private institution. 8.200.5.C Dental hygienists may be directly reimbursed for unsupervised dental hygiene services.

a. Hygienists employed by a dentist, clinic, or institution shall submit claims under the employer’s provider identification number. 8.200.5.D The amount of reimbursement for Certified Family Planning Clinic services may be paid directly to the clinic and is the lower of the following:

Submitted charges; or 2. Fee schedule as determined by the Department of Health Care Policy and Financing which may be a manual pricing. 8.200.5.E A provider shall not be reimbursed directly for services if the provider is acting as a contract agent or employee of a nursing home, hospital, Federally Qualified Health Center, Rural Health Center, clinic, home health agency, school, or physician. 8.200.5.F A provider shall not be reimbursed for services as a billing provider if the provider is a student in a graduate education program and the facility where the provider delivers services receives Graduate Medical Education payments pursuant to Colorado Revised Statutes Section 25.5-4-402.5 or 10 C.C.R. 2505- 10, Sections 8.300.7.

8.200.6 INCREASED MEDICAL PAYMENTS TO PRIMARY CARE PHYSICIANS

PROGRAM

The Increased Medical Payments to Primary Care Physicians Program provides reimbursement above the fee schedule to defined and attested primary care physicians for certain services provided in calendar years 2013 and 2014. 8.200.6.A Authority This rule is made pursuant to title 42 of the Code of Federal Regulations, Section 438.6,

Section 438.804, Part 441 Subpart L, and Part 447 Subpart G (2012). 8.200.6.B Definitions 1. Primary Care Physician means a medical doctor who attests to the Department that he or she has a primary specialty designation of family medicine, general internal medicine, or pediatric medicine or a subspecialty recognized by the American Board of Medical Specialties, the American Board of Physician Specialties, or the American Osteopathic Association.

Personal Supervision means the physician accepts professional responsibility and legal liability for the services provided by the nonphysician provider. Personal Supervision does not require physical presence at the location of the services. 8.200.6.C Attestation 1. A Primary Care Physician is required to self-identify, using the form available on the www.colorado.gov/hcpf, provider’s web page, to a specialty designation of family medicine, general internal medicine or pediatric medicine or a subspecialty recognized by the American Board of Medical Specialties, the American Board of Physician Specialties or the American Osteopathic Association. A physician must self-attest that he/she:

a. Is Board certified with such a specialty or subspecialty; and/or b. Has furnished evaluation and management services and vaccine administration services under codes described in 8.200.6.E that equal at least 60 percent of the Medicaid codes he or she has billed during the most recently completed calendar year or, for newly eligible physicians, the prior month. 8.200.6.D Reimbursable Services 1. Primary care services with procedure codes listed in 8.200.6.E provided by a Primary Care Physician, as defined in 8.200.6.B.1, are eligible for increased reimbursement.

Primary care services with procedure codes listed in 8.200.6.E provided by a Physician Assistant or Advanced Nurse Practitioner under the personal supervision of a Primary Care Physician, as defined in 8.200.6.B.1, are eligible for increased reimbursement.

a. For this program, when services by a non-physician provider are provided under the personal supervision of a physician, the physician may be identified as the rendering provider on claims. 8.200.6.E Procedure Codes The procedure codes covered by the Colorado Medical Assistance program designated in the Healthcare Common Procedure Coding System (HCPCS) for increased reimbursement shall be 99201-99499 and Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473, and 90474. 8.200.6.F Supplemental Payment Procedure 1. Supplemental payments to eligible providers are calculated in the manner defined in 42 C.F.R. part 447.405 and identified in the schedule of maximum payments published on the website of the Department of Health Care Policy and Financing. Title 42 of the Code of Federal Regulations,

Part 447.405 (2012) is hereby incorporated by reference into this rule.

Such incorporation, however, excludes later amendments to or additions of the referenced material. These regulations are available for public inspection at the Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203.

Supplemental payments will be made on a quarterly basis.
The initial supplemental payment will be made after approval of the State Plan Amendment approving the increase. 8.200.6.G Audits 1. Eligible providers shall maintain all increased payment to primary care provider program-related records including documentation to support attestations.
Eligible providers shall permit the Department, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency:

a. To audit, inspect, examine, excerpt, copy and/or transcribe the records related to this incentive program, to assure compliance with the program requirements, Corrective Action Plans and attestations.

b. To access the provider’s premises, to inspect and monitor, at all reasonable times, the provider’s compliance with program requirements, Corrective Action Plans and attestations. Monitoring includes, but is not limited to, internal evaluation procedures, examination of program data, special analyses, on-site checking, observation of employee procedures and use of electronic health information systems, formal audit examinations, or any other procedure.

Eligible providers shall cooperate with the State, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency seeking to audit a provider’s compliance with program requirements.
The Department may recoup by offset from any payment due to the provider any supplemental payment made to the provider for services rendered during the period that the provider did not meet the requirements for attestation in 8.200.6.C or does not have documentation supporting the required attestation. The Department may recoup by offset any improper or overpaid medical services paid to or on behalf of an eligible provider. 8.200.6.H Informal Reconsideration and Appeal 1. A provider may request an informal reconsideration of his or her exclusion from participation in the Increased Medical Payments to Primary Care Providers Program by submitting a written request within 30 days of date of notice that the provider is not eligible to participate in the program.
A provider may request an informal reconsideration of the supplemental payment amount by submitting a written request within 30 days of the receipt of the supplemental payment.
The Department shall respond to the request for informal reconsideration with a decision no later than 45 days after receipt of the request.
A provider dissatisfied with the Department’s decision may appeal the informal reconsideration decision according to the procedures set forth in 10 C.C.R. 2505-10 Section 8.050.3 PROVIDER APPEALS. 8.200.7 Prospective Medical Payments to Primary Care Medical Providers 8.200.7.A Definitions 1. APM code set refers to a set of Evaluation and Management (E&M) codes that are defined by the Department and included on the Department’s Primary Care Alternative Payment Model Fee Schedule (https://www.colorado.gov/pacific/hcpf/provider-rates-fee-schedule)
Gainsharing refers to upside only shared savings, where a participating PCMP can earn additional reimbursement for meeting metrics/thresholds that are defined by the Department.
Primary Care Medical Provider (PCMP) refers to an individual physician, advanced practice nurse or physician assistant, who participates in the Accountable Care Collaborative (ACC) as a Network Provider, with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology.
Prospective Payments refer to monthly payments made at the beginning of each month that are intended to cover primary care services for a PCMP’s attributed members.
Qualifying Patients: The subset of medical assistance beneficiaries that are attributed to a PCMP, excluding those that are assigned to the PCMP on the basis of geographical attribution and excluding those who are eligible for Medicare. The Participating Physician’s Qualifying Patients will change on an ongoing basis because of new patient attribution to the PCMP, removal of patients from the list of those attributed to the PCMP, change in attribution reason, and either gain or loss of dual Medicare and Medicaid enrollment.
Reconciliation refers to a process established by the Department to correct under- or overpayment for services rendered in the APM code set. 8.200.7.B Eligibility for Participation 1. Primary Care Medical Providers (PCMPs) enrolled in the ACC.
PCMPs must exceed a mathematical standard which is determined by the Department’s actuary and this standard will be communicated to interested participants before the program starts.
This payment methodology is voluntary and PCMPs must elect to participate. The Department will send a letter to confirm a PCMP’s intent to join the program. The PCMP then has 10 business days from the date of receipt of the letter to confirm or deny participation. 8.200.7.C Prospective Per Member Per Month (PMPM) Payments 1. PCMPs will earn monthly prospective payments for services in the APM code set a. The prospective PMPM payments will be PCMP specific.

b. The PCMP will elect what percentage of their revenue for primary care services they will earn as a prospective PMPM payment.

i. The amount of PMPM payment a PCMP will receive will be indicated in the letter sent by the Department to confirm participation in the program.

c. PCMPs will earn the rest of their revenue from reduced fee for service in the corresponding percentage for the APM code set.

i. The percentage reduction for the services included in the APM code set received, will be indicated in the letter sent by the Department to confirm participation in the program. 8.200.7.D Gainsharing 1. PCMPs will be eligible to earn extra revenue for participating in gainsharing.

a. Gainsharing thresholds will be specific to each PCMP.

b. The Department will publish thresholds for gainsharing that show the targets PCMPs must meet to be eligible to receive extra payments. Services that comprise the targets will also be published.

i. PCMPs will agree to the thresholds and services for gainsharing in the letter sent by the Department which confirms participation in the program.

The PCMP may contest the Department’s determination of the gainsharing payments. PCMPs who contest the Department’s determination must first submit in writing to the Department the reason for contesting the determination within 60 days of receiving the gainsharing payment. The Department will review all contested determinations within 30 calendar days of receipt of the notice and will respond to the PCMP with its final decision. If the PCMP does not agree with the Department’s final decision, the PCMP has the right to file an appeal with the Office of Administrative Courts in accordance with Section 8.050.3. 8.200.7.E Reconciliation 1. A PCMP will be responsible for meeting quality minimums that are established and accepted by the PCMP in the letter sent by the Department which confirms participation in the program. The quality minimums must be met for a PCMP to earn their full prospective PMPM payments.

a. If the PCMP exceeds the quality minimums then they will not be subject to reconciliation, unless the PMPM payment is lower than the amount which would have been earned had the PCMP been reimbursed through the fee schedule payment b. If the PCMP does not meet quality minimums then the Department will reduce the PMPM payment to equal the corresponding amount which would have been earned had the PCMP been reimbursed the fee schedule payment.

c. A PCMP will be made whole through an upward reconciliation process if the Department finds that a PCMP would have earned more had the PCMP been reimbursed the fee schedule payment.

Appeals Process for Prospective PMPM Payments a. The PCMP may contest the Department’s determination for reconciliation of prospective PMPM payments. PCMPs who contest the Department’s determination must submit in writing to the Department the reason for contesting the determination within 60 days of receiving the notice of reconciliation of prospective PMPM payments. The Department will review all contested determinations within 30 calendar days of receipt of the notice and will respond to the PCMP with its final decision. If the PCMP does not agree with the Department’s final decision, the PCMP has the right to file an appeal with the Office of Administrative Courts in accordance with

Section 8.050.3. 8.200.7.F Withdrawal from Program Participation 1. A PCMP may choose to voluntarily withdraw from the program at any time so long as proper notification is given to the Department.

a. A PCMP must give 30 days written notice to the Department to be withdrawn from the program. The PCMP will be withdrawn from the program on the first day of the month following the end of the 30 day notice period.

b. If a PCMP chooses to voluntarily withdraw from the program before the end of the program year, the PMPM and gainsharing payments will be prorated to reflect months of participation in the program.

A PCMP may involuntarily be withdrawn from the program in the event the PCMP is terminated as a Medicaid provider and the PCMP will not be eligible to contest the determination. Involuntary withdrawal on this basis will be effective immediately. The Department will notify the PCMP in writing within 10 business days if this occurs.
The Department reserves the right to terminate the participation of a PCMP in the program at any time without cause. The Department will notify the PCMP of their termination in writing within 10 business days and the termination will become effective the first day of the month following 30 days of the notice. (Add not appealable)

8.201 ADULT DENTAL SERVICES

8.201.1 DEFINITIONS

A. Adult Client means an individual who is 21 years or older and eligible for medical assistance benefits.

B. Comprehensive Oral Evaluation – New or Established Patient means a thorough evaluation and documentation of a client's dental and medical history to include extra-oral and intra-oral hard and soft tissues, dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, and oral cancer screening, as defined by the Current Dental Terminology (CDT).

C. Comprehensive Periodontal Evaluation means the procedure that is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patient’s dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation, as defined by the CDT.

D. Dental Caries is a common chronic infectious transmissible disease resulting from tooth-adherent specific bacteria that metabolize sugars to produce acid which demineralizes tooth structure over time (tooth decay).

E. Dental professional means a licensed dentist, dental hygienist, or dental therapist enrolled with Colorado Medicaid.

F. Detailed and Extensive Oral Evaluation – Problem Focused, By Report means a detailed and extensive problem focused evaluation entailing extensive diagnostic and cognitive modalities based on the findings of a comprehensive oral evaluation. Integration of more extensive diagnostic modalities to develop a treatment plan for a specific problem is required. The condition requiring this type of evaluation shall be described and documented. Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown origin, conditions requiring multi-disciplinary consultation, etc., as defined by the CDT.

G. Diagnostic Imaging means a visual display of structural or functional patterns for the purpose of diagnostic evaluation, as defined by the CDT.

H. Endodontic services means services which are concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues.

I. Emergency Services means the need for immediate intervention by a physician, osteopath or dental professional to stabilize an oral cavity condition.

J. Evaluation means a patient assessment that may include gathering of information through interview, observation, examination, and use of specific tests that allows a dentist to diagnose existing conditions, as defined by the CDT.

K. High Risk of Caries is indicated in Adult Clients who present with demonstrable caries, a history of restorative treatment, dental plaque, and enamel demineralization.

L. Immediate Intervention or Treatment is when a patient presents with symptoms and/or complaints of pain, infection or other conditions that would require immediate attention.

M. Limited Oral Evaluation – Problem Focused means an evaluation limited to a specific oral health problem or complaint, as defined by the CDT.

N. Oral Cavity means the jaw, mouth or any structure contiguous to the jaw.

O. Palliative Treatment for Dental Pain means emergency treatment to relieve the client of pain; it is not a mechanism for addressing chronic pain.

P. Periodic Oral Evaluation means an evaluation performed on a client of record to determine any changes in the patient’s dental and medical status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures, as defined by the CDT.

Q. Periodontal Treatment means the therapeutic plan intended to stop or slow periodontal (gum) disease progression.

R. Preventive services means services concerned with promoting good oral health and function by preventing or reducing the onset and/or development of oral diseases or deformities and the occurrence of oro-facial injuries, as defined by the CDT.

S. Prophylaxis (Cleaning) is the removal of dental plaque and calculus from teeth, in order to prevent dental caries, gingivitis and periodontitis.

T. Re-Evaluation - Limited, Problem Focused (Established Patient; Not Post- Operative Visit) means assessing the status of a previously existing condition.

For example, a traumatic injury where no treatment was rendered but patient needs follow-up monitoring, an evaluation for undiagnosed continuing pain, or a soft tissue lesion requiring follow-up evaluation, as defined by the CDT.

U. Restorative means services rendered for the purpose of rehabilitation of dentition to functional or aesthetic requirements of the client, as defined by the CDT.

V. Year begins on the date of service.

8.201.2 BENEFITS 8.201.2.A Covered Services 1. Covered Evaluation Procedures:

a. Periodic Oral Evaluation, i. Shall be limited to two (2) per year.

ii. Is limited to any combination of two (2) periodic oral iii. Must be rendered by a dental professional.

b. Limited Oral Evaluation – Problem Focused; available to Adult Clients presenting with a specific oral health condition or problem i. Shall be limited to two (2) per year per provider or location.

ii. Is limited to any combination of two (2) limited problemproblem-focused oral evaluations per year per provider or iii. Does not count towards other oral evaluation frequencies.

iv. Must be rendered by a dental professional. Dental hygienists shall only provide limited oral evaluations for an Adult Client of record.

v. Limited Oral Evaluation – Problem Focused will not be reimbursed if it is provided on the same day as a periodic oral evaluation, a comprehensive oral evaluation, or a comprehensive periodontal evaluation. When both are c. Comprehensive Oral Evaluation, New or Established Patient i. Shall be limited to one (1) every three (3) years per provider or location.

ii. Is limited to any combination of two (2) periodic oral iii. Must be rendered by a dentist only.

d. Detailed and Extensive Oral Evaluation – Problem Focused, By Report i. Shall be limited to two (2) per year per provider or location.

ii. Is limited to any combination of two (2) limited problemproblem-focused oral evaluations per year.

iii. Does not count towards other oral evaluation frequencies.

iv. Must be rendered by a dental professional.

v. Will not be reimbursed if it is provided on the same day as a periodic oral evaluation, a comprehensive oral evaluation, or a comprehensive periodontal evaluation. When both are e. Re-evaluation – Limited, Problem Focused (Established Patient;

Not Post-Operative Visit)

i. Shall be limited to two (2) per year per provider or location.

ii. Is limited to any combination of two (2) limited problemproblem-focused oral evaluations per year.

iii. Does not count towards other oral evaluation frequencies.

iv. Must be rendered by a dental professional.

v. Will not be reimbursed if it is provided on the same day as a periodic oral evaluation, a comprehensive oral evaluation, or a comprehensive periodontal evaluation. When both are f. Comprehensive Periodontal Oral Evaluation i. Shall be limited to one (1) every three (3) years.

ii. Is limited to any combination of two (2) periodic oral iii. Must be rendered by a dental professional.

Covered Diagnostic Imaging Procedures:

a. Intra-oral - Complete Series of Radiographic Images, shall be limited to one (1) per five (5) years; minimum of ten (10) (periapical or posterior bitewing) images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone required in the radiographic survey counts as one (1) set of bitewings per year.

b. Intra-oral - Periapical F irst Radiographic Image, shall be limited to six (6) per one (1) year. Intra-oral first periapical x-ray will not be reimbursed if it is provided on the same day as an intra-oral complete series. Where both are provided on the same day, only the intra-oral - complete series will be reimbursed.

c. Intra-oral - Periapical Each Additional Radiographic Image. Each additional periapical x-ray will not be reimbursed if it is provided on the same day as an intra-oral - complete series. Where both are provided on the same day, only the intra-oral - complete series will be reimbursed. Working and final treatment films for endodontics are not covered.

d. Bitewing – Single Radiographic Image, shall be limited to one (1) set per year; one (1) set is equal to one (1) to four (4) films.

e. Bitewing – Two Radiographic Images, shall be limited to one (1) set per year; one (1) set is equal to two (2) to four (4) films.

f. Bitewing – Three Radiographic Images, shall be limited to one (1) set per year; one (1) set is equal to two (2) to four (4) films.

g. Bitewing – Four Radiographic Images, shall be limited to one (1) set per year; one (1) set is equal to two (2) to four (4) films.

h. Vertical Bitewings – Seven (7) to Eight (8) Radiographic Images, shall be limited to one (1) every five (5) years per provider or location. Counts as an intra-oral - complete series.

i. Panoramic Radiographic Image; with or without bitewing, shall be limited to one (1) per five (5) years per provider or location. Counts as an intra-oral - complete series.

Covered Preventive Services a. Prophylaxis (cleaning) shall be limited to two (2) per year. Tooth brushing alone does not qualify as a prophylaxis.

i. Adult Clients who indicate as high risk of periodontal disease or high risk of caries may receive any combination of up to a total of four (4) prophylaxes (cleanings) or four (4) periodontal maintenance visits per year. Indicators of high risk of periodontal disease include:

Demonstrable caries at the time of examination;
History of periodontal scaling and root planing;
History of periodontal surgery;
Diabetic diagnosis; or 5. Pregnancy.

b. Topical Application of Fluoride Varnish, shall be limited to two (2) per year, limited to Adult Clients with:

i. History of dry mouth; or ii. History of head or neck radiation; or iii. Indication of high risk for caries as that term is defined at

Section 8.201.1. If, at the end of the year the Adult Client no longer has demonstrable caries, he or she is no longer considered high risk.

Limited to any combination of two (2) topical application of fluoride varnish or topical application of fluoride per year.

c. Topical Application of Fluoride, shall be limited to two (2) per year, limited to Adult Clients with:

i. History of dry mouth; or ii. History of head or neck radiation; or iii. Indication of high risk for caries as that term is defined at

Section 8.201.1. If, at the end of the year the Adult Client no longer has demonstrable caries, he or she is no longer considered high risk.

iv. Limited to any combination of two (2) fluoride varnish or topical fluoride applications per year.

Covered Minor Restorative Services.

a. Routine amalgam and composite fillings on posterior and anterior teeth are covered services.

b. Amalgam and composite fillings shall be limited to one (1) time per surface per tooth, every three (3) years. The limitation shall begin on the date of service and multi-surface fillings are allowable.

Amalgam and composite fillings will not be reimbursed if it is provided on the same day of treatment as a crown on the same tooth. Where both are provided on the same day, only the crown c. The occlusal surface is exempt from the three (3) year frequency limitations listed under Section 8.201.2.A.4.b. when a multi-surface restoration is required or following endodontic therapy.

d. Prefabricated Stainless Steel Crown, Permanent Tooth; may be e. Prefabricated Stainless Steel Crown, with Resin Window; may be f. Protective Restoration, shall be limited to once per lifetime per tooth, primary and permanent teeth.

Covered Major Restorative Services a. The following crowns are covered:

i. Single crowns, shall be limited to one (1) per tooth every seven (7) years.

ii. Core build-up, building shall be limited to one (1) per tooth every seven (7) years.

iii. Pre-fabricated post and core, shall be limited to one (1) per tooth every seven (7) years.

b. Crowns are covered services only when all of the following conditions are met:

i. The tooth is in occlusion; and ii. The cause of the problem is either decay or fracture; and iii. The tooth is not a third molar; and iv. The tooth is not a second molar, unless crowning the second molar is necessary to support a partial denture or to maintain eight (8) artificial or natural posterior teeth in occlusion; and v. The Adult Client’s record reflects evidence of good and consistent oral hygiene; and One of the following is also true:

The tooth in question requires a multi-surface restoration and it cannot be restored with other restorative materials; or 2. A crown is requested by the dental professional for cracked tooth syndrome and the tooth is symptomatic and appropriate testing and documentation is provided.

c. Crown materials are limited to porcelain, full porcelain, noble metal, or high noble metal on anterior teeth and premolars.

Covered Endodontic Services a. The following endodontic procedures are covered:

i. Pulpal debridement shall be limited to one (1) per tooth per lifetime, permanent teeth only.

Covered in emergency situations only.
Exempt from prior authorization process but may be 3. Will not be reimbursed when root canal is completed on the same day by the same dental provider or ii. Root Canal, Anterior T ooth shall be limited to one (1) per tooth per lifetime, permanent teeth only.

iii. Root Canal, Bicuspid Tooth shall be limited to one (1) per tooth per lifetime, permanent teeth only.

iv. Root canal, Molar Tooth shall be limited to one (1) per tooth per lifetime, permanent teeth only.

v. Retreatment of Previous Root Canal Therapy, Anterior Tooth shall be limited to one (1) per lifetime; permanent teeth only.

Will not be reimbursed if the original treatment was previously reimbursed to the same dental provider or vi. Retreatment of Previous Root Canal Therapy, Bicuspid Tooth shall be limited to one (1) per lifetime; permanent teeth only. Will not be reimbursed if the original treatment was previously reimbursed to the same dental provider or vii. Retreatment of Previous Root Canal Therapy, Molar Tooth shall be limited to one (1) per lifetime; permanent teeth only.

Will not be reimbursed if the original treatment was previously reimbursed to the same dental provider or b. Endodontic procedures are covered services when:

i. The tooth is not a third molar; and ii. The tooth is not a second molar; root canal treatment on second molars is covered only when the second molar is necessary to support a partial denture or to maintain eight (8) artificial or natural posterior teeth in occlusion; and iii. The Adult Client’s record reflects evidence of good and consistent oral hygiene; and 1. The cause of the problem is either decay or fracture; and one of the following is also true:

a. The tooth is in occlusion; or b. A root canal is requested by the dental professional for cracked tooth syndrome and the tooth is symptomatic and appropriate testing and documentation is provided.

c. In all instances in which the Adult Client is in acute pain or there d. Working films (including the final treatment film) for endodontic procedures are considered part of the procedure and will not be paid for separately.

Covered Periodontal Treatment a. Gingivectomy or Gingivoplasty, Four or More Contiguous Teeth or Tooth Bounded Spaces per Quadrant shall be limited to one (1) per three (3) years per Adult Client per quadrant. Includes six (6) months of postoperative care.

b. Gingivectomy or gingivoplasty, One to Three Contiguous Teeth or Tooth Bounded Spaces per Quadrant shall be limited to one (1) per three (3) years per Adult Client per quadrant. Includes six (6) months of postoperative care.

c. Gingivectomy or Gingivoplasty to Allow Access for Restorative Procedure, per Tooth shall be limited to one (1) per three (3) years per Adult Client per quadrant.

d. Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis; shall be limited to one (1) per three (3) years per Adult Client.

i. Full mouth debridement will not be reimbursed if Adult Client’s patient record demonstrates that the Adult Client has had a prophylaxis (cleaning) or periodontal maintenance in the previous twelve (12) month period.

ii. Other periodontal treatments will not be reimbursed when provided on the same date as full mouth debridement.

Where other periodontal services are provided on the same day, only the full mouth debridement will be reimbursed.

iii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as full mouth debridement. Where both are provided on the same day, only the full mouth debridement e. Periodontal Scaling and Root Planing, Four (4) or More Teeth per Quadrant shall be limited to one (1) per quadrant every three (3) years. Requires prior authorization.

i. Only covered by report. Periodontal disease must be documented in the patient record.

ii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as a periodontal scaling and root planing, four (4) or more teeth per quadrant. Where both are provided on the same day, only the periodontal scaling and root planing, four (4) or more teeth per quadrant will be iii. No more than two (2) quadrants per day.

f. Periodontal Scaling and Root Planing, One (1) to Three (3) Teeth per Quadrant shall be limited to one (1) per quadrant every three (3) years. Requires prior authorization.

i. Only covered by report. Periodontal disease must be documented in the patient record.

ii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as a periodontal scaling and root planing, one (1) to three (3) teeth per quadrant. Where both are provided on the same day, only the periodontal scaling and root planing, one (1) to three (3) teeth per quadrant will be iii. No more than two (2) quadrants per day.

g. Periodontal Maintenance, shall be limited to two (2) times per year; counts as a prophylaxis (cleaning).

Demonstrable caries at the time of examination;
History of periodontal scaling and root planing;
History of periodontal surgery;
Diabetic diagnosis; or 5. Pregnancy.

h. In all instances in which the Adult Client is in acute pain or there 8. Covered Removable Prosthetics a. Removable prosthetics are not covered if eight (8) or more posterior teeth (natural or artificial) are in occlusion. Anterior teeth shall be covered, irrespective of the number of teeth in occlusion.

b. Removable prosthetics covered include:

i. Complete Upper Dentures shall be limited to one (1) time every seven (7) years. Includes initial six (6) months of relines. Requires prior authorization.

ii. Complete Lower Dentures shall be limited to one (1) time every seven (7) years. Includes initial six (6) months of relines. Requires prior authorization.

iii. Removable Partial Upper Denture, Resin Based shall be iv. Removable Partial Lower Denture, Resin Based shall be v. Removable Partial Upper Denture, Cast Metal Framework shall be limited to one (1) time seven (7) years. Requires vi. Removable Partial Lower Denture, Cast Metal Framework shall be limited to one (1) time every seven (7) years.

vii. Removable Partial Upper Denture, Flexible Base shall be viii. Removable Partial Lower Denture, Flexible Base shall be 9. Covered Oral Surgery, Palliative Treatment and Anesthesia a. The following surgical and palliative treatments are covered:

i. Simple Extraction shall be limited to one (1) time per tooth.

ii. Surgical Extraction shall be limited to one (1) time per tooth.

iii. Incision and Drainage of Abscess, concurrent with extraction will be covered by report when narrative of medical necessity can be documented. Will not be reimbursed in same surgical area and on same visit as any other definitive treatment codes, except for covered services necessary for diagnosis.

Such incision and drainage procedures may be subject to post-treatment and pre-payment review.

iv. Minor surgical procedures to prepare the mouth for removable prostheses shall be limited to one (1) time per lifetime per quadrant.

v. Palliative Treatment of Dental Pain will not be reimbursed on same visit as any definitive treatment codes; except for radiographs necessary for diagnosis. Will not be reimbursed when only other service is writing a prescription.

vi. Deep Sedation/General Anesthesia.

Only covered for Adult Clients when there is sufficient evidence to support medical necessity.
Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered will be reimbursed.

vii. Intravenous Conscious Sedation.

Only covered for Adult Clients when there is sufficient evidence to support medical necessity.
Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered will be reimbursed.

b. In all instances in which the Adult Client is in acute pain or there c. Biopsies are covered only in instances where there is a suspicious lesion.

d. Removal of third molars is only covered in instances of acute pain and overt symptomatology.

Covered Hospital-Based Services a. Dental treatment is covered in a hospital or outpatient facility, under deep sedation or general anesthesia, only when there is medical b. Under this Section 10, medical necessity shall be limited to the i. Patients with a documented physical, mental or medically compromising condition.

ii. Patients who have a dental need and for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy.

iii. Patients who are extremely uncooperative, unmanageable, anxious or uncommunicative and who have dental needs deemed sufficiently urgent that care cannot be deferred.

Evidence of the attempt to manage in an outpatient setting must be provided; or iv. Patients who have sustained extensive orofacial and dental trauma.

c. All operating room cases require prior authorization, even if the complete treatment plan is not available.

d. General anesthesia and sedation are not covered services when the patient is cooperative and requires minimal dental treatment, or when the patient has a concomitant medical condition which would make general anesthesia or sedation unsafe. 8.201.2.B. Exclusions.

The following services/treatments are not a benefit for Adult Clients age 21 years and older under any circumstances:

a. Cosmetic Procedures.

b. Crowns in the following categories:

i. Cosmetic Crowns (i.e., crowns solely for cosmetic purposes);

ii. Multiple units of crown and bridge;

iii. To restore vertical dimension;

iv. When an Adult Client has active and advanced periodontal disease;

v. When the tooth is not in occlusion; or vi. When there is evidence of periapical pathology.

c. Implants.

d. Screening and assessment.

e. Periodontal surgery.

f. Graft procedures.

g. Endodontic surgery.

h. Treatment for temporomandibular joint disorders.

i. Orthodontic treatment.

j. Tobacco cessation counseling.

k. Oral hygiene instruction.

l. Any service that is not listed as covered.

8.201.3 PRIOR AUTHORIZATION REQUEST

Emergency Services do not require a prior authorization before services can be rendered, and shall be subject to pre-payment review.
Prior authorizations or benefits shall be denied for reasons of poor dental prognosis, lack of dental necessity or appropriateness or because the requested services do not meet the generally accepted standard of dental care.
The following services require prior authorization:

a. Complete and partial dentures.

b. Scaling and root planing (periodontal maintenance).

c. Retreatment of root canals.

d. Hospital-based services when treatment is required.

e. Unspecified procedures, by report.

8.201.4. PROVIDER REQUIREMENTS/REIMBURSEMENT 8.201.4.A. Dental services shall only be provided by a licensed dental professional who is enrolled with Colorado Medicaid. Providers shall only provide covered services that are within the scope of their practice. 8.201.4.B. The following billing limitations apply:

Restorations:

a. Tooth preparation, anesthesia, all adhesives, liners and bases, polishing and occlusal adjustments shall be included within the reimbursement rate for restoration. Unbundling of dental restorations for billing purposes is not allowed.

b. Amalgam and composite restorations shall be reimbursed at the c. Claim payment to a dental provider for one (1) or more restorations for the same tooth shall be limited to a total of four (4) or more tooth surfaces.

8.201.5 ELIGIBLE C LIENTS

Dental services described in 8.201.2 shall apply to Adult Clients age 21 years and older.

8.201.6 ANNUAL LIMITS

Dental services provided on or after August 1, 2024, shall not be subject to an annual or lifetime limit.
The complete and partial dentures benefit shall require prior authorization to be eligible for reimbursement and will be reimbursed in the amount set forth in the Medicaid Dental Fee-for-Service Fee Schedule in effect on the date of service.

8.202 DENTAL SERVICES FOR CHILDREN

8.202.1 DEFINITIONS

Apexication is a method of inducing a calcified barrier at the apex of a nonvital tooth with incomplete root formation.
Apexogenesis refers to a vital pulp therapy procedure performed to encourage physiological development and formation of the root end.
Child Client means an individual who is age 20 years or under and eligible for medical assistance benefits.
Comprehensive Oral Evaluation means a thorough evaluation and documentation of a client's dental and medical history to include extra-oral and intra-oral hard and soft tissues, dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, and oral cancer screening, as defined by the Current Dental Terminology (CDT) (2014).
Comprehensive Periodontal Evaluation means the procedure that is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patient’s dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation, as defined by the Current Dental Terminology (CDT) (2014).
Dental Caries is a common chronic infectious transmissible disease resulting from tooth-adherent specific bacteria that metabolize sugars to produce acid which demineralizes tooth structure over time (tooth decay).
Dental professional means licensed dentist, dental therapist or dental hygienist enrolled with Colorado Medicaid.
Detailed and Extensive Oral Evaluation – Problem Focused, By Report means a detailed and extensive problem focused evaluation entails extensive diagnostic and cognitive modalities based on the findings of a comprehensive oral evaluation. Integration of more extensive diagnostic modalities to develop a treatment plan for a specific problem is required. The condition requiring this type of evaluation should be described and documented. Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown origin, conditions requiring multi-disciplinary consultation, etc., as defined by the Current Dental Terminology (CDT) (2014).
Diagnostic Imaging means a visual display of structural or functional patterns for the purpose of diagnostic evaluation, as defined by the Current Dental 10. Early, Periodic Screening, Diagnosis and Treatment (EPSDT) Services means services that are available to clients 20 and under which are determined to be medically necessary and offered through the State Plan even if not available to other eligibility categories.
Endodontic services means services which are concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues.
Emergency Services means the need for immediate intervention by a physician, osteopath or dental professional to stabilize an oral cavity condition.
Evaluation means a patient assessment that includes gathering of information through interview, observation, examination, and use of specific tests to diagnose existing conditions, as defined by the Current Dental Terminology (CDT) (2014).
High Risk of Caries is indicated in Child Clients who present with demonstrable caries, a history of restorative treatment, dental plaque, and enamel demineralization; or Child Clients of mothers with a high caries rate, especially with untreated caries; or Child Clients who sleep with a bottle containing anything other than water, or who breastfeed throughout the night (at-will nursing); or Child Clients with special health care needs.
Immediate Intervention or Treatment is when a patient presents with symptoms and/or complaints of pain, infection or other conditions that would require immediate attention.
Limited Oral Evaluation – Problem Focused means an evaluation limited to a specific oral health problem or complaint, as defined by the Current Dental 17. Oral Cavity means the jaw, mouth or any structure contiguous to the jaw.
Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver means the diagnostic services performed for a child under the age of three, preferably within the first six months of the eruption of the first primary tooth, including recording the oral and physical health history, evaluation of caries susceptibility, development of an appropriate preventive oral health regimen and communication with and counseling of the child’s parent, legal guardian and/or primary caregiver, as defined by the Current Dental Terminology (CDT) (2014).
Palliative Treatment for Dental Pain means emergency treatment to relieve the client of pain; not a mechanism for addressing chronic pain.
Periodic Oral Evaluation means an evaluation performed on a client of record to determine any changes in the patient’s dental and medical status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures, as defined by the Current Dental Terminology (CDT) (2014).
Periodontal Treatment means the therapeutic plan intended to stop or slow periodontal (gum) disease progression.
Preventive services means services concerned with promoting good oral health and function by preventing or reducing the onset or development of oral diseases or deformities and the occurrence of oro-facial injuries, as defined by the Current Dental Terminology (CDT) (2014).
Prophylaxis (Cleaning) is the removal of dental plaque and calculus from teeth in order to prevent dental caries, gingivitis and periodontis.
Qualified Medical Personnel means physicians (MDs), osteopaths (DOs), nurse practitioners and physician assistants with a focus on primary care, general practice, internal medicine, pediatrics and who have participated in on-site training by the “Cavity Free at Three” team or have completed Module 2 (child oral health) and Module 6 (fluoride varnish) in the Smiles for Life curriculum when treating Child Clients age 0 years through 12 years of age. The qualified medical personnel must have participated in Module 3 (adult oral health) and Module 6 (fluoride varnish) in the Smiles for Life curriculum when treating Child Clients ages 12 years and older. Qualified medical personnel who complete this training must provide the documentation of this training when requested.
Re-Evaluation - Limited, Problem Focused (Established Patient; Not Post- Operative Visit) means assessing the status of a previously existing condition.

For example, a traumatic injury where no treatment was rendered but patient needs follow-up monitoring; an evaluation for undiagnosed continuing pain; or a soft tissue lesion requiring follow-up evaluation, as defined by the Current Dental 26. Restorative means services rendered for the purpose of rehabilitation of dentition to functional or aesthetic requirements of the client, as defined by the Current Dental Terminology (CDT) (2014).

Screening means a program designed to evaluate the health status and potential of an individual. In the process it may be found that a person has a particular disease or condition or is at greater-than-normal risk of its development.

Screening may include taking a personal and family health history and performing a physical examination, tests, laboratory tests, or radiologic examination and may be followed by counseling, education, referral, or further testing.

Special Healthcare Needs means any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs. The condition may be developmental or acquired and may cause limitations in performing daily self-maintenance activities or substantial limitations in a major life activity.

Year begins on the date of service.

8.202.2 BENEFITS 8.202.2.A Covered Services 1. Covered Evaluation Procedures:

a. Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver; shall be limited to Child Clients age 0 through 2, two (2) per year per provider or location.

i. Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver shall include:

Risk assessment;
Oral hygiene instruction; and 3. Anticipatory guidance.

ii. For Child Clients age 0 through 2 who are at high risk for caries, an additional two (2) Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver is allowed per year for a total of four (4) per year; a formal caries risk assessment shall be performed and documented as part of the patient record.

iii. May be performed by dental professional or qualified iv. Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver will not be reimbursed if it is provided on the same day as a periodic oral evaluation.

When both are provided on the same day, only the periodic oral evaluation will be reimbursed.

b. Screening for Child Clients ages 3 and 4, Including State or Federally Mandated Screenings; shall be limited to two (2) per year.

i. For Child Clients ages 3 and 4 who are at high risk for caries, an additional two (2) screenings is allowed per year for a total of four (4) per year; a formal caries risk assessment must be performed and documented as part of the patient record.

ii. Shall be performed by a dental professional or qualified iii. A screening will not be reimbursed if it is provided on the same day of service as any comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluation. When provided on the same day, only the comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluation will be reimbursed.

c. Screening of a Patient; shall be limited to Child Clients ages 5 years and older, three (3) per year.

i. Shall be performed by dental professional or qualified ii. Does not count towards other evaluation frequency limits.

iii. A screening will not be reimbursed if it is provided on the same day of service as any comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluation. When provided on the same day, only the comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluation will be reimbursed.

d. Periodic Oral Evaluation, Established Patient; shall be limited to two (2) per year per provider or location.

i. Limited to any combination of two (2) comprehensive, ii. Must be rendered by a dental professional.

iii. Periodic oral evaluation will not be reimbursed if it is provided on the same day as an oral evaluation for a patient under three years of age and counseling with primary caregiver. When both are provided on the same day, only the periodic oral evaluation will be reimbursed.

e. Limited Oral Evaluation – Problem Focused; available to Child Clients presenting with a specific oral health condition or problem shall be limited to limited to two (2) per year per provider or i. Must be rendered by a dental professional. Dental hygienists shall only provide limited oral evaluations for a Child Client of record.

ii. Does not count against other oral exam frequencies.

f. Comprehensive Oral Evaluation, New or Established Patient; shall be limited to one (1) every three (3) years per provider or location.

i. Limited to any combination of two (2) comprehensive, ii. Must be rendered by a dental professional.

g. Detailed and Extensive Oral Evaluation – Problem Focused, By Report; shall be limited to two (2) per year per provider or location.

i. Limited to any combination of two (2) comprehensive, ii. Must be rendered by a dental professional.

h. Re-evaluation – Limited, Problem Focused (Established Patient;

Not Post-Operative Visit); shall be limited to two (2) per year per provider or location.

i. Limited to any combination of two (2) comprehensive, ii. Must be rendered by a dental professional.

i. Comprehensive Periodontal Oral Evaluation, New or Established Patient; shall be limited to Child Clients ages 15 through 20, one (1) per year per provider or location.

i. Limited to any combination of two (2) comprehensive, ii. Must be rendered by a dental professional.

Covered Diagnostic Imaging Procedures:

a. Intra-oral; complete series, for Child Clients age 6 through 20, shall be limited to one (1) per five (5) years per provider or location; minimum of ten (10) (periapical or posterior bitewing) images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone required in the radiographic survey counts as one (1) set of bitewings per year.

b. Intra-oral first periapical x-ray, shall be limited to six (6) per one (1) year per provider or location. Intra-oral first periapical x-ray will not be reimbursed if it is provided on the same day as a full mouth series. Where both are provided on the same day, only the full mouth series will be reimbursed.

c. Each additional periapical x-ray. Each additional periapical x-ray will not be reimbursed if it is provided on the same day as a full mouth series. Where both are provided on the same day, only the full mouth series will be reimbursed. Working and final treatment films for endodontics are not covered.

d. Bitewing; single image, shall be limited to Child Clients ages 2 through 20, one (1) set per year per provider or location; one set is equal to one (1) to four (4) films.

i. For Child Clients ages 2 through 20 years who are at high risk of caries, bitewing x-rays are a benefit once every six (6)

e. Bitewing; two images, shall be limited to Child Clients ages 2 i. For Child Clients ages 2 through 20 who are at high risk of f. Bitewing; three images, shall be limited to Child Clients ages 10 i. For Child Clients ages 10 through 20 who are at high risk of g. Bitewing; four images, shall be limited to Child Clients ages 10 i. For Child Clients ages 10 through 20 who are at high risk of h. Vertical bitewings; shall be limited to Child Clients ages 6 through 20, seven (7) to eight (8) images, one (1) every five (5) years per provider or location. Counts as a full mouth series.

i. Panoramic image; shall be limited to Child Clients ages 6 through 20, with or without bitewing, one (1) per three (3) years per provider or location. Counts as full mouth series.

i. For Child Clients age 6 or under with trauma or suspected pathology, additional panoramic films may be approved subject to EPSDT guidelines.

j. Occlusal film; shall be limited to one (1) per arch per two (2) years per provider or location.

i. For Child Clients with trauma or pulpal treatment, additional occlusal films may be approved subject to EPSDT guidelines.

Covered Preventive Services a. Dental Prophylaxis (Cleaning); shall be limited to two (2) per year.

Tooth brushing alone does not qualify as a prophylaxis.

b. Fluoride varnish or fluoride gel, shall be limited to two (2) per year.

Fluoride rinse is not a covered benefit.

i. Ages 0 through 4:

Child Clients at high risk of caries may receive an additional two (2) per year for a total of four (4) per year; a formal caries risk assessment must be performed and documented as part of the Clients medical record.
May be provided by dental professional or qualified a. Qualified medical personnel administering this service must do so:

i. in conjunction with an oral evaluation for a patient under age 3 (up until day before the third birthday); or ii. in conjunction with a screening for patients ages 3 through 4 (up until day before the fifth birthday).

Fluoride varnish is the only acceptable topical treatment for Child Clients age 0 through 4.
Only qualified medical personnel and dental professionals may perform this service.

ii. Age 5 and older:

Child Clients age 5 and over may receive an additional one (1) per year with no adjustment for risk for a total of three (3) per year.
Fluoride varnish is the only acceptable topical treatment for Child Clients age 5. Fluoride gel will be reimbursed for Child Clients ages 6 and over.
Only qualified medical personnel and dental professionals shall perform this service.

c. Sealants for Child Clients ages 5 through 15, shall be limited to two (2) per lifetime per tooth. Sealants are limited to:

i. Permanent molars only.

ii. Occlusal surfaces only.

iii. Tooth must be caries-free and have no restorations.

d. Child Clients age 20 or under who indicate as high risk of periodontal disease or high risk of caries may receive any combination of up to four (4) prophylaxes (cleanings) or four (4) periodontal maintenance visits per year. Indicators of high risk of periodontal disease include:

i. Active and untreated caries (decay) at the time of examination; or ii. History of periodontal scaling and root planning; or iii. History of periodontal surgery; or iv. Diabetic diagnosis; or v. Pregnancy.

Covered Space Maintenance.

a. Fixed Space Maintainers for Lost Primary Molars; shall be limited to Child Clients age 0 through 14, two (2) per quadrant per lifetime.

Includes maintenance and repair.

b. Removable Space Maintainers for Lost Primary Molars; shall be limited to Child Clients age 0 through 14, two (2) per quadrant per lifetime. Includes maintenances and repair.

c. Re-cementation of Space Maintainer; shall be limited to Child Clients age 0 through 14, one (1) per year. Will not be reimbursed within six (6) months of original placement by the same dentist or group.

d. Removal of a Fixed Space Maintainer; shall be limited to Child Clients age 0 through 20, one (1) per lifetime. Will not be reimbursed to the dentist who placed the appliance or the group where the appliance was originally delivered within six (6) months of original placement. May be subject to post-treatment and pre- 5. Covered Minor Restorative Services.

a. Routine amalgam and composite fillings on posterior and anterior teeth are covered services. Restoration of primary teeth close to exfoliation is not covered.

i. For Child Clients who present with overt symptomatology or ectopic eruption because of an inability to extract the exfoliating teeth themselves, extraction of primary teeth may be approved subject to EPSDT guidelines.

b. The occlusal surface is exempt from the three (3) year frequency limitations listed below when a multi-surface restoration is required or following endodontic therapy.

c. Amalgam and composite fillings shall be limited to one (1) time per surface per tooth, every three (3) years. The limitation shall begin on the date of service and multi-surface fillings are allowable.

Amalgam and composite fillings will not be reimbursed if it is provided on the same day of treatment as a crown. Where both are provided on the same day, only the crown will be reimbursed.

d. Prefabricated Stainless Steel Crown, Primary Tooth; may be e. Prefabricated Stainless Steel Crown, Permanent Tooth; may be f. Prefabricated Stainless Steel Crown, with Resin Window; may be g. Protective Restoration, shall be limited to once per lifetime per tooth, primary and permanent teeth.

h. Interim Therapeutic Restoration, Primary Dentition; shall be limited to once per lifetime per tooth, primary teeth only. Not considered a definitive restoration.

Covered Major Restorative Services a. The following crowns are a covered service:

i. Single crowns, shall be limited to one (1) per tooth every seven (7) years. Requires prior authorization.

ii. Core build-up; building, shall be limited to one (1) per tooth every seven (7) years. Requires prior authorization.

iii. Pre-fabricated post and core, shall be limited to one (1) per tooth every seven (7) years. Requires prior authorization.

b. Permanent crowns shall be limited to Child Clients ages 16 years and older.

c. Crowns are covered services only when all of the following conditions are met:

i. The tooth is in occlusion; and ii. The cause of the problem is either decay or fracture; and iii. The tooth is not a third molar; and iv. The Child Client’s record reflects evidence of good and consistent oral hygiene; and one of the following is also true:

The tooth in question requires a multi-surface restoration and it cannot be restored with other restorative materials; or 2. A crown is requested by the dental professional through the prior authorization process for cracked tooth syndrome and the tooth is symptomatic and appropriate testing and documentation is provided.

d. Crown materials shall be limited to porcelain, full porcelain, noble metal, or high noble metal, on anterior teeth and premolars.

Covered Endodontic Services a. The following endodontic procedures are covered:

i. Therapeutic Pulpotomy (Excluding Final Restoration; removal of the top part of the pulp and application of medicament), shall be limited to one (1) per tooth per lifetime, primary teeth only. Therapeutic Pulpotomy is not allowable as the first state of root canal treatment or for Apexogenesis. Will not be reimbursed if the original treatment was previously reimbursed to the same Provider by Colorado Medicaid.

ii. Pulpal Debridement, shall be limited to one (1) per tooth per lifetime; permanent teeth only.

Covered in emergency situations only.
Exempt from prior authorization process but may be 3. Will not be reimbursed when root canal is completed on the same day by the same dentist or dental office.

iii. Partial Pulpotomy for Apexogenesis; shall be limited to one (1) per tooth per lifetime; permanent teeth only.

Exempt from prior authorization process but may be iv. Root Canal, Anterior Tooth; shall be limited to one (1) per tooth per lifetime; permanent teeth only.

v. Root Canal, Bicuspid; shall be limited to one (1) per tooth per lifetime; permanent teeth only.

vi. Root Canal, Molar; shall be limited to one (1) per tooth per lifetime; permanent teeth only.

vii. Retreatment of Previous Root Canal Therapy, Anterior Tooth; shall be limited to one (1) per lifetime; permanent teeth only. Will not be reimbursed if the original treatment was previously reimbursed to the same dentist or group by Colorado Medicaid. Requires prior authorization.

viii. Retreatment of Previous Root Canal Therapy, Bicuspid Tooth; shall be limited to one (1) per tooth per lifetime. Will not be reimbursed if the original treatment was previously reimbursed to the same dentist or group by Colorado Medicaid. Requires prior authorization.

ix. Retreatment of Previous Root Canal Therapy, Posterior Tooth; shall be limited to one (1) per tooth per lifetime. Will not be reimbursed if the original treatment was previously reimbursed to the same dentist or group by Colorado Medicaid. Requires prior authorization.

x. Apexification/ Recalcification procedures; shall be limited to one (1) per tooth per lifetime; permanent teeth only.

Exempt from prior authorization process but may be xi. Pulpal Regeneration; shall be limited to one (1) per tooth per lifetime.
Exempt from prior authorization process but may be b. Endodontic procedures are covered services when:

i. The tooth is not a third molar; and ii. The Child Client’s record reflects evidence of good and consistent oral hygiene; and 1. The cause of the problem is either decay or fracture; and one of the following is also true:

a. The tooth is in occlusion; or b. A root canal is requested by the dental professional through the prior authorization process for cracked tooth syndrome and the tooth is symptomatic and appropriate testing and documentation is provided.

c. In all instances in which the Child Client is in acute pain or there exists acute trauma, the dentist should take the necessary steps to relieve the pain and complete the Emergency Services. In these instances, there may not be time for prior authorization. Such emergency services shall be subject to post-treatment and pre-payment review.

d. Working films (including the final treatment film) for endodontic procedures are considered

part of the procedure and will not be reimbursed separately.

Covered Periodontal Treatment a. Gingivectomy or Gingivoplasty, Four or More Contiguous Teeth or Tooth Bounded Spaces per Quadrant; shall be limited to one (1) per three (3) years per Child Client per quadrant. Includes six (6) months of postoperative care. Requires prior authorization.

b. Gingivectomy or gingivoplasty, One to Three Contiguous Teeth or Tooth Bounded Spaces per Quadrant; shall be limited to one (1) per three (3) years per Child Client per quadrant. Includes six (6) months of postoperative care. Requires prior authorization.

c. Gingivectomy or Gingivoplasty to Allow Access for Restorative Procedure, per Tooth; shall be limited to one (1) per three (3) years per Child Client per quadrant.

d. Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis; shall be limited to Child Clients ages 13 through 20.

i. Exempt from prior authorization process for Child Clients ages 13 through 20 but may be subject to post-treatment and pre-payment review.

ii. Other periodontal treatments will not be reimbursed when provided on the same date as full mouth debridement.

Where other periodontal services are provided on the same day, only the full mouth debridement will be reimbursed.

iii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as full mouth debridement. Where both are provided on the same day, only the full mouth debridement e. Periodontal Scaling and Root Planing; Four (4) or More Teeth per Quadrant; shall be limited to once per quadrant every three (3) years.

i. Only covered by report. Periodontal disease must be documented. Requires prior authorization.

ii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as a periodontal scaling and root planing; four (4) or more teeth per quadrant. Where both are provided on the same day, only the periodontal scaling and root planing; four (4) or more teeth per quadrant will be iii. No more than two (2) quadrants per day.

f. Periodontal Scaling and Root Planing; One (1) to Three (3) Teeth per Quadrant; shall be limited to once per quadrant every three (3) years.

i. Only covered by report. Periodontal disease must be documented in the medical record. Requires prior ii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as a periodontal scaling and root planing; one (1) to three (3) teeth per quadrant. Where both are provided on the same day, only the periodontal scaling and root planing; one (1) to three (3) teeth per quadrant will be iii. No more than two (2) quadrants per day.

g. Periodontal Maintenance; shall be limited to two (2) times per year; counts as a prophylaxis (cleaning).

i. Periodontal maintenance is a covered service for Child Clients age 20 or under who are at high risk of periodontal disease or for caries. Indicators of high risk of periodontal disease include:

History of periodontal scaling and root planing; or 2. History of periodontal surgery; or 3. Diabetic diagnosis; or 4. Pregnancy; or 5. By report when periodontal disease can be documented. Requires prior authorization.

h. For child clients who are at high risk for periodontal disease as indicated above, any combination of up to four (4) prophylaxes (cleanings) or four (4) periodontal maintenance visits are allowed per year.

i. In all instances in which the Child Client is in acute pain or there exists acute trauma, the dentist should take the necessary steps to relieve the pain and complete the necessary emergency services.

In these instances, there may not be time for prior authorization.

Such emergency services shall be subject to post-treatment and pre-payment review.

Covered Removable Prosthetics a. Removable prosthetics are not covered if eight (8) or more posterior teeth (natural or artificial) are in occlusion. Anterior teeth shall be covered, irrespective of the number of teeth in occlusion.

b. Removable prosthetics covered include:

i. Removable Partial Upper Denture, Resin Based; shall be ii. Removable Partial Lower Denture, Resin Based; shall be iii. Removable Partial Upper Denture, Cast Metal Framework; shall be limited to one (1) time every five (5) years. Requires iv. Removable Partial Lower Denture, Cast Metal Framework; shall be limited to one (1) time every five (5) years. Requires v. Removable Partial Upper Denture, Flexible Base; shall be vi. Removable Partial Lower Denture, Flexible Base; shall be vii. Complete Upper Dentures; shall be limited to one (1) time every five (5) years. Includes initial six (6) months of relines.

viii. Complete Lower Dentures; shall be limited to one (1) time every five (5) years. Includes initial six (6) months of relines.

ix. Immediate Upper Dentures; shall be limited to one (1) per lifetime per patient. Includes initial six (6) months of relines.

x. Immediate Lower Dentures; shall be limited to one (1) per lifetime per patient. Includes initial six (6) months of relines.

xi. Obturator Prosthesis, Surgical, Definitive and/or Modification; covered by report. Requires prior authorization.

Covered Oral Surgery, Palliative Treatment and Anesthesia a. The following surgical and palliative treatments are covered:

i. Simple Extraction; shall be limited to one (1) time per tooth.

ii. Surgical Extraction; shall be limited to one (1) time per tooth.

iii. Extraction, Coronal Remnants, Deciduous Tooth; shall be limited to one (1) time per tooth.

iv. Incision and Drainage of Abscess; concurrent with extraction will be covered by report when narrative of medical necessity can be documented. Will not be reimbursed in same surgical area and on same visit as any other definitive treatment codes; except for covered services necessary for diagnosis.

Such incision and drainage procedures may be subject to post-treatment and pre-payment review.

v. Palliative Treatment of Dental Pain; will not be reimbursed on same visit as any definitive treatment codes; except for radiographs necessary for diagnosis. Will not be reimbursed when only other service is writing a prescription.

vi. Deep Sedation/General Anesthesia.

Only for Child Clients with special health care needs 2. Nitrous oxide will not be reimbursed if provided on the same day as deep sedation/general anesthesia, intravenous conscious sedation, or non-intravenous conscious sedation. Where multiple levels of anesthesia are provided on the same day, only the deep sedation/general anesthesia will be reimbursed.

vii. Nitrous Oxide; will not be reimbursed if it is provided on the same day as deep sedation/general anesthesia, intravenous conscious sedation, or non-intravenous conscious sedation.

Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered viii. Intravenous Conscious Sedation.

Only for Child Clients with special health care needs 2. Intravenous conscious sedation will not be reimbursed if provided on the same day as deep sedation/general anesthesia, nitrous oxide, or nonintravenous conscious sedation. Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered will be reimbursed.

ix. Non-Intravenous Conscious Sedation.

Only for Child Clients with special health care needs 2. Non- intravenous conscious sedation will not be reimbursed if provided on the same day as deep sedation/general anesthesia, nitrous oxide, or intravenous conscious sedation. Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered will be reimbursed.

b. In all instances in which the Child Client is in acute pain, the dentist should take the necessary steps to relieve the pain and complete the necessary emergency services. In these instances, there may not be time for prior authorization. Such emergency services shall be subject to post-treatment and pre-payment review.

c. Biopsies are covered only in instances where there is a suspicious lesion.

d. Removal of third molars is only covered in instances of acute pain and overt symptomatology.

e. Extraction of primary teeth which are close to exfoliation will not be covered.

Covered Hospital-Based Services a. Dental treatment is covered in a hospital or outpatient facility, under deep sedation or general anesthesia, only when there is medical b. Under this Section 11, medical necessity, shall be limited to the i. Patients with a documented physical, mental or medically compromising condition.

ii. Patients who have a dental need and for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy.

iii. Patients who are extremely uncooperative, unmanageable, anxious or uncommunicative and who have dental needs deemed sufficiently urgent that care cannot be deferred.

Evidence of the attempt to manage in an outpatient setting must be provided.

iv. Patients who have sustained extensive orofacial and dental trauma.

v. Child Clients ages 6 and under who present with rampant decay.

c. All operating room cases require prior authorization, even if the complete treatment plan is not available.

d. Consistent with the Guidelines of the American Academy of Pediatric Dentistry, the following shall be considered when contemplating treatment of a child under d.eep sedation or general anesthesia:

i. Alternative behavioral guidance modalities.

ii. Dental needs of the patient.

iii. The effect on the quality of dental care.

iv. The patient’s emotional development.

v. The patient’s medical status.

e. General anesthesia and sedation are not covered services when the patient is cooperative and requires minimal dental treatment, or when the patient has a concomitant medical condition which would make general anesthesia or sedation unsafe.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Services will be provided to Child Clients age 20 years and under if the criteria are met. 8.202.2.B. Exclusions.

Notwithstanding exceptions for EPSDT Services, the following services/treatments are not a benefit for Child Clients age 20 years and under:

a. Cosmetic procedures.

b. Crowns in the following categories:

i. Cosmetic crowns;

ii. Multiple units of crown and bridge;

iii. To restore vertical dimension;

iv. When Child Client has active and advanced periodontal disease;

v. When the tooth is not in occlusion; or vi. When there is evidence of periapical pathology.

c. Implants.

d. Endodontic surgery.

e. Treatment for temporomandibular joint disorders.

f. Oral hygiene instruction.

g. Working and final treatment films for root canal treatment.

h. Root canals for third molars.

i. Removal of third molars. Removal of third molars is only covered in instances of acute pain and overt symptomatology.

j. Any service that is not listed as covered.

8.202.3 PRIOR AUTHORIZATION REQUEST

Emergency Services do not require a prior authorization and shall be subject to pre-payment review.
Prior authorizations or benefits shall be denied for reasons of poor dental prognosis, lack of dental necessity or appropriateness or because the requested services do not meet the generally accepted standard of dental care.
The following services require prior authorization:

a. Single crowns; core build-ups; post and cores.

b. Gingivectomy.

c. Complete, partial, and immediate dentures.

d. Obturators.

e. Scaling and root planing (periodontal maintenance).

f. Retreatment of root canals; prior authorization is not required for pulpal debridement in instances of acute pain.

g. Hospital-based services when treatment is required.

8.202.4. PROVIDER REQUIREMENTS/REIMBURSEMENT 8.202.4.A. Dental services shall only be provided by a dental professional who is enrolled with Colorado Medicaid with the exception of services rendered to Child Clients by qualified medical personnel. Providers shall only provide covered services that are within the scope of their practice. 8.202.4.B. The following billing limitations apply:

Restorations:

a. Tooth preparation, anesthesia, all adhesives, liners and bases, polishing and occlusal adjustments are included within the reimbursement rate for restoration. Unbundling of dental restorations for billing purposes is not allowed.

b. Restorations for permanent and primary teeth are paid at the c. The total restorative fee for a primary tooth cannot exceed the current maximum benefit for a prefabricated stainless steel crown.

d. Amalgam and composite restorations are reimbursed at the e. Claim payment to a dental provider for one (1) or more restorations for the same tooth is limited to a total of four (4) tooth surfaces.

Pulpal debridement; if a dentist completes a pulpal debridement procedure, and subsequently completes a root canal on the same tooth; payment for the pulpal debridement will be subtracted from the final root canal payment.
Hospital procedures; payment for services performed in the operating room or outpatient facility, when scheduled for the convenience of the provider or the patient in the absence of medical necessity, will not be reimbursed.
In the event that two or more treatments could be used to adequately diagnose and treat a dental condition, the Provider shall use the least costly of those options in accordance with best dental practices.
If a procedure is not listed as covered benefit, the procedure will not be covered, unless special consideration and approval has been obtained, to reflect extenuating circumstances.
A client may make personal expenditures for services not covered by Medicaid and shall be charged the lower of the Medicaid Fee Schedule or submitted charges.

8.202.5 ELIGIBLE CLIENTS

Dental services described in this Section 8.202 shall apply to Child Clients age 20 years and under.

8.203 VISION SERVICES 8.203.1 Definitions A. Adult Member means a Health First Colorado member 21 years of age or older.

B. Comprehensive Eye Exam means the examination, diagnosis, treatment, and management of diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identified related systemic conditions affecting the eye.

C. Low Vision Aid means one of a range of magnification devices that may be necessary to supplement eyeglasses for people with vision loss or low vision.

D. Refractive Error means a failure of the eye to focus images sharply on the retina, causing blurred vision. 8.203.2 Member Eligibility 8.203.2.A. All Health First Colorado members are eligible for covered vision services, subject to the service-specific criteria and restrictions detailed in this section 8.203. 8.203.3 Provider Eligibility 8.203.3.A. Ordering, Prescribing, Referring (OPR) Providers 1. The following providers are eligible to order, prescribe, or refer vision services when enrolled with Health First Colorado and licensed by the Colorado Department of Regulatory Agencies, or the licensing agency of the state in which they do business, and when operating within their scope of practice according to state law:

a. Optometrists b. Ophthalmologists and other physicians acting within the scope of their licensure c. Advanced Practice Nurses d. Physician Assistants e. Registered Nurses 2. Claims for vision services, including durable medical equipment (DME), must contain the National Provider Identifier (NPI) of the enrolled Medicaid provider who orders, prescribes or refers a service. Providers who are not enrolled in Medicaid may not order, prescribe, or refer for a Medicaidcovered service. 8.203.3.B. Rendering Providers 1. The following providers are eligible to render vision services when enrolled with Health First Colorado and licensed by the Colorado Department of Regulatory Agencies, or the licensing agency of the state in which they do business, and when operating within their scope of practice according to state law:

a. Optometrists b. Ophthalmologists and other physicians acting within the scope of their licensure c. Advanced Practice Nurses d. Physician Assistants e. Registered Nurses 8.203.4 Covered Services 8.203.4.A. Examinations and Eye Care Services 1. Comprehensive Eye Exam (CEE)

a. Limited to one (1) comprehensive eye exam per member, per calendar year.

Post-Comprehensive Eye Exam Follow-Up Visit a. Covered if medically necessary, as defined in Section 8.076.1.8, and under Section 8.280.4.E. if the member is under 21 years of age, to address a change in member’s condition.
Orthoptic and Pleoptic Vision Therapy a. Covered for a member 20 years of age or younger, when medically necessary, as defined in Section 8.076.1.8. 8.203.4.B. Eyeglasses 1. Frames and Lenses – Adult Members a. Frames and lenses are covered for an Adult Member if:

i) Member has previously undergone eye surgery; and ii) Medically necessary, as defined in Section 8.076.1.8.

b. Covered frames and lenses for an Adult Member are limited to:

i) One (1) eyeglasses frame; and ii) Up to two (2) lenses that are:

Single or multi-focal;
Clear glass or plastic; and 3) Without filters or coatings.

iii) Aspheric single vision and multifocal lenses are only covered when medically necessary and the spherical equivalent of the prescription is equal to or greater than +/- 6.0 diopters.

c. Limited to one (1) pair of eyeglasses per Adult Member, per 24month period.

Frames and Lenses – Members 20 Years of Age or Younger a. Frames and lenses are covered for a member 20 years of age or younger if:

i) Medically necessary, as defined in Section 8.076.1.8;

ii) Prescribed by a provider who meets the criteria at Section 8.203.3.A.; and iii) Purchased through a provider who meets the criteria at

Section 8.203.3.B.

b. Per prescription, covered frames and lenses for a member 20 years of age or younger are limited to:

i) One (1) eyeglasses frame; and ii) Up to two (2) lenses that are:

Single or multi-focal; and 2) Clear glass, plastic, or polycarbonate.

iii) Aspheric single vision and multifocal lenses are only covered when medically necessary and the spherical equivalent of the prescription is equal to or greater than +/- 6.0 diopters. 8.203.4.C. Contact Lenses 1. Contact lenses are covered for an Adult Member if:

a. Member meets the criteria for eyeglasses frames and lenses in

Section 8.203.4.B.1.a.; and b. Eyeglasses are not sufficient to treat the member’s refractive error.

Contact lenses are covered for a member 20 years of age or younger if:

a. Member meets criteria for eyeglasses frames and lenses in Section 8.203.4.B.2.a.; and b. Eyeglasses are not sufficient to treat the member’s refractive error. 8.203.4.D. Ocular Prosthetics Ocular prosthetics are covered for all members when medically necessary, as defined in

Section 8.076.1.8. 8.203.4.E. Low Vision Aids Low Vision Aids are covered for a member 20 years of age or younger when medically necessary, as defined at Section 8.076.1.8. 8.203.4.F. Eyewear Replacement 1. Eyewear replacement is covered for a member 20 years of age or younger in the event of:

a. Loss;

b. A change in prescription; or c. Damage, if the cost to repair exceeds the cost of replacement.

Eyewear replacement for a member 20 years of age or younger is limited to the following types of eyewear:

a. Eyeglasses frames and lenses;

b. Contact lenses;

c. Ocular prosthetics; and d. Low vision aids.

Eyewear replacement is not covered for Adult Members. 8.203.5 Prior Authorization 8.203.5.A. Prior authorization may be required for vision services described in

Section 8.203.4. 8.203.6 Limitations, Exceptions, Non-Covered Services 8.203.6.A. Non-Covered Services 1. LASIK surgery and other eye surgeries which are not medically necessary.

8.205 MEDICAID STATEWIDE MANAGED CARE SYSTEM

8.205.1 DEFINITIONS 8.205.1.A. Attribution means the process by which the Department enrolls a Member with a Primary Care Medical Provider or Managed Care Organization. 8.205.1.B. Covered Services means the health care services defined in the contract between the Department and a Managed Care Organization or Prepaid Inpatient Health Plan that are paid through a Monthly Capitation Payment. 8.205.1.C,. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention or behavioral health services to result in the following:

Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) or the health of another in serious jeopardy.
Serious impairment to bodily functions.
Serious dysfunction of any bodily organ or part. 8.205.1.D. Emergency services means covered inpatient and outpatient services that are as follows:
Furnished by a provider that is qualified to furnish these services.
Needed to evaluate or stabilize an emergency medical condition. 8.205.2.E. Managed Care Organization (MCO) shall mean an entity that has, or is seeking to qualify for, a comprehensive risk contract under 42 CFR 438.2, and that is:
A Federally qualified HMO that meets the advance directives requirements of subpart I of 42 CFR 489; or 2. Any public or private entity that meets the advance directives requirements and is determined by the Secretary of the U.S. Department of Health and Human Services to also make the services it provides to its Medicaid members as accessible (in terms of timelines, amount, duration, and scope) as those services are to other Medicaid beneficiaries within the area served by the entity; and meets the solvency standards of 42 CFR 438.116. 8.205.1.F. Medicaid Statewide Managed Care System, also known as the Accountable Care Collaborative, means any Managed Care Organization, Primary Care Case Management Entity, or Prepaid Inpatient Health Plan established under the State authorities established in Title 25.5, Article 5, Part 4, C.R.S. and under the federal authority established in 42 C.F.R. Part 438 and approved by the Centers for Medicare and Medicaid Services (CMS). 8.205.1.G. Member means any person enrolled in the Medicaid Statewide Managed Care System. 8.205.1.H. Prepaid Inpatient Health Plan (PIHP) shall mean an entity that provides medical services to members under contract with the State agency, and on the

basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates; provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its members; and does not have a comprehensive risk contract. 8.205.1.I. Primary Care Case Management Entity (PCCM Entity) means an entity contracted with the state department to furnish case management services, including the coordination and monitoring of primary health care services, as defined in 42 CFR § 438.2. 8.205.1.J. Primary Care Medical Provider (PCMP) means a primary care provider contracted with PCCM Entity to serve as a medical home for members. 8.205.1.K. Utilization Management means the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.

8.205.2 MEMBER ELIGIBILITY 8.205.2.A. A Medicaid member with full Medicaid benefits must be enrolled into the Medicaid Statewide Managed Care System, with the exception of the individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE) as defined in

Section 8.497. 8.205.2.B. The following individuals are not eligible for enrollment in the Medicaid Statewide Managed Care System:

Qualified Medicare Beneficiary only (QMB-only).
Qualified Disabled and Working Individuals (QDWI)
Qualified Individuals 1 (QI 1).
Special Low Income Medicare Beneficiaries (SLMB).
Undocumented immigrants, with the exception of individuals who meet the criteria in Section 8.100.3(G)(1)(g)(viii).
Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE).
Individuals between ages 21 and 64 who are inpatient at the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan.
Individuals who are incarcerated.
Individuals while determined presumptively eligible for Medicaid.

8.205.3 MEMBER RIGHTS AND PROTECTIONS 8.205.3.A. A Member enrolled in a PCCM Entity, MCO, or PIHP has the following rights and protections:

To be treated with respect and with due consideration for the Member’s dignity and privacy.
To receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee's condition and ability to understand.
To participate in decisions regarding the Member’s health care, including the right to refuse treatment and the right to a second opinion.
To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
To obtain family planning services and family planning-related services directly from any provider duly licensed or certified to provide such services without regard to enrollment in a PCCM Entity, MCO, or PIHP, without referral.
To request and receive a copy of the Member’s medical records and to request that they be amended or corrected, as specified in 45. CFR Part 164.
To select a PCMP from those available in the PCCM Entity or MCO network.
To request any change of PCMP in a PCCM Entity network from the Department or its designee.
To select or request a change of a provider from those providers available in the MCO or PIHP provider network.
To have access to written materials that are critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices available in the prevalent non-English languages. All materials shall be written in English and Spanish, or any other prevalent language, as directed by the Department or as required by 42 CFR 438.10.
To have oral interpretation available in all languages and written translation available in each prevalent non-English language at no cost to any Member.
To exercise the Member’s rights without any adverse effect on the way the Member is treated.

8.205.4 MEMBER ENROLLMENT AND DISENROLLMENT 8.205.4.A. Enrollment in the Medicaid Statewide Managed Care System is mandatory for eligible Members. 8.205.4.B. Members enrolled into the Medicaid Statewide Managed Care System are attributed to a PCMP or MCO.

Members may be attributed to an MCO in accordance with the Department’s member enrollment policy that takes into consideration the a. County of residence.

i. Members residing in Garfied, Gunnison, Mesa, Montrose, Pitkin, and Rio Blanco counties may be attributed to the MCO operated by or under the control of Rocky Mountain Health Plans.

ii. Members residing in Adams, Arapahoe, Denver, and Jefferson Counties may be attributed to the MCO operated by or under the control of Denver Health and Hospital

Authority.

b. Member’s age.

c. Member’s Medicaid aid category.

Members will be attributed to a PCMP based on factors that include Member choice, Member utilization history, provider capacity, and geographic location in accordance with the Department’s member enrollment policy in the following instances:

a. The Member resides in a county that is not covered by an MCO.

b. The Member opts out of enrollment in an MCO.

Members may change their attribution to a PCMP by contacting the Department or its designee. Any change in attribution to a PCMP is effective the first day of the month following the member’s formal submission of the change request to the Department or its designee.
Members may change their attribution to an MCO as specified in 8.205.5.

H, I, J, and K. 8.205.4.C. Members attributed to a PCMP are assigned to a PCCM Entity/PIHP based on the PCMP’s contract with a PCCM Entity/PIHP. 8.205.4.D. Members attributed to an MCO are assigned to the PIHP contracted with the MCO. 8.205.4.E Child and youth Members determined eligible for Medicaid as a result of a dependency and neglect action resulting in out-of-home placement pursuant to

article 2 of title 19 C.R.S. must be assigned to the PCCM Entity and PIHP that cover the county with jurisdiction over the action.

The Department or its designee may change the child or youth Member’s PCCM Entity and PIHP assignment only at the request of the county with jurisdiction over the action or by the child’s or youth’s legal guardian. 8.205.4.F. Members who are disenrolled from a PCCM Entity, MCO, or PIHP for a period of two (2) months or less due to loss of eligibility shall be reenrolled into the same program upon regaining eligibility within the two (2) month period. 8.205.4.G. A Member who is enrolled with an MCO remains assigned to that MCO for a period of twelve (12) months except as otherwise provided in these rules. 8.205.4.H. A Member may request disenrollment from their MCO without cause during the ninety (90) days following the date of their initial enrollment or the date the Department or its designee sends the notice of enrollment, whichever is later. 8.205.4.I. A Member may request disenrollment without cause at least every twelve (12) months after the date of initial enrollment with an MCO. 8.205.4.J. A Member may request disenrollment when the Department imposes intermediate sanctions as set forth in the Department's contract with the MCO. 8.205.4.K. A Member may request disenrollment from an MCO for cause at any time.

Cause shall be defined as any of the following:

The Member moves out of the MCO service area.
The MCO does not, because of moral or religious objections, cover the service the Member needs.
The Member needs related services to be performed at the same time and not all related services are available within the MCO network, and the Member’s provider determines that receiving the services separately would subject the Member to unnecessary risk.
The Department or its designee unintentionally enrolls a Member into the wrong plan.
Poor quality of care, as documented by the Department.
Lack of access to covered services, as documented by the Department.
Lack of access to providers experienced in dealing with the Member’s health care needs, as documented by the Department.
The Member’s primary care provider leaves the MCO.
Other reasons satisfactory to the Department. 8.205.4.L. For Members who are unable to make decisions for themselves, a family member, legal guardian or designated advocate shall be included in all decisionmaking concerning enrollment and disenrollment of the Member.

8.205.5 DISMISSAL OF MEMBER BY A PROVIDER 8.205.5.A. Providers, excluding safety net providers, participating in a PCCM Entity, MCO, or PIHP may dismiss an enrolled Member from their practice for cause at any time. Cause shall be defined as any of the following:

A documented, ongoing pattern of failure on the part of the Member to keep scheduled appointments or meet any other Member responsibilities.
A documented ongoing pattern of failure to follow the recommended treatment plan or medical instructions.
The provider cannot provide the level of care necessary to meet the Member’s needs.
The Member and /or Member’s family is abusive to provider and/or staff.
The provider moves out of the service area.
Other reasons approved by the Department. 8.205.5.B. Providers must take the following steps prior to dismissing a Member from their practice:
The provider shall give no less than 45 days notice to both the Member and the PCCM Entity, MCO or PIHP.
For Members with behavioral health needs who are at risk of dismissal, the provider must make a referral for care coordination to the Member’s MCO, PIHP, or PCCM Entity prior to giving written notice of dismissal.
The provider shall give the Member a reasonable opportunity to find substitute care and information necessary to obtain the patient’s medical records; 8.205.5.C. The PCCM Entity, MCO or PIHP shall respond within 48 hours of any request to coordinate Member access to a new provider.

8.205.6 ESSENTIAL COMMUNITY PROVIDERS 8.205.6.A In order to be eligible for designation as an Essential Community Provider, the following health care providers shall be determined to have historically served medically needy or medically indigent patients and demonstrated a commitment to serve low-income and medically indigent populations who make up a significant portion of their patient population or, in the case of a sole community provider, serve the medically indigent patients within their medical capability:

Disproportionate share hospitals.
Local county and district health departments, county nursing services and regional health department operating pursuant to Title 25, C.R.S., as amended.
Federally Qualified Health Centers (FQHCs).
School based health centers that can verify that 25% of students enrolled in the school are at or below 185% of the Federal Poverty Level and that services are offered to the entire student population enrolled in the school without regard to the patient's ability to pay.
Family Medicine Residency Training Programs that can verify that 25 % of the patients served are at or below 185% of the Federal Poverty Level.
Rural Health Clinics that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
State certified Title X Family. Planning Agencies that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
Sole community providers that are not located within a metropolitan statistical area, as designated by the U.S. Office of Management and Budget, and in whose community there is no other similar type of health care and the provider can verify that it provides health care services to patients below 185% of the Federal Poverty Level within its medical capability.
New health care providers operating under a sponsoring or participating entity that qualifies as an Essential Community Provider.
Health care providers that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level. 8.205.6.B. In order to be eligible for designation as an Essential Community Provider, the provider shall waive charges or charge for services on a sliding scale for patients/families at or below 185% of the Federal Poverty Level. 8.205.6.C. Health care providers, except those set forth a 8.206.1(1) through (3), who seek to be designated as an Essential Community Provider, shall submit their application, including a copy of their sliding fee scale to the Department.

8.205.7 QUALIFIED PHARMACY PROVIDERS 8.205.7.A. An MCO shall contract with qualified pharmacy providers in a manner permitting a nursing facility to continue to comply with federal Medicaid requirements of participation. 8.205.7.B. A qualified pharmacy provider shall meet all of the following requirements:

Employ, on a full-time basis, a pharmacist licensed by the State of Colorado.
Demonstrate a capability of procuring, preparing, dispensing and distributing pharmaceutical products in an institutional setting.
Demonstrate a capability of monitoring Members on an ongoing basis to identify, prevent and resolve drug-related problems including, but not limited to, the monitoring of drug-drug interactions and drag-allergy interactions.
Provide pharmaceutical consulting services twenty-four (24) hours per day.
Perform medication-use assessments with the assistance of a pharmacist licensed by the State of Colorado at least once each month. Such assessments shall be Member-centered, ensuring that the Member’s medication regimen meets his or her needs.
Participate with the Member’s physicians, nurses, dieticians and other health care professionals in inter-disciplinary care planning.
Provide continuous pharmaceutical care and services to Members twentyfour (24) hours per day every day.
Reasonably respond to emergency situations and maintain an emergency kit registered with the. Colorado. State Board of Pharmacy at each nursing home.
Utilize appropriate unit dose or unit of issue distribution systems to ensure that Members receive proper medications, at the proper time, and at the proper dosage.
Demonstrate its capability to provide physician orders and medication administration records on a monthly basis.

8.205.8 PERSONS WITH SPECIAL HEALTH CARE NEEDS 8.205.8.A. Persons with Special Health Care Needs shall mean persons having ongoing health conditions that 1. Have a biologic, psychologic or cognitive basis;

Have lasted or are virtually certain to last for at least one year; and 3. Produce one or more of the following sequelae:

a. Significant limitation in areas of physical, cognitive or emotional function;

b. Dependency on medical or assistive devices to minimize limitation of function or activities;

c. In addition, for children:

(i) Significant limitation in social growth or developmental function;

(ii) Need for psychologic, educational, medical or related services over and above the usual for the child's age; or (iii) Special ongoing treatments such as medications, special diets, interventions or accommodations at home or at school.

8.205.9 STATEWIDE SYSTEM OF COMMUNITY BEHAVIORAL HEALTH CARE 8.205.9.A The Medicaid Statewide Managed Care System must include PIHPs to administer a statewide system of community behavioral health care. 8.205.9.B. The following are required services of the statewide system of community behavioral health care:

Inpatient Behavioral Health Services -- A program in which the Member receives services in a hospital or health care facility 24 hours a day.

a. Inpatient Psychiatric Services -- A program of psychiatric care in which the Member remains 24 hours a day in a psychiatric hospital, State Institute for Mental Disease (IMD), or other facility licensed as a hospital or Psychiatric Residential Treatment Facility by the State.

i. Members under age 21 and members 65 years of age or older may receive services in an IMD.

ii. Members ages 21-64 are excluded from receiving services in an IMD for more than 15 days within a month.

b. Residential and Inpatient Substance Use Disorder Services i. Inpatient Substance Use Disorder Services – Substance use disorder services that provide a planned and structured regimen of 24-hour professionally directed evaluation, observation, medical monitoring and addiction treatment in an inpatient setting. American Society of Addiction Medicine level 4 services are reimbursed fee for service and are not covered by the PIHP as part of the statewide system of community behavioral health care.

ii. Residential Substance Use Disorder Services – Substance use disorder services that are delivered in settings that provide 24-hour structure, support and clinical interventions for patients. These services are appropriate for Members who require time and structure to practice and integrate their recovery and coping skills in a residential, supportive environment. Higher levels of residential treatment provide safe, stable living environments for Members who need them to establish or maintain their recovery apart from environments that promote continued use in the community.

Outpatient Services -- A program of care in which the Member receives services in a hospital or other health care facility, but does not remain in the facility 24 hours a day, including:

a. Physician Services, including psychiatric care – Behavioral health services provided within the scope of practice of medicine as defined by State law.

b. Rehabilitative Services – Any remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of behavioral/emotional disability and restoration of a Member to the Member’s best possible functional level, including:

i. Individual Behavioral Health Therapy - Therapeutic contact with one Member of more than 30 minutes, but no more than two (2) hours.

ii. Individual Brief Behavioral Health Therapy- Therapeutic contact with one Member of up to and including 30 minutes.

Iii Group Behavioral Health Therapy- Therapeutic contact with more than one Member, of up to and including two (2) hours.

iv. Family Behavioral Health Therapy– Therapeutic contact with a Member and family member(s), or other persons significant to the Member, for improving Member-family functioning. Family behavioral health therapy is appropriate when intervention in the family interactions is expected to improve the Member’s emotional/behavioral health. The primary purpose of family behavioral health therapy is treatment of the Member.

v. Behavioral Health Assessment – Clinical assessment of a Member by a behavioral health professional that determines the nature of the Member’s problem(s), factors contributing to the problem(s), a Member’s strengths, abilities and resources to help solve the problem(s), and any existing diagnoses.

vi. Pharmacologic Management – Monitoring of medications prescribed and consultation provided to Members by a physician or other medical practitioner authorized to prescribe medications as defined by State law, including associated laboratory services, as indicated.

vii. Outpatient Day Treatment – Therapeutic contact with a Member in a structured, non-residential program of therapeutic activities lasting more than four (4) hours but less than twenty-four (24) hours per day. Services include assessment and monitoring; individual/group/family therapy; psychological testing; medical/nursing support; psychosocial education; skill development and socialization training focused on improving functional and behavioral deficits; medication management; expressive and activity therapies; and coordination of needed services with other agencies.

When provided in an outpatient hospital program, may be called “partial hospitalization.”

viii. Intensive Outpatient Substance Use Disorder Services – Therapeutic contact with a member to help the member achieve changes in their alcohol and/or other drug use.

Intensive outpatient treatment services are delivered with greater frequency than standard outpatient services. This level of care is appropriate for patients who have more complex needs. Allowable services include substance use disorder assessment, individual and family therapy, group therapy, and alcohol/drug screening counseling.

ix. Emergency/Crisis Services - Services provided during a behavioral health emergency which involve unscheduled, immediate, or special interventions in response to crisis situation with a Member, including associated laboratory services, as indicated.

Targeted Case Management – Case management services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services.
School-Based Behavioral Health Services - Behavioral health services provided to school-aged children and adolescents on-site in their schools, with the cooperation of the schools.
Drug Screening and Monitoring – Substance use disorder counseling services provided along with screening results to be discussed with client.
Detoxification Services – Services relating to detoxification including all of the following: Physical assessment of detox progression including vital signs monitoring; level of motivation assessment for treatment evaluation; provision of daily living needs (includes hydration, nutrition, cleanliness and toiletry); safety assessment, including suicidal ideation and other behavioral health issues.
Medication-Assisted Treatment – Administration of Methadone or another approved controlled substance to an opiate-dependent person for the

purpose of decreasing or eliminating dependence on opiate substances.

Alternative behavioral health services—Administration of non-traditional, community-based services not available through the State Plan but authorized through the Department’s 1915(b) waiver with the Centers for Medicare and Medicaid Services.

a. Assertive Community Treatment (ACT) – Comprehensive, locallybased, individualized treatment for adults with serious behavioral health disorders, that is available 24 hours a day, 365 days a year.

The ACT team actively engages Members in their community to develop skills and monitor status, rather than function as an officebased team. Services include case management, initial and ongoing behavioral health assessment, psychiatric services, employment and housing assistance, family support and education, and substance use disorders services.

b. Clubhouse and Drop-in Center services – Peer support services for people who have behavioral health disorders, provided in a Clubhouse or Drop-In Center setting. Clubhouse participants may use their skills for clerical work, data input, meal preparation, providing resource information and outreach to clients. Drop-in Centers offer planned activities and opportunities for individuals to interact socially, promoting and supporting recovery.

c. Intensive Case Management -- Community-based services averaging more than one hour per week, provided to adults with serious behavioral health disorders who are at risk of a more intensive 24 hour placement and who need extra support to live in the community. Services are assessment, care plan development, multi-system referrals, assistance with wraparound and supportive living services, monitoring and follow-up. Intensive case management may be provided to children/youth under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

d. Mental Health Residential Services – Twenty-four (24) hour care, excluding room and board, provided in a non-hospital, non-nursing home setting, appropriate for Members whose mental health issues and symptoms are severe enough to require a 24-hour structured program but do not require hospitalization. Services are provided in the setting where the client is living, in real-time, with immediate interventions available as needed. Clinical interventions are assessment and monitoring of mental and physical health status; assessment and monitoring of safety; assessment of/support for motivation for treatment; assessment of ability to provide for daily living needs; observation and assessment of group interactions; individual, group and family therapy; medication management; and behavioral interventions. Residential services may be provided to children/youth under EPSDT.

e. Prevention/Early Intervention Services – Proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive behavioral health.

Services include behavioral health screenings; educational programs promoting safe and stable families; senior workshops related to aging disorders; and parenting skills classes.

f. Recovery Services – Community-based services that promote selfmanagement of behavioral health symptoms, relapse prevention, treatment choices, mutual support, enrichment, rights protection, social supports. Services are peer counseling and support services, peer-run drop-in centers, peer-run employment services, peer mentoring, consumer and family support groups, warm lines, and advocacy services.

g. Respite Care – Temporary or short-term care of a child, youth or adult client provided by adults other than the birth parents, foster/adoptive parents, family members or caregivers that the Member normally resides with. Respite is designed to give the caregivers some time away from the Member to allow them to emotionally recharge and become better prepared to handle normal day-to-day challenges. Respite care providers are specially trained to serve individuals with behavioral health issues.

h. Vocational -- Services designed to help adult and adolescent clients who are ineligible for state vocational rehabilitation services to gain employment skills and employment. Services are skill and support development interventions, educational services, vocational assessment, and job coaching. 8.205.9.C. The PIHPs must offer Members an initial or subsequent nonurgent behavioral health care visit where medically necessary and at appropriate therapeutic intervals in compliance with C.R.S. § 25.5-5-402 (3)(g).

8.205.10 UTILIZATION MANAGEMENT 8.205.10.A. The MCOs and PIHPs must ensure Covered Services delivered to Members are Medically Necessary as defined in Section 8.076.1.8 as well as

Section 8.280 for Members under 21 years of age, delivered in the least restrictive setting, and most likely to address the Member’s health care needs by employing Utilization Management best practices.

If it is determined that the Member does not meet criteria of Medical Necessity or the Member has a diagnosis not covered by the capitated payment arrangement, MCOs and PIHPs must inform the Member about how other appropriate Medicaid State Plan services may be obtained and coordinate referrals to appropriate providers within the region within 48 hours of request from the Member, a family member, legal guardian or designated advocate. 8.205.10.B. Utilization Management practices shall align with the following guidelines:
Establish and regularly update Utilization Management policies and procedures for evaluating the clinical appropriateness, efficacy, or efficiency of Covered Services, referrals, procedures or settings in accordance with the most recent national and industry standards or guidelines and with federal and department rules and regulations.
Ensure Utilization Management policies and procedures are designed in compliance with 42 CFR 438. Part 2.
Design and implement Utilization Management policies and procedures in compliance with the federal Mental Health Parity and Addiction Equity Act requirements defined in 42 CFR 438 Subpart K, including the application of financial requirements, treatment limitations, and non-quantitative treatment limitations, as well as the process for determining access to outof-network providers. 4 Appropriately incorporate use of prior authorization and continued stay reviews for residential and inpatient behavioral health services that are not for treatment of an Emergency Medical Condition to ensure that the services requested or furnished are medically necessary and sufficient in amount, duration, or scope to reasonably be expected to achieve the

purpose for which the services are furnished.

a. Utilize the American Society of Addiction Medicine criteria to determine medical necessity for residential and inpatient substance use disorder treatment services.

b. Engage in care coordination and discharge planning to appropriately transition members across the continuum of care.

Make Utilization Management decision-making criteria available to members and providers upon request.
Designate an appropriately licensed medical professional to provide oversight and evaluation of the Utilization Management policies and activities.
Establish standards for Utilization Management personnel to consult with the ordering provider prior to denial or limitation of requested/provided 8. Ensure Utilization Management processes do not impede timely access to 8.205.10.C. The MCOs and PIHPs must ensure that the services requested or furnished are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. 8.205.10.D. The PIHPs must cover all medically necessary Covered Services for covered behavioral health diagnoses under the Capitated Behavioral Health Benefit, regardless of any co-occurring conditions. 8.205.10.E. The MCOs and PIHPs must not deny a Covered Service based solely on the Member having a diagnosis of a co-occurring intellectual or developmental disability, a neurological or neurocognitive disorder, or a traumatic brain injury. 8.205.10.F. The MCOs and PIHPs must not require prior authorization for the nonpharmaceutical components of medication-assisted treatment. 8.205.10.G. The MCOs must not impose any prior authorization requirements or step therapy requirements as a prerequisite to authorizing coverage for any prescription medication approved by the Food and Drug Administration for the treatment of substance use disorders. 8.205.10.H. The MCOs and PIHPs must coordinate State Plan covered services that are paid fee-for-service. 8.205.10.I. The MCOs and PIHPs must have a grievances and appeals process as specified in Section 8.209.

8.205.11 EMERGENCY SERVICES 8.205.11.A. The MCOs and PIHPs must cover and pay for emergency services regardless of whether the provider that furnishes the services has a contract with the MCO or PIHP, to the extent that services required to treat an emergency medical condition fall within the scope of services for which the MCO or PIHP is responsible. 8.205.11.B. The MCOs and PIHPs may not deny payment for treatment obtained under either of the following circumstances:

A Member had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of emergency medical condition in 8.205.1.C of this section.
A representative of the MCO or PIHP instructs the Member to seek emergency services. 8.205.11.C. The MCOs and PIHPs may not:
Limit what constitutes an emergency medical condition with reference to of the definition in 8.205.1.C of this section, on the basis of lists of diagnoses or symptoms, except to the extent that services required to treat an emergency medical condition fall outside the scope of the services for which the MCO and PIHP is responsible; and 2. Refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent not notifying the Member's primary care provider, MCO, PIHP, or applicable State entity of the Member's screening and treatment within 10 calendar days of presentation for emergency 8.205.11.D. A Member who has an emergency medical condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the Member.

8.209 MEDICAID MANAGED CARE GRIEVANCE AND APPEAL PROCESSES

8.209.1 GENERAL PROVISIONS

Medicaid members or their Designated Client Representatives enrolled in Managed Care Organizations (MCOs), Prepaid Inpatient Health Plans (PIHPs), or Prepaid Ambulatory Health Plans (PAHPs) may access and utilize the Medicaid Managed Care Grievance and Appeal Systems. The Grievance and Appeal Systems shall include a Grievance process and an Appeal process for handling Grievances and Appeals at the MCO, PIHP, or PAHP level and access to the State Fair Hearing process for Appeals.

8.209.2 DEFINITIONS 8.209.2.A. Adverse Benefit Determination shall mean:

The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of covered benefit;
The reduction, suspension or termination of a previously authorized service;
The denial, in whole or in part, of payment for a service;
The failure to provide services in a timely manner;
The failure to act within the timeframes provided in § 8.209.4 below;
The denial of a Medicaid member’s request to exercise his or her right to obtain services outside the network for members in rural areas with only one MCO; or 7. The denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities. 8.209.2.B. Appeal shall mean, for the purposes of this Section 8.209 only, a request for review by an MCO, PIHP, or PAHP of an Adverse Benefit Determination. 8.209.2.C. Designated Client Representative shall mean any person, including a treating health care professional, authorized in writing by the member or the member's legal guardian to represent his or her interests related to complaints or Appeals about health care benefits and services. 8.209.2.D. Grievance shall mean an oral or written expression of dissatisfaction about any matter other than an Adverse Benefit Determination, including but not limited to quality of care or services provided and aspects of interpersonal relationships such as rudeness of provider or employee, or failure to respect the member’s rights. 8.209.2.E. Managed Care Organization (MCO) shall mean an entity that has, or is seeking to qualify for, a comprehensive risk contract under 42 C.F.R. § 438.2 (2024) is hereby incorporated by reference. The incorporation of 42 C.F.R. § 438.2 excludes later amendments to, or editions of the referenced material.

Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.ecfr.gov. The MCO shall be:

A Federally qualified HMO that meets the advance directives requirements of subpart I of 42 C.F.R. § 489 (2024), which is hereby incorporated by reference. The incorporation of 42 C.F.R. § 489 excludes later amendments to, or editions of, the referenced material. Pursuant to § 24- 4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

Incorporated materials may also be obtained from the original issuer at www.ecfr.gov.; or 2. Any public or private entity that meets the advance directives requirements and is determined by the Secretary of the U.S. Department of Health and Human Services to also make the services it provides to its Medicaid members as accessible (in terms of timelines, amount, duration, and scope) as those services are to other Medicaid beneficiaries within the area served by the entity; and meets the solvency standards of 42 C.F.R. § 438.116 (2024), which is hereby incorporated by reference. The incorporation of 42 C.F.R. § 438.116 excludes later amendments to, or editions of, the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.ecfr.gov. 8.209.2.F. Prepaid Inpatient Health Plan (PIHP) shall mean an entity that provides medical services to members under contract with the State agency, and on the

basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates; provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its members; and does not have a comprehensive risk contract. 8.209.2.G. Prepaid Ambulatory Health Plan (PAHP) shall mean an entity that provides medical services to members under contract with the State agency, and on the basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates; does not provide, arrange for, or otherwise has a responsibility for the provision of any inpatient hospital or institutional services for its members; and does not have a comprehensive risk contract. 8.209.2.H. State Fair Hearing shall mean the formal adjudication process for Appeals described at Section 8.057.

8.209.3 GRIEVANCE AND APPEAL SYSTEM 8.209.3.A. The Grievance and Appeal System means the processes the Managed Care Organizations (MCOs), Prepaid Inpatient Health Plans (PIHPs), or Prepaid Ambulatory Health Plans (PAHPs), implement to handle appeals of an adverse benefit determination and grievances, as well as the processes to collect and track information about grievances and appeals. 8.209.3.B. The MCO, PIHP, or PAHP shall provide a Department-approved description of the Grievance, Appeal and State Fair Hearing procedures and timeframes to all providers and subcontractors at the time the provider or subcontractor enters into a contract with the MCO, PIHP, or PAHP. The description shall include:

The member’s right to request a State Fair Hearing after the MCO, PIHP, or PAHP has made a determination on a member’s Appeal, which is adverse to the member.

a. The method to obtain a hearing 2. The member’s right to file Grievances and Appeals.

The requirements and timeframes for filing Grievances and Appeals.
The availability of assistance in the filing process.
The toll-free numbers that the member can use to file a Grievance or an Appeal by telephone.
The fact that, when requested by a member:

a. Benefits will continue if the member files an Appeal or a request for State Fair Hearing within the timeframes specified for filing 8.209.3.C. The MCO, PIHP, or PAHP shall maintain record of Grievances and Appeals and submit a monthly report to the Department, including expedited Grievances in Section 8.209.5.E. The record of each Grievance and Appeal shall include:

A general description of the reason for the Grievance or Appeal;
The date and time the Grievance or Appeal was received;
The date of each review, or if applicable, review meeting;
The resolution at each level of the Grievance or Appeal, if applicable;
The date of resolution of the Grievance or Appeal; and 6. The name of the member for whom the Grievance or Appeal was filed.

8.209.4 APPEAL PROCESS 8.209.4.A. Notice of Adverse Benefit Determination 1. The MCO, PIHP, or PAHP shall send the member written notice for each Adverse Benefit Determination. The notice shall be in writing and shall be available in English and the prevalent non-English languages spoken by members throughout the State. “Prevalent” means a non-English language spoken by a significant number or percentage of members in the service area as identified by the State.

The notice shall state the following:

a. The Adverse Benefit Determination the MCO, PIHP, or PAHP or its contractor has taken or intends to take;

b. The reasons for the Adverse Benefit Determination, including the right of the member to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the member’s Adverse Benefit Determination. Such information includes medical necessity criteria and any processes, strategies, or evidentiary standards used in setting coverage limits;

c. The member’s or the Designated Client Representative's right to file an MCO, PIHP, or PAHP Appeal;

d. The date the Appeal is due;

e. The member’s right to request a State Fair Hearing after receiving notice that the adverse benefit determination is upheld;

f. The procedures for exercising the right to a State Fair Hearing;

g. The circumstances under which expedited resolution is available and how to request it;

h. The member’s right to have benefits continue pending resolution of the Appeal, and how to request that benefits be continued; and i. The circumstances under which the member may be required to pay the cost of these services.

The MCO, PIHP, or PAHP shall mail the notice of Adverse Benefit Determination within the following timeframes:

a. For termination, suspension or reduction of previously authorized Medicaid covered services, at least ten (10) calendar days before the date of Adverse Benefit Determination, except in the following circumstances:

i) The MCO, PIHP, or PAHP may shorten the period of advance notice to five (5) calendar days for the date of Adverse Benefit Determination if:

The MCO, PIHP, or PAHP has facts indicating probable fraud by the member; and 2) The facts have been verified, if possible, through secondary sources.

ii) The MCO, PIHP, or PAHP may mail notice not later than the date of Adverse Benefit Determination if:

The MCO, PIHP, or PAHP has factual information confirming the death of the member;
The MCO, PIHP, or PAHP receives a clear written statement signed by the member stating that:

a) The member no longer wishes services; or b) Gives information that requires termination or reduction of services and indicates that the member understands that this is the result of supplying the information;

iii) The member has been admitted to an institution where the member is ineligible under the plan for further services;

iv) The member’s whereabouts are unknown and the post office returns mail directed to him or her indicating no forwarding address;

v) The MCO, PIHP, or PAHP establishes the fact that the member has been accepted for Medicaid services by another local jurisdiction, state, territory, or commonwealth;

vi) A change in the level of medical care is prescribed by the member’s physician;

vii) The notice involves an Adverse Benefit Determination made with regard to the preadmission screening requirements of 1919(e) (7) of the Social Security Act; or viii) Notice may be made as soon as practicable before transfer or discharge when:

The safety of individuals in the facility would be endangered;
The health of individuals in the facility would be endangered;
The resident's health improves sufficiently to allow a more immediate transfer or discharge;
An immediate transfer or discharge is required by the resident's urgent medical needs; or 5) A resident has not resided in the facility for 30 days.

b. For denial of payment, at the time of any Adverse Benefit Determination affecting the claim.

c. For standard service authorization decisions that deny or limit services, within ten (10) calendar days. For expedited service authorizations, within seventy-two (72) hours.

i) If the MCO, PIHP, or PAHP extends the timeframe for making a service authorization decision, it must give the member written notice of the reason for extending the timeframe and inform the member of the right to file a Grievance to disagree with the timeframe extension.

ii) The MCO, PIHP, or PAHP must carry out its determination as expeditiously as the member’s health condition requires, and no later than the date the extension expires.

d. For service authorization decisions not reached within the timeframes specified (which constitutes a denial and is thus an adverse benefit determination), on the date the timeframes expire. 8.209.4.B. The member of an MCO, PIHP, or PAHP shall file an Appeal within sixty(60) calendar days from the date of the MCO’s, PIHP’s, or PAHP’s notice of Adverse Benefit Determination. 8.209.4.C. The MCO, PIHP, or PAHP shall give members reasonable assistance in completing any forms required by the MCO, PIHP, or PAHP, putting oral requests for a State Fair Hearing into writing and taking other procedural steps, including, but not limited to, providing interpretive services and toll-free numbers that have adequate TTY/TTD and interpreter capability. 8.209.4.D. The MCO, PIHP, or PAHP shall send the member written acknowledgement of each Appeal within two (2) working days of receipt, unless the member or designated client representative requests an expedited resolution. 8.209.4.E. The MCO, PIHP, or PAHP shall ensure that the individuals who make decisions on Appeals are individuals who:

Were not involved in any previous level of review or decision-making, nor a subordinate of any such individual, 2. Who have the appropriate clinical expertise, as determined by the Department, in treating the member’s condition or disease if deciding any of the following: an Appeal of a denial that is based on lack of medical necessity, a Grievance regarding denial of expedited resolution of an Appeal, or a Grievance or Appeal that involves clinical issues, and 3. Who take into account all comments, documents, records, and other information submitted by the member or their representative without regard to whether such information was submitted or considered in the initial adverse benefit determination. 8.209.4.F. The MCO, PIHP, or PAHP shall accept Appeals orally or in writing. 8.209.4.G. The MCO, PIHP, or PAHP shall provide the member a reasonable opportunity to present evidence, and legal or factual arguments, in person as well as in writing. The MCO, PIHP, or PAHP shall inform the member of the limited time available in the case of expedited resolution. 8.209.4.H. The MCO, PIHP, or PAHP shall provide the member and the Designated Client Representative opportunity, before and during the Appeal process, to examine the member’s case file, including medical records and any other documents and records considered during the Appeal process. 8.209.4.I. The MCO, PIHP, or PAHP shall include as parties to the Appeal, the member and the Designated Client Representative or the legal representative of a deceased member’s estate. 8.209.4.J. The MCO, PIHP, or PAHP shall resolve each Appeal, and provide notice as expeditiously as the member’s health condition requires, not to exceed the 1. For standard resolution of an Appeal and notice to the affected parties, ten (10) working days from the day the MCO, PIHP, or PAHP receives the 2. For expedited resolution of an Appeal and notice to affected parties, seventy-two (72) hours after the MCO, PIHP, or PAHP receives the 8.209.4.K. The MCO, PIHP, or PAHP may extend timeframes for the resolution of Appeals by up to fourteen (14) calendar days:
If the member requests the extension; or 2. The MCO, PIHP, or PAHP shows that there is a need for additional information and that the delay is in the member’s best interest. The MCO, PIHP, or PAHP shall:

a. Make reasonable efforts to give the member prompt oral notice of the delay.

b. Within 2 calendar days, give the member prior written notice of the reason for delay if the timeframe is extended and informs the member of their right to file a grievance if the member disagrees with the extension. 8.209.4.L. The MCO, PIHP, or PAHP shall notify the member in writing of the resolution of an Appeal. For notice of an expedited resolution, the MCO, PIHP, or PAHP shall also make reasonable efforts to provide oral notice. 8.209.4.M. The written notice shall include the results of the disposition/resolution process and the date it was completed.

For Appeals not resolved wholly in favor of the member, the written notice shall include:

a. The right to request a State Fair Hearing and how to do so;

b. The right to request and to receive benefits while the hearing is pending, and how to make the request; and c. That the member may be held liable for the cost of those benefits if the hearing decision upholds the MCO’s, PIHP’s, or PAHP’s Appeal determination. 8.209.4.N. The member of an MCO, PIHP, or PAHP shall exhaust the MCO, PIHP, or PAHP level Appeal process before requesting a State Fair Hearing. The member shall request a State Fair Hearing within one hundred and twenty (120) calendar days from the date of the MCO’s, PIHP’s, or PAHP’s notice of Appeal determination. 8.209.4.O. If the MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements regarding resolution and notification of an Appeal, the member is deemed to have exhausted the Appeals process and may request a State Fair Hearing. 8.209.4.P. In cases where the parent or guardian of a member submits a request for a third-party review to the Department of Human Services under 27-67-104 C.R.S. of the Child Mental Health Treatment Act, the member, parent or guardian and the MCO or PIHP shall have the right to request a State Fair Hearing. The request for the State Fair Hearing shall be submitted to the Division of Administrative Hearings within thirty (30) calendar days from the date of the determination. The State Fair Hearing shall be considered a member Appeal. 8.209.4.Q. The MCO, PIHP, or PAHP shall establish and maintain an expedited review process for Appeals when the MCO, PIHP, or PAHP determines, or the provider indicates, that taking the time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function. 8.209.4.R. The MCO, PIHP, or PAHP shall ensure that punitive action is not taken against a provider who requests an expedited resolution or supports a member’s 8.209.4.S. If the MCO, PIHP, or PAHP denies a request for expedited resolution, it shall transfer the Appeal in the timeframe for standard resolution, make reasonable effort to give the member prompt oral notice of the denial and send a written notice of the denial for an expedited resolution within two (2) calendar days and inform the member of the right to file a grievance if the member disagrees with the decision to deny the expedited review. 8.209.4.T. The MCO, PIHP, or PAHP shall, consistent with federal law, provide for the continuation of benefits while the MCO, PIHP, or PAHP level Appeal and the State Fair Hearing are pending if:

The member:

a. Files for continuation of services (a) within ten (10) calendar days of the MCO, PIHP, or PAHP sending the notice of Adverse Benefit Determination, or (b) on or before the intended date of the MCO’s, PIHP’s, or PAHP’s proposed Adverse Benefit Determination, whichever is later;

b. Files the request for the appeal within 60 calendar days following the notice of adverse benefit determination.

The Appeal involves the termination, suspension or reduction of a previously authorized course of treatment;
The services were ordered by an authorized provider;
The original period covered by the original authorization has not expired; and 5. The member requests extension of benefits. 8.209.4.U. If at the member’s request, the MCO, PIHP, or PAHP continues or reinstates the member’s benefits while the Appeal is pending, the benefits shall be continued until one of the following:
The member withdraws the Appeal.
The member fails to request a State fair hearing and continuation of benefits (services) within 10 calendar days after the MCO, PIHP, or PAHP sends the notice of an adverse appeal resolution.
A State Fair Hearing office issues a final agency decision adverse to the member. 8.209.4.V. If the final resolution of the Appeal upholds the MCO’s, PIHP’s, or PAHP’s Adverse Benefit Determination, the MCO, PIHP, or PAHP may recover the cost of the services furnished to the member while the Appeal is pending to the extent that the services were furnished solely because of the requirements of this rule. 8.209.4.W. If the final resolution of the Appeal reverses the MCO’s, PIHP’s, or PAHP’s Adverse Benefit Determination to deny, limit or delay services that were not furnished while the Appeal was pending, the MCO, PIHP, or PAHP shall authorize or provide the disputed services promptly and as expeditiously as the member’s health condition requires, but no later than 72 hours from the date it receives notice reversing the determination. 8.209.4.X. If the final resolution of the Appeal reverses the MCO’s, PIHP’s, or PAHP’s Adverse Benefit Determination to deny authorization of services and the member received the services while the Appeal was pending, the MCO, PIHP, or PAHP must pay for those services.

8.209.5 GRIEVANCE PROCESS 8.209.5.A. The member of the MCO, PIHP, or PAHP can file a Grievance expressing his/her dissatisfaction with any matter other than an Adverse Benefit Determination at any time. 8.209.B. The MCO, PIHP, or PAHP shall send the member written acknowledgement of each Grievance within two (2) business days of receipt. 8.209.5.C. The MCO, PIHP, or PAHP shall ensure that the individuals who make decisions on Grievances are individuals who were not involved in any previous level of review or decision-making, nor a subordinate of any such individual, and who have the appropriate clinical expertise, as determined by the Department, in treating the member’s condition or disease if deciding a Grievance that involves clinical issues. 8.209.5.D. The MCO, PIHP, or PAHP shall accept Grievances orally or in writing.

The MCO, PIHP, or PAHP shall resolve each Grievance and provide notice to the affected parties as expeditiously as the member’s health condition requires, not to exceed ninety (90) calendar days from the day the MCO, PIHP, or PAHP receives the Grievance.
A Grievance is resolved when a. The MCO, PIHP, or PAHP has reached a final conclusion with respect to the member’s submitted Grievance; and, b. The MCO, PIHP or PAHP has provided a letter or email notice to the member, in accordance with the minimum standards of notice described at 42 C.F.R. § 438.10 (2024) which is hereby incorporated by reference. The incorporation of 42 C.F.R. § 438.10 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

Incorporated materials may also be obtained from the original issuer at www.ecfr.gov. The letter or email notice shall include the following, so long as there is no conflict with C.R.S. § 12-30-204 and C.R.S. § 12-30-205:

Conclusions of the investigation; and 2) The date of the final conclusion of the investigation.

An escalation to another team does not mean a Grievance is resolved. 8.209.5.E. Expedited Grievance Process 1. Every MCO, PIHP or PAHP must include a process to rapidly assess, evaluate, and address within 72 hours from receipt of Grievance the safety of a member when there is concern that the Grievance involves an imminent and serious threat to the health of the member, including, but not limited to, severe pain, potential loss of life, limb or major bodily function.

At a minimum, the process for expedited Grievances shall include:

a. Notice given to the member in a method that best suits the needs of the member within 72 hours from receipt of a Grievance.

b. Notice shall include a status update, documentation of the date and time the Grievance was received, and any available alternative resources based upon the member’s condition to ensure member safety is being assessed.

The MCO, PIHP or PAHP must provide a monthly report to the Department of its expedited Grievance resolutions.
All other Grievances that do not fall under Section 8.209.5.E.1 shall be resolved through the standard Grievance resolution process timeframe and may not exceed 90 calendar days unless an extension is appropriate under Section 8.209.5.F. 8.209.5.F. The MCO, PIHP, or PAHP may extend the ninety (90) day timeframe by up to 14 calendar days if the requirements of 42 C.F.R. § 438.408(c) are met. 42 C.F.R. § 438.408(c) (2024) is hereby incorporated by reference. The incorporation of 42 C.F.R. § 438.408(c) excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.ecfr.gov. 8.209.5.G. The MCO, PIHP, or PAHP shall notify the member in writing of the resolution of a Grievance in the format established by the Department. 8.209.5.H. The written notice shall include the results of the resolution process and the date it was completed. 8.209.5.I. If the member is dissatisfied with the resolution of a Grievance provided by the MCO, PIHP or PAHP, or the Grievance is not resolved within the 90 days including any approved extensions, the member may bring the unresolved Grievance to the Department in accordance with the process outlined in the member handbook.
The Department will acknowledge receipt of the Grievance and resolve the issue.
The resolution offered by the Department will be final.

8.209.6 OMBUDSMAN ASSISTANCE CONCERNING SERVICES FOR

MEMBERS ENROLLED IN MCOS, PIHPS, and PAHPS 8.209.6.A. An Ombudsman under contract with the Department of Health Care Policy and Financing shall provide Ombudsman assistance concerning services for members enrolled in Medicaid MCOs, PIHPS, and PAHPs. 8.209.6.B. Upon request, the Ombudsman shall respond to and analyze a Grievance from a member enrolled in a Medicaid MCO, PIHP, or PAHP, or that member’s Designated Client Representative, by:

Assisting the member or Designated Client Representative to articulate the Grievance, to understand the options available to resolve the Grievance and his/her rights and responsibilities, and to negotiate the appropriate Grievance process for his/her MCO, PIHP, or PAHP;
Acting as the member’s Designated Client Representative if the member requests except that the Ombudsman shall not act as the Designated Client Representative in any State Fair Hearing as described at 10 CCR 2505-10, §8.057;
Facilitating problem resolution with the MCO, PIHP, or PAHP, or its network providers;
Referring members to other agencies as appropriate, including agencies that can directly assist members in a State Fair Hearing;
Conducting and reporting member satisfaction studies and/or quality assessment surveys authorized by the Department to measure member experience and satisfaction with Ombudsman staff and services;
Providing members with information on the exclusions and limitations that may be imposed on care, services, equipment and supplies under the Medicaid benefits structure;
Having a practical understanding of all applicable provisions of Title X,

Article 16, C.R.S. and Medicaid Volume 8 rules; and 8. Avoiding any relationship or circumstance which creates or gives the appearance of a conflict of interest.

8.209.7 COMPLIANCE REQUIREMENTS FOR ALL MCOS, PIHPS, PAHPS AND

THE OMBUDSMAN 8.209.7.A. MCOs, PIHPs, PAHPs, and the Ombudsman shall recognize and ensure members’ rights to make and file Grievances and to Appeal Adverse Benefit Determinations through the Grievance and Appeal process for any reason. 8.209.7.B. For members with a disability, if the medical necessity of a requested procedure has not been established by the MCO, PIHP, or PAHP, the requesting physician must be consulted in person or by telephone before a final determination is made. If the requesting physician is not available, another network provider of the member/Designated Client Representative’s choice shall be consulted. Such consultation shall be referenced in the notice. If the requesting physician is not available and the member/Designated Client Representative does not choose another network provider within two working days of the MCO’s, PIHP’s, or PAHP’s request to make such a choice, the MCO, PIHP, or PAHP may proceed without consultation. 8.209.7.C. MCOs, PIHPs, PAHPs, and the Ombudsman shall develop written procedures for accepting, processing, and responding to all Grievances and Appeals from Medicaid members. For MCOs, PIHPs, and PAHPs, summaries of these procedures shall be disseminated to all participating providers and shall include summaries in the Member Handbook as described in Department contract requirements. The MCO, PIHP, or PAHP shall provide its complete Grievance and Appeal procedures to subcontractors and ensure subcontractor compliance with these rules and the MCO’s, PIHP’s, or PAHP’s procedures.

MCOs, PIHPs, PAHPs, and the Ombudsman shall obtain written approval from the Department for their internal Grievance and Appeals procedures. 8.209.7.D. MCOs, PIHPs, PAHPs, and the Ombudsman shall establish and maintain a timely and organized system(s) for recording, tracking, and resolving Medicaid members’ Grievances and Appeals as specified in contract. 8.209.7.E. MCOs, PIHPs, PAHPS, and the Ombudsman shall confidentially maintain original records of all Grievances and Appeals from Medicaid members, including the original Grievance or Appeal, Adverse Benefit Determination, or resolution taken by the entity, and evidence of review activities. All such information shall be archived for ten (10) years from the date of the initial Grievance or Appeal. 8.209.7.F. MCOs, PIHPs, and PAHPs shall ensure that neither cultural, expressive, or receptive communication differences negatively impact the Grievance and Appeals process. MCOs, PIHPs, and PAHPs shall provide services to facilitate members’ and Designated Client Representatives’ effective use of the Grievance and Appeals process, inclusive of qualified interpreters for (1) persons with communication disabilities or differences and (2) non-English-speaking members. The MCO, PIHPs, or PAHP shall consult with the member or the Designated Client Representative about the individual or medium that will assist, and such assistance shall be at the cost of the MCO, PIHP, or PAHP. 8.209.7.G. MCOs, PIHPs, and PAHPs shall provide the member, Designated Client Representative, or any other person, upon written release from the member or the member's legal guardian, access to or a copy of medical records, at no cost to the member, for dates of service occurring during enrollment in the MCO, PIHP, or PAHP. Such records shall be provided within a time frame that provides members copies of their records prior to any decision on a Grievance or Appeal, or in two weeks or less, if required by C.R.S. § § 25-1-801 and 25-1-802. The MCO, PIHP, or PAHP is only obligated to provide one copy of the member's medical records free of charge for each of the Medicaid member's Grievances or Appeals. 8.209.7.H. MCOs, PIHPs, and PAHPs shall monitor participating network subcontractors or providers to ensure compliance with all Grievance and Appeals rules and contract requirements. 8.209.7.I. MCOs, PIHPs, PAHPs, and the Ombudsman shall handle specific Medicaid member Grievance and Appeals information in the same way that medical record information is handled confidentially under State and Federal law and regulations. 8.209.7.J. Upon request by a member, the member's Designated Client Representative, or the member's provider, the MCO, PIHP, or PAHP shall disclose its standards for denial of treatments or other benefits on the grounds that such treatment or other covered benefit is not medically necessary, appropriate, effective, or efficient free of charge. 8.209.7.K. To assist members in making inquiries and filing Grievances and Appeals, MCOs, PIHPs, PAHPs, and the Ombudsman shall ensure that members and Designated Client Representatives can contact them during routine business hours through a toll-free telephone number.

8.215 MEDICAID STATEWIDE MANAGED CARE SYSTEM CAPITATION RATE

SETTING

8.215.1 DEFINITIONS 8.215.1.A. Actuary – Individuals who both meet the qualifications of the division of insurance, and who also are Members of the American Academy of Actuaries, and therefore are able to provide for actuarial certification of Medicaid rates in accordance with 42 CFR 438.6(c).

The Department incorporates by reference 42 CFR 438.6(c). No amendments or later additions of this regulation are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Any material that has been incorporated by reference in this rule may be examined at any state publications depository library. 8.215.1.B. Actuarially sound rates – For a defined population, a per member per month risk capitation amount that meets the requirements of 42 CFR 438.6(c) and is certified as actuarially sound by an actuary acting in his/her professional capacity. 8.215.1.C. Enrollee – A person who is eligible to receive services under a risk contract with the Department as a participant in the Medicaid Statewide Managed Care System. 8.215.1.D. Independent actuary – An actuary contracted by the Department who has not and will not contract with a Colorado Medicaid provider during the rate setting or rate effective periods and whose employer has not and will not provide actuarial services to a Managed Care Organization or Prepaid Inpatient Health Plan participating in the Medicaid Statewide Managed Care System during the rate setting or rate effective periods. 8.215.1.E. Managed Care Organization (MCO) shall mean an entity that has, or is seeking to qualify for, a comprehensive risk contract under 42 CFR § 438.2 to operate as part of the State agency’s Medicaid Statewide Managed Care System as defined in Section 8.205. 8.215.1.F. Medicaid Statewide Managed Care System means the program defined in

Section 8.205. 8.215.1.G. Prepaid Inpatient Health Plan (PIHP) shall mean an entity that administers the State agency’s statewide system of community behavioral health care as defined in Section 8.205.9 under contract with the State agency, and on the basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates; provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its members; and does not have a comprehensive risk contract.

8.215.2 LEGAL BASIS

The Medicaid Statewide Managed Care System is authorized by state law at 25.5-5, C.R.S. Part 4.

8.215.3 GENERAL PROVISIONS 8.215.3.A. The Department shall make prepaid capitation payments based on actuarially certified rates to MCOs and PIHPs based upon a scope of services defined in the MCOs and PIHPs contracts. 8.215.3.B. The Department shall contract with an independent actuary to prepare and certify actuarially sound rate ranges. 8.215.3.C. The Department’s contracts with the MCOs and PIHPs shall contain rates within the actuarially certified rate ranges prepared by the independent actuary. 8.215.3.D. Rates calculations shall include estimates of future utilization of covered services that are:

Relevant to the expected or reasonable use of services by the MCOs and PIHP’s enrollees, and 2. Based upon data that are of sufficient quality for rate setting. 8.215.3.E. To determine a reasonable cost of the service utilization described above in 8.215.3.D, the Department shall establish a price per unit of service. Such pricing:
Shall be consistent with the principles of actuarial soundness.
May be based upon the Medicaid fee-for-service payment for like services, provider costs, MCO or PIHP contracted rates, or other sources. 8.215.3.G. Data used to set rates shall be made available in summary form to any interested stakeholder. 8.215.3.H. The MCOs and PIHPs are required to maintain medical loss ratios of no less than 85% of total Medicaid capitations. Medical loss ratios of less than 85% shall result in a refund of premiums due to the Department in an amount such that the recalculated medical loss ratio, accounting for the premium change, meets the agreed upon threshold.

8.215.4 RATE SETTING TIMELINE 8.215.4.A. The Department shall publish a rate setting timeline when starting the process of establishing actuarially sound rate ranges. 8.215.4.B. The rate setting timeline shall provide explicitly for stakeholder feedback as part of the rate setting process. 8.215.4.C. The independent actuary shall consider stakeholder feedback in collaboration with the Department.

The decision to adopt the stakeholder feedback in the calculations of the actuarially sound rate ranges shall be at the discretion of the independent actuary.
Notwithstanding the above, the independent actuary is encouraged to fully consider stakeholder feedback, in consultation with the Department, when the feedback provides for better quality or efficiency in the process of calculating actuarially sound rate ranges, and the feedback is consistent with principles of efficiency, economy and actuarial soundness.

8.215.5 CERTIFICATIONS 8.215.5.A. To the extent that the data used in rate setting come from the MCO or PIHPs, the MCO or PIHP shall provide a certification that the data supplied by the MCO or PIHP to the Department are accurate, truthful and represent costs and utilization solely for services covered under the MCO or PIHP contract for Medicaid eligible enrollees of that MCO or PIHP. 8.215.5.B. In accordance with 25.5-5-408 (e) and prior to entering into a contract with the Department, the MCO or PIHP shall certify that the rates set forth in the contract are sufficient to assure the financial stability of the MCO or PIHP. 8.215.5.C. In accordance with 25.5-5-408 (f)(l) and prior to entering into a contract with the Department, the MCO or PIHP shall retain an actuary to certify that the capitation rates set forth in the contract between the MCO or PIHP and the Department comply with all applicable federal and state requirements that govern said capitation payments. This certification must explicitly reference that the capitation rates conform to the federal requirement that rates be actuarially sound.

8.215.6 COST CONTAINMENT MECHANISMS 8.215.6.A. The Department shall establish cost-effective, capitated rates for the statewide system of community behavioral health care defined in Section 8.205.9 in a manner that includes cost containment mechanisms. 8.215.6.B. The cost containment mechanisms shall be consistent with the principles of actuarial soundness, as determined by the independent actuary. 8.215.6.C. These cost containment mechanisms shall include:

Limiting costs and data considered in rate setting to that reasonable based upon enrollees’ need for services within the scope of services in the PIHPs’ contracts.
Establishing health status based risk adjusted case rates for a negotiated portion of the actuarially sound capitation rate. Case rates shall be calculated based upon a statewide average cost, providing PIHPs an incentive for efficiency relative to peers. 8.215.6.D. The Department may, upon consultation and feedback from the PIHPs and the stakeholder community, implement other cost containment mechanisms that it finds necessary to constrain rate growth to a level that is sustainable and 8.220 COMPETITIVE PROCUREMENT AND SELECTIVE CONTRACTING, INCLUDING GLOBAL FEE PAYMENT PROGRAMS This section of Staff Manual Volume 8 describes Medicaid competitive procurement and selective contracting. 8.221 GENERAL PROVISIONS [Repealed eff. 08/14/2025]

8.280 EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT

8.280.1 DEFINITIONS

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) means the child health component of Medicaid. The EPSDT program requires coverage of periodic and interperiodic screens, vision, dental and hearing care, diagnostic services needed to confirm the existence of a physical or mental illness or condition, and all medical assistance services that are recognized under Section 1905 of the Social Security Act, even if not offered under the state plan pursuant to federal laws applicable to the program (including 1905(a), 42 U.S.C. §§1396a(a)(42), 1396d(a)(4)(B) and 1396d(r)).

EPSDT Case Management means an activity that assists Medicaid clients in getting and/or coordinating services based on individual need.

EPSDT Outreach means methods to inform recipients or potential recipients, such as those found to be presumptively eligible, to enter into care.

EPSDT Outreach and Case Management Entity means an entity that has contracted with the Department to provide the activities specified in 8.280.3 below.

Personal Care Services means assistance with non-skilled activities of daily living in order to meet the client’s physical, maintenance and supportive needs. This assistance may take the form of hands-on assistance (actually performing a task for the person), or prompting or cueing the client to complete the task.

8.280.2 EPSDT ELIGIBILITY

A child or youth age 20 and under enrolled in Medicaid are eligible for EPSDT services.

8.280.3 EPSDT OUTREACH AND CASE MANAGEMENT 8.280.3.A. EPSDT Outreach and Case Management entities shall provide pregnant women, children, their parents or legal guardians (based on the current eligibility information received from the Department) the following within 60 days of eligibility through oral communication including face to face meetings, discussions or telephone conversations, as well as written materials:

Information about EPSDT services and how to access them.
Education on the importance of preventive health care with an emphasis on well child exams, developmental and depression screenings, dental examinations, immunizations, and prenatal care.
Assistance in selecting a Primary Care Physician (PCP) or Managed Care Organization (MCO), and to supply a list of available options if requested.

Children without a PCP shall be informed of the choices of PCPs and/or MCOs. Families/children shall notify the enrollment broker of their choice as described in 10 C.C.R. 2505-10, Section 8.205.

Assist clients in choosing an Accountable Care Organization if 5. Assistance with coordinating primary health coverage with Medicaid benefits.
Assistance with coordinating appointments with providers, including assistance with missed appointments.
Assistance with reporting the birth of newborns to the local department of human/social services.
A current list of covered and uncovered services available in the community.
Information regarding the availability of non-emergency medical transportation.

8.280.4 EPSDT SERVICES 8.280.4.A. Periodic screening is a procedure used to determine a child’s mental and physical growth progress, and to identify a disease or abnormality. Screening identifies additional diagnosis and treatments of physical or emotional problems.

Screening shall include a comprehensive health assessment performed soon after birth or as early as possible in a child’s life and repeated at periodic intervals of time as recommended by the Colorado periodicity schedules.
The periodicity schedules describe the intervals at which preventive physical, sensory, developmental and behavioral screening, including vision; hearing and dental services shall be performed for enrolled children and youth age 20 and under. The periodicity schedules also include the recommended frequency of follow-up examinations.
The components of a screen shall include:

a. A comprehensive unclothed physical exam.

b. A detailed health and development history.

c. An assessment of vision, hearing, mouth, oral cavity and teeth, including referral to a dentist beginning at age 1, and other systems including but not limited to: Respiratory, Cardiovascular, Gastrointestinal, Genitourinary, Musculoskeletal, Skin, Neurologic, Psychiatric/Emotional/Education, and Nutrition.

d. A developmental screening including a range of activities to determine whether a child’s emotional and developmental processes fall within a benchmarked range of achievement schedule according to the child’s age group and cultural background. This screening shall include self-help and self-care skills, gross and fine motor development, communication skills or language development, social-emotional development, cognitive skills and appropriate mental/behavioral health screening.

e. Appropriate immunizations according to the schedule established by the Advisory Committee on Immunization Practices (ACIP) for pediatric vaccines.

f. Lead Toxicity Screening - All children are considered at risk and should be screened for lead poisoning via blood testing. Children between the ages of 36 months and 72 months of age should receive a blood lead test if they have not been previously tested for lead poisoning.

g. Any appropriate age-specific screening or laboratory tests at intervals recommended by the Colorado Periodicity Schedule.

h. Health education and anticipatory guidance.

Screenings shall be age appropriate and performed in a culturally and linguistically sensitive manner by a provider qualified to furnish primary medical and/or mental health care services.
Results of screenings and examinations shall be recorded in the child’s medical record. Documentation shall include at a minimum identified problems and negative findings and further diagnostic studies and/or treatments needed and date ordered. 8.280.4.B. Inter-Periodic exam Inter-periodic exam shall be any health care that occurs outside the periodic preventive care screening such as a further diagnosis, evaluation, acute or sick care. 8.280.4.C. Diagnosis and treatment 1. When a screening examination indicates the need for further evaluation of the individual’s health, diagnostic services are provided.
If the screening provider is not licensed or equipped to render the necessary treatment or further diagnosis, the screening provider shall refer the individual to an appropriate enrolled practitioner or facility, or to the EPSDT Outreach and Case Management Office for supportive help in locating an appropriate provider.
Treatment to correct or ameliorate defects, physical and mental illnesses or conditions discovered by the screening and diagnostic services shall be available. 8.280.4.D. Personal Care Services Personal Care Services as defined in 8.280.1, are a benefit for clients age 20 and under who meet the criteria for EPSDT. 8.280.4.E Other EPSDT Benefits 1. All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b – g.

8.280.5 LIMITATIONS/SPECIAL CONSIDERATIONS 8.280.5.A. Experimental services or procedures are excluded. 8.280.5.B. Services or items not generally accepted as effective by the medical community are excluded. 8.280.5.C. Pharmaceutical items not requiring a prescription are excluded unless prior authorized and medically necessary. 8.280.5.D. Orthodontic services are available for children with congenital, severe developmental or acquired handicapping malocclusions when the orthodontist documents Medical Necessity that is confirmed by pre-treatment case review.

Orthodontists shall submit requests for prior authorization of covered orthodontic 8.280.5.E. Early language intervention for children age birth through three with a hearing loss may be provided by audiologists, speech therapists, speech pathologists and Colorado Home Intervention Program (CHIP) providers 8.280.6 REFERRALS When a client is enrolled a managed care plan, a referral from his/her primary care physician may be required for care provided by anyone other than the primary care physician. Any client may self-refer for routine vision, dental, hearing, mental health services or family planning services.

8.280.7 PRIOR AUTHORIZATIONS

Providers shall be responsible for obtaining prior authorization when required for identified services such as home health, orthodontia, private duty nursing and pharmaceuticals. Prior authorization of services is not a guarantee of payment.

8.280.8 MANAGED CARE AND CONTRACTED HEALTH CARE SERVICES 8.280.8.A The Contractor must ensure the delivery of EPSDT services for Contractor Covered Services. The Contractor must have written policies and procedures for providing EPSDT services including lead testing and immunizations to the eligible population. 8.280.8..B. The Contractor must comply with all EPSDT regulations set forth in 1905(a), 42 USC 1396d(r)(5) and 42 USC 1396d(a), and performance will be verified by paid claims. 8.280.8.C. The Contractor must assure the provision of all required components of periodic health screens. 8.280.8.D. At a minimum, such efforts shall include:

education and outreach to eligibles of the importance of EPSDT services;
a proactive approach to ensure eligibles obtain EPSDT services;
systematic communication process with network providers regarding the Department’s EPSDT requirements;
process to measure and assure compliance with the EPSDT schedule; and, 5. a process to assure that the medically necessary services not covered by the Contractor are referred to the Office of Clinical Services for action; and, 6. comply with all reporting requirements and data needs for federal reporting.

8.280.9 REIMBURSEMENT

Reimbursement shall be in accordance with the regulations for pricing health services as reflected at 10 C.C.R. 2505-10, Section 8.200 for all EPSDT medical screening, diagnostic and treatment services 8.290 SCHOOL HEALTH SERVICES 8.290.1 DEFINITIONS Administrative activities means service coordination, outreach, referral, enrollment and administrative functions that directly support the Medicaid program and are provided by qualified personnel or qualified health care professionals employed by or subcontracting with a participating district.

Board of Cooperative Education Services (BOCES) means a regional organization that is created when two or more school districts decide they have similar needs that can be met by a shared program. BOCES help school districts save money by providing opportunities to pool resources and share costs.

Care coordination plan means a document written by the district that describes how the district coordinates client services across multiple providers to assure effective and efficient access to service delivery and prevent duplication of services.

Case management services mean activities that assist the target population in gaining access to needed medical, social, educational and other services.

Disability means a physical or mental impairment that substantially limits one or more major life activities.

District means any BOCES established pursuant to article 5 of title 22, C.R.S., any state educational institution that serves students in kindergarten through twelfth grade including, but not limited to, the Colorado School for the Deaf and the Blind, created in

article 80 of title 22, C.R.S., and any public school district organized under the laws of Colorado, except a junior college.

Early and Periodic Screening Diagnostic and Treatment (EPSDT) Services as defined pursuant to 10 C.C.R. 2505-10, Section 8.280.1 Free Care Services (services provided to Medicaid enrolled students at no charge, and/or provided to the community at large free of charge) to be reimbursed where medical necessity has been established. This means Medicaid eligible services provided to enrolled students are available for reimbursement if all other Medicaid requirements are met.

Individualized Education Program (IEP) means a document developed pursuant to the federal Individuals with Disabilities Education Act (IDEA). The IEP guides the delivery of special education supports and services for the student with a disability.

Individualized Family Services Plan (IFSP) means a document developed pursuant to the IDEA. The IFSP guides the delivery of early intervention services provided to infants and toddlers (birth to age 3) who have disabilities, including developmental delays. The IFSP also includes family support services, nutrition services, and case management.

Local Services Plan (LSP) means a document written by the district that describes the types and the costs of services to be provided with the federal funds received as reimbursement for providing School Health Services.

Medicaid Administrative Claiming (MAC) means a method for a participating district to claim federal reimbursement for the cost of performing allowable administrative activities.

Medically at risk means a client who has a diagnosable physical or mental condition having a high probability of impairing cognitive, emotional, neurological, social, or physical development.

Medically necessary service means a benefit service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce or ameliorate the pain and suffering, or the physical, mental, cognitive or developmental effects of an illness, injury or disability and for which there is no other equally effective or substantially less costly course of treatment suitable for the client's needs.

Participating district means a district that is contracted with the Department of Health Care Policy and Financing (the Department) to provide and receive funding for School Health Services.

Qualified health care professional means an individual who is registered, certified or licensed by the Department of Regulatory Agencies (DORA) as a health care professional and who acts within the profession's scope of practice. In the absence of state regulations, a qualified health care professional means an individual who is registered or certified by the relevant national professional health organization.

Qualified personnel means an individual who meets Colorado Department of Educationrecognized certification, licensing, registration, or other comparable requirements of the profession in which they practice.

School health service means medical or health-related assistance provided to a client, by qualified personnel or qualified health care professionals; which is required for the diagnosis, treatment, or care of a physical or mental disorder and is recommended by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law.

Specialized transportation means transportation service necessary to provide a client with access to Medicaid services performed in the school or at another site in the community.

8.290.2 CLIENT ELIGIBILITY 8.290.2.A. Clients shall be eligible to receive services from participating districts if they are:

Enrolled in Medicaid, 2. Enrolled with a participating district;
Under the age of 21;
Have a disability or are medically at risk; and 5. Receive a referral for School Health Services according to an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP), 504 Plan, other individualized health or behavioral health plan, or where medical necessity has been otherwise established.

8.290.3 PARTICIPATING DISTRICTS 8.290.3.A. Contracts may be executed with districts throughout Colorado that meet the following minimum criteria:

Approval of a Local Service Plan (LSP) by the Colorado Department of Education and the Department;
An assessment, documented in the LSP, of the health needs of students enrolled in the District; and 3. Evidence, documented in the LSP, of community input on the health services to be delivered to public school students. 8.290.3.B. The participating district may employ or subcontract with qualified personnel or qualified health care professionals to provide school health services or administrative activities.

8.290.4 SCHOOL HEALTH SERVICES, BENEFITS AND LIMITATIONS 8.290.4.A. School health services provided by participating districts to clients shall be medically necessary and prescribed under an IEP, IFSP or other medical plans of care. 8.290.4.B. School health services shall be provided in accordance with the client’s individual need and shall not be subject to any arbitrary limitations as to scope, amount or duration. 8.290.4.C. School health services shall be delivered in the least restrictive environment consistent with the nature of the specific service(s) and the physical and mental condition of the client. 8.290.4.D. School health services shall not be for academic assessment. 8.290.4.E. Except for school health services delivered pursuant to the federal Individuals with Disabilities Education Act (IDEA), the Participating District shall not claim reimbursement for School Health Services to clients enrolled in managed care organizations that would normally be provided for clients by their managed care organization. 8.290.4.F. School health services may be performed in the school, at the client’s home or at another site in the community by qualified personnel or a qualified health care professional. A qualified provider is defined as an individual who is registered, certified or licensed in accordance with and authorized to provide services by Colorado state law or federal regulations. In the absence of state regulations, a qualified provider must be registered or certified by the relevant national professional health organization and must be allowed to practice if the provider is qualified per Colorado state law. The following service categories are eligible for reimbursement in the School Health Services Program as further defined in the Department's School Health Services Program Manual.

Physician Services 2. Nursing Services 3. Personal Care Services 4. Psychological, Counseling and Social Work Services 5. Audiology Services 6. Speech, Language and Hearing Services 7. Occupational Therapy Services 8. Physical Therapy Services 9. Specialized Transportation Services 8.290.5 COORDINATION OF CARE 8.290.5.A. The participating district shall coordinate the provision of care with the client’s primary health care provider for routine and preventive health care. 8.290.5.B. The participating district shall refer clients to their primary care provider, health maintenance organization or managed care provider for further diagnosis and treatment that may be identified as the result of EPSDT services. 8.290.5.C. When the client is receiving Medicaid services from other health care providers and the participating district, the participating district shall coordinate medical care with the providers to ensure that service goals are complementary and mutually beneficial to the client or shall show cause as to why coordination did not occur. 8.290.5.D. The participating district shall inform a family receiving case management services from more than one provider that the family may choose one lead case manager to facilitate coordination.

8.290.6 REIMBURSEMENT 8.290.6.A. The participating district shall obtain from the client or the client's guardian a written informed consent to submit Medicaid claims on behalf of the client. 8.290.6.B. The participating district shall abide by the Third Party Liability rule at 10 C.C.R. 2505-10, Section 8.061.2.23. 8.290.6.C. The participating district shall participate in a periodic time study based on instructions documented in the Department’s School Health Services Program Manual, to determine the percentage of allowable time spent providing Medicaidclaimable school health services. 8.290.6.D. Claims Submission and Interim Payment 1. The participating district shall submit a procedure code specific fee-forservice claim for each school health service provided for each client.

Interim payment for school health services provided shall be reimbursed on a monthly rate. The monthly rate shall be based on the participating districts actual, certified costs identified in the participating districts most recently filed annual cost report. For a new participating district, the monthly rate shall be calculated based on historical data.
Interim payment shall be tied to claims submission by the participating district. Claims shall be monitored by the Department and if claim volume decreases significantly or drops to zero in any two consecutive months while school is in session, interim payment shall be withheld until the issue has been resolved.
The participating district shall be notified of the monthly rate each state fiscal year no later than 30 days prior to July 1 of that state fiscal year.
The participating district shall receive the federal share of the rate, not to exceed 100% of the federal match rate, as interim payment.
School health services provided shall be billed as an encounter or in 15minute unit increments, in accordance with proper billing practices as defined by the Health Insurance Portability and Accountability Act or by the Healthcare Common Procedure Coding System.
Specialized transportation services shall be billed as one-way trips to and from the destination.
Each participating district submitting claims for reimbursement shall follow proper billing instructions as outlined in the Department’s School Health Services Program Manual and in accordance with 10 C.C.R. 2505-10,

Section 8.040.2.

Each participating district shall submit claims for School Health Services program eligible services provided to eligible Medicaid recipients. To comply with the School Health Services program cost reconciliation requirements, all claims must be received by the fiscal agent within 120 days from the date of service. Claims submitted more than 120 days after the end of the state fiscal year (June 30 th ) will not be included in the cost reconciliation calculation and final payment as specified under Section 8.290.6.E. 8.290.6.E. Cost Reconciliation and Final Payment 1. Each participating district shall complete an annual cost report for school health services delivered during the previous state fiscal year covering July 1 through June 30. The cost report shall:

a. Document the participating district’s total Medicaid allowable costs for delivering school health services, based on an approved cost allocation methodology; and b. Reconcile the interim payments made to the participating district to the Medicaid allowable costs, based on an approved cost allocation methodology.

Each participating district shall complete an annual cost report for all school health services delivered during the previous state fiscal year covering July 1 through June 30. The cost report is due no later than 120 days after the close of the quarter ending June 30th as detailed in the Department’s School Health Services Program Manual.
All annual cost reports shall be subject to an audit by the Department or its designee.
If a participating district’s interim payments exceed the actual, certified costs of providing school health services, the participating district shall return an amount equal to the overpayment.
If a participating district’s actual, certified cost of providing school health services exceeds the interim payments, the Department will pay the federal share of the difference to the Participating district.
Each participating district shall follow cost-reporting procedures detailed in the Department’s School Health Services Program Manual. 8.290.6.F. Certification of Funds 1. The participating district shall complete a certification of funds statement, included in the cost report, certifying the participating district’s actual, incurred costs and expenditures for providing school health services.

8.290.7 MEDICAID ADMINISTRATIVE CLAIMING, BENEFITS AND

LIMITATIONS 8.290.7.A. Medicaid Administrative Claiming (MAC) services shall be performed in a school setting or at another site in the community. 8.290.7.B. MAC services include administrative activities and the activities listed in this Section 8.290.7.B. Additionally, MAC may include related paperwork, clerical functions or travel by employees or subcontractors which is solely related to and required to perform MAC services:

Medicaid Outreach a. Medicaid outreach shall be activities that inform Medicaid eligible or potentially eligible individuals about Medicaid and how to access the program.

b. Medicaid outreach may only be conducted for populations served by the participating districts such as students and their parents or guardians.

Facilitating Medicaid Enrollment Determination a. Facilitating Medicaid enrollment determination shall be activities that assist individuals in the Medicaid enrollment process.

b. Facilitating Medicaid enrollment determination may include making referrals for Medicaid enrollment determinations, explaining the enrollment process to prospective applicants, and providing assistance to individuals or families in completing or collecting documents for the Medicaid application.

Translation Related to Medicaid Services a. Translation related to Medicaid services are translation services provided solely to assist individuals with access to Medicaid covered services, which services are not included in or paid for as

part of a school health service. translation services may be provided by employees of, or subcontractors with participating districts.

b. Translation related to Medicaid services may include arranging for or providing oral or signing translation services that assist individuals with accessing and understanding necessary care or treatment covered by Medicaid or developing associated translation materials.

Medical Program Planning, Policy Development and Interagency Coordination a. Medical program planning, policy development and interagency coordination shall be activities associated with the development of strategies to improve the coordination and delivery of Medicaid covered medical, dental or mental health services to school age children.

b. Medicaid program planning, policy development and interagency coordination may include performing collaborative activities with other agencies or providers.

Medical/Medicaid Related Training and Professional Development a. Medical/Medicaid related training and professional development shall be activities for outreach staff of participating districts that include coordinating, conducting or participating in training events or seminars regarding the benefits of medical or Medicaid related b. Medical/Medicaid related training and professional development may include how to assist individuals or families with accessing medical or Medicaid related services and how to effectively refer students for those services.
Referral, Coordination and Monitoring of Medicaid Services a. Referral, coordination and monitoring of Medicaid services shall be activities that include making referrals for, coordinating or monitoring the delivery of Medicaid covered services. Activities that function as part of a school health service may not be included in this category.
Transportation Related to Medicaid Services a. Transportation related to Medicaid services shall be activities when assisting an individual to obtain transportation to services covered by Medicaid (does not include the provision of the actual transportation service).

8.290.8 MEDICAID ADMINISTRATIVE CLAIMING REIMBURSEMENT 8.290.8.A. The participating district shall participate in a periodic CMS approved time study to determine the percentage of allowable time spent on providing Medicaid administrative activities. 8.290.8.B. The participating district shall complete a cost report for MAC for each time study quarter the district participated in based on a reporting schedule established by the Department.

The cost report shall document the participating district’s total Medicaid allowable costs for providing Medicaid administrative activities, based on a CMS approved cost allocation methodology.
If a participating district’s cost report for MAC is not submitted within the Department established reporting schedule the participating district shall not be able to seek reimbursement for the associated period.
By July 30th of each fiscal year, the participating district shall receive a notification letter from the Department identifying the MAC cost reporting schedule. 8.290.8.C. Each participating district shall follow cost reporting procedures for MAC detailed in the Department’s School Health Services Program Manual. 8.290.8.D. Payment 1. Each participating districts cost report for MAC shall be developed into a claim by the Department and submitted to CMS for reimbursement if 2. Reimbursement to participating districts that have properly submitted valid claims for MAC shall be made on a quarterly basis. 8.290.8.E. Certification of Funds 1. Each participating district shall complete a certification of funds statement, included in the cost report for MAC, certifying the participating district’s actual, incurred costs and expenditures for providing Medicaid administrative activities.
All cost reports and claims for MAC shall be subject to an audit by the Department or its designee. 8.295 School-Based Health Center 8.295.1 Definitions 8.295.1.A. Individualized Education Plan (IEP) is defined in Section 8.290.1. 8.295.1.B. Individualized Family Service Plan (IFSP) is defined in Section 8.290.1. 8.295.1.C. School-Based Health Center (SBHC) is defined in Section 25-20.5-502(1), C.R.S (2023). 8.295.1.D. School Health Service means medical or health-related assistance provided to a member by school district employees who meet the definition of “qualified personnel” or “qualified health care professionals,” as those terms are defined at Section 8.290.1, that is required for the diagnosis, treatment, or care of a physical or mental disorder and is recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under Colorado law. 8.295.2 Member Eligibility 8.295.2.A. Eligible members include Colorado Medicaid enrolled members ages twenty (20) and under; and Colorado Medicaid enrolled adult members who qualify under medically necessary services. 8.295.2.B Informed and written consent by a parent or legal guardian of a student, in accordance with Section 25.5-5-318(4)(a)(I) and (II)(B), C.R.S. (2023), is required. 8.295.2.C. Confidentiality concerning eligible members, in accordance with Section 8.606, is required. 8.295.3 Provider Eligibility 8.295.3.A. SBHCs must follow the enrollment requirements of their chosen provider type and specialty code. Enrolled providers are eligible to provide services in the SBHC setting if:
Licensed by the Colorado Department of Regulatory Agencies or the licensing agency of the state in which the provider practices, or registered with the Colorado Department of Public Health and Environment, if required by state statute, or nationally certified as a Board-Certified Behavioral Analyst; and 2. Services are within the scope of the provider’s practice. 8.295.4 Eligible Place of Service 8.295.4.A. Colorado Medicaid services are covered under this benefit when provided in the following places of service:
SBHC;
Office; or 3. Home/Community 8.295.5 Covered Services 8.295.5.A. The scope of services provided in an SBHC is dependent upon the licensures and scopes of practice of the eligible rendering providers at that SBHC. These services may include, but are not limited to:
Clinical services;
Behavioral health services and substance use disorder services;
Dental services; and 4. Nutrition services. 8.295.6 Prior Authorization Requirements 8.295.6.A. Prior authorization requirements for services at SBHCs are the same as those for the specific Colorado Medicaid covered service(s) being provided, and are consistent with Section 8.058. 8.295.7 Non-Covered Services 8.295.7.A. The following school-based services are not covered by Colorado Medicaid:
Services that are already covered under another program, such as School Health Services prescribed within a child or youth’s Individualized Education Plan (IEP), Individualized Family Service Plan (IFSP), other medical plan(s) of care or where medical necessity is established.
Services that are duplicative of care being reimbursed under another benefit or funding source.
Services that are not covered by Colorado Medicaid in other settings.

Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.300 MEDICAL ASSISTANCE - SECTION 8.300 Hospital Services {#sec-10-ccr-2505-10-8.300 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.300}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

MEDICAL ASSISTANCE - SECTION 8.300 HOSPITAL SERVICES

10 CCR 2505-10 8.300 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

8.300 HOSPITAL SERVICES 8.300.1 Definitions 8.300.1.A. Abbreviated Client Stay means an Inpatient stay ending in client death or in which the client leaves against medical advice. 8.300.1.B. Concurrent Review means a review of quality, Medical Necessity and/or appropriateness of a health care procedure, treatment or service during the course of treatment. 8.300.1.C. Continued Stay Review means a review of quality, Medical Necessity and appropriateness of an Inpatient health care procedure, treatment or service. 8.300.1.D. Corrective Action is a step-by-step plan approved by the Department to achieve targeted outcomes and address patterns of inappropriate behavior, including, but not limited to, improper billing, unwarranted utilization, or questionable quality of care. Corrective action may include, but is not limited to, Concurrent Review, Continued Stay Review, Prospective Review, Retrospective Review, requirement to self-audit, or any other action as determined appropriate by the Department. 8.300.1.E. Department means the Department of Health Care Policy and Financing. 8.300.1.F. Diagnosis Related Group (DRG) means a cluster of similar conditions within a classification system used for Hospital reimbursement. It reflects clinically cohesive groupings of Inpatient hospitalizations that utilize similar amounts of Hospital resources. 8.300.1.G. DRG Hospital means a Hospital that is reimbursed by the Colorado Medicaid program based on a system of DRGs. Those Hospitals reimbursed based on a DRG system are: General Hospitals, Critical Access Hospitals, Pediatric Hospitals. 8.300.1.H. Diagnostic Services means any medical procedures or supplies recommended by a licensed professional within the scope of his/her practice under state law to enable him/her to identify the existence, nature, or extent of illness, injury, or other health condition in a client. 8.300.1.I. Disproportionate Share Hospital (DSH) Factor is a percentage add-on adjustment that qualified Hospitals receive for serving a disproportionate share of low-income clients. 8.300.1.J. Emergency Care Services, for the purposes of this rule, means services for a medical condition, including active labor and delivery, manifested by acute symptoms of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (1) placing the client’s health in serious jeopardy, (2) serious impairment to bodily functions or (3) serious dysfunction of any bodily organ or part. 8.300.1.K. Enhanced Ambulatory Patient Group (EAPG) means a cluster of similar procedures within a classification system used for Hospital reimbursement. It reflects clinically cohesive groupings of services performed during Outpatient visits that utilize similar amounts of Hospital resources. 8.300.1.L. Hospital means an institution that is (1) primarily engaged in providing, by or under the supervision of physicians, Inpatient medical or surgical care and treatment, including diagnostic, therapeutic and rehabilitation services, for the sick, disabled and injured; (2) licensed, when located in Colorado, as a Hospital by the Colorado Department of Public Health and Environment (CDPHE); and, when not located in Colorado, by the state in which it is located; and (3) certified for participation in the Centers for Medicare and Medicaid Services (CMS)

Medicare program. Hospitals can have multiple satellite locations as long as they meet the requirements under CMS. For the purposes of the Colorado Medicaid program, distinct part units and satellite locations are considered part of the Hospital under which they are licensed. Transitional Care Units (TCUs) are not considered part of the Hospital for purposes of the Colorado Medicaid program.

Types of Hospitals are:

A General Hospital is licensed and CMS-certified as a General Hospital that, under an organized medical staff, provides Inpatient services, emergency medical and surgical care, continuous nursing services, and necessary ancillary services. A General Hospital may also offer and provide Outpatient services, or any other supportive services for periods of less than twenty-four hours per day.
A Critical Access Hospital (CAH) is licensed and CMS-certified as a Critical Access Hospital. CAHs offer emergency services and limited Inpatient care. CAHs may offer limited surgical services and/or obstetrical services including a delivery room and nursery.
A Pediatric Hospital is licensed as a General Hospital and CMS-certified as a children’s Hospital providing care primarily to populations aged seventeen years and under.
A Rehabilitation Hospital is licensed and CMS-certified as a Rehabilitation Hospital which primarily serves an Inpatient population requiring intensive rehabilitative services including but not limited to stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of femur, brain injury, and other disorders or injuries requiring intensive rehabilitation.
A Long-Term Care Hospital is licensed as a General Hospital and CMScertified as a Long-Term Care Hospital which primarily serves an inpatient population requiring long-term care services including but not limited to respiratory therapy, head trauma treatment, complex wound care, IV antibiotic treatment and pain management.
A Spine/Brain Injury Treatment Specialty Hospital licensed as a General Hospital and CMS-certified as a Long-Term Care Hospital OR CMScertified as a Rehabilitation Hospital is a Not-for Profit Hospital as determined by the CMS Cost Report for the most recent fiscal year. A Spine/Brain Injury Treatment Specialty Hospital primarily serves an inpatient population requiring long term acute care and extensive rehabilitation for recent spine/brain injuries. To qualify as a Spine/Brain Injury Treatment Specialty Hospital, for at least 50% of Medicaid members discharged in the preceding calendar year the hospital must have submitted Medicaid claims including spine/brain injury treatment codes (previously grouped to APR-DRG 40, 44, 55, 56, and 57). The Department shall revoke the designation if the percentage of Medicaid members discharged falls below the 50% requirement for a calendar year.

Designation is removed the calendar year following the disqualifying year.

A Psychiatric Hospital is licensed and CMS-certified as a Psychiatric Hospital to plan, organize, operate, and maintain facilities, beds, and treatment, including diagnostic, therapeutic and rehabilitation services, over a continuous period exceeding twenty-four (24) hours, to individuals requiring early diagnosis, intensive and continued clinical therapy for mental illness; and mental rehabilitation. A Psychiatric Hospital can qualify to be a state-owned Psychiatric Hospital if it is operated by the Colorado Department of Human Services.
A Medicare Dependent Hospital is defined as set forth at 42 C.F.R § 412.103 (2022). 42 C.F.R. § 412.108(1) (2022) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This regulation is available for public inspection at the Department of Health Care Policy and Financing, 303 E.17th Ave, Denver, CO 80203. Pursuant to C.R.S § 24-4- 410(12.5)(V)(b), the Department shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule.
A Non-independent Urban Hospital is a hospital which reports a name of the home office of the chain with which they are affiliated on the CMS- 2552-10 Cost Report in Worksheet S-2 Part 1, Line 141, Column 1, with the exception of individual hospitals reporting an affiliation not reported amongst other hospitals located in Colorado.
A Sole Community Hospital (SCH) is defined by CMS which classifies a hospital as a sole community hospital if it is located more than 35 miles from other like hospitals, or it is located in a rural area (as defined in 412.64) and meets one of the following conditions. No more than 25 percent of residents who become hospital inpatients or no more that 25 percent of the Medicare beneficiaries who become hospital inpatients in the hospital’s service area are admitted to other like hospitals located within a 35-mile radius of the hospital, or, if larger within its service area.

The hospital has fewer than 50 beds and intermediary certifies that the hospital would have met the criteria in paragraph (a)(I)(i) of this section were it not for the fact that some beneficiaries or residents were forced to seek care outside the service area due to the unavailability of necessary specially services at the hospital are inaccessible for at least 30 days in each 2 out of 3 years.

For the purposes of Section 8.300: Hospital Services, Prospective Payment System (PPS) inpatient hospitals are categorized by CMS as hospitals which Medicare pays on a prospective basis and which provide data in the Medicare IPPS IMPACT file and supporting data files/tables from which to create their PPS rate. Conversely, non-Prospective Payment System (PPS) inpatient hospitals are categorized by CMS as Pediatric and Critical Access Hospitals for which Medicare does not pay on a prospective basis and which do not have data available on the Medicare IPPS IMPACT file or supporting data files/tables.
Rebasing years are every other odd year starting in state fiscal year 2023- 24. Non-rebasing years are every other even year starting in state fiscal year 2024-25. 8.300.1.M. Inpatient is a person who has been admitted to a Hospital for purposes of receiving Inpatient Hospital Services. 8.300.1.N. Inpatient Hospital Services means services that are furnished by a Hospital for the care and treatment of an Inpatient and are provided in the Hospital by or under the direction of a physician. 8.300.1.O. Medical Necessity is defined at Section 8.076.1 and, for members ages 20 and under receiving Early and Periodic Screening, Diagnosis, and Treatment services, at Section 8.280.4.E.2. 8.300.1.P. Non-DRG Hospital means a Hospital that is not reimbursed by the Colorado Medicaid program based on a system of DRGs. Psychiatric Hospitals, Long-Term Care Hospital, Rehabilitation Hospital and Spine/Brain Injury Treatment Specialty Hospital are considered Non-DRG Hospitals since their reimbursement is based on a per diem rate. 8.300.1.Q. Observation Stay means Outpatient Hospital Services provided in a Hospital for the purposes of evaluating a person for Inpatient admission, stabilization, or extended recovery. 8.300.1.R. Outlier Days mean the days in a Hospital stay that occur after the Trim Point Day. 8.300.1.S. Outpatient means a person who is receiving professional services at a Hospital or an off- campus location of a Hospital but is not admitted as an Inpatient. 8.300.1.T. Outpatient Hospital Services means services that are furnished to Outpatients; and are furnished by or under the direction of a physician or dentist. 8.300.1.U. Prospective Review means a review of quality, Medical Necessity and/or appropriateness of a health care procedure, treatment, or service prior to treatment. 8.300.1.V. Rehabilitative Services means any medical or remedial services recommended by a physician within the scope of his/her practice under state law, for maximum reduction of physical or mental disability and restoration of a client to his/her best possible functional level. 8.300.1.W. Relative Weight (DRG weight or EAPG weight) means a numerical value which reflects the relative resource consumption for the DRG or EAPG to which it is assigned. Modifications to these Relative Weights are made when needed to ensure payments reasonably reflect the average cost for each DRG or EAPG.

Relative Weights are intended to be cost effective and based upon the data sources applicable to the DRG version effective during the last date of the inpatient hospitalization. 8.300.1.X. Retrospective Review means a review of quality, Medical Necessity and/or appropriateness of a health care procedure, treatment or service following treatment. A Retrospective Review can occur before or after reimbursement has been made. 8.300.1.Y. Rural Hospital means a Hospital not located within a metropolitan statistical area (MSA) as designated by the United States Office of Management & Budget. 8.300.1.Z. State University Teaching Hospital means a Hospital which provides supervised teaching experiences to graduate medical school interns and residents enrolled in a state institution of higher education; and in which more than fifty percent (50%) of its credentialed physicians are members of the faculty at a state institution of higher education. 8.300.1.AA. Swing Bed Designation means designation of Hospital beds in a Rural Hospital with less than 100 beds for reimbursement under Medicare for furnishing post-hospital extended care services to Medicare beneficiaries in compliance with the Social Security Act, Sections 1883 and 1866. Such beds are called “swing beds.” 8.300.1.BB. Trim Point Day (Outlier Threshold Day) means the day during an inpatient stay after which Outlier Days are counted.. The Trim Point Day is based upon the data sources applicable to the DRG version effective during the last date of service of the inpatient hospitalization. 8.300.1.CC. Urban Hospital means a Hospital located within a MSA as designated by the United States Office of Management & Budget. 8.300.1.DD. Urban Safety Net Hospital means an Urban, General Hospital for which the Medicaid Inpatient eligible days plus Colorado Indigent Care Program (CICP)

Inpatient days relative to total Inpatient days, rounded to the nearest percent are equal to or exceed sixty-five percent. To qualify as an Urban Safety Net Hospital, a Hospital must submit its most current information on Inpatient days by March 1 of each year for the Inpatient rates effective on July 1 of that same year. The Department may rely on other data sources for the calculation if there are discrepancies between the data submitted by the Hospital and alternative data sources such as claims or cost report data. 8.300.2 Requirements for Participation 8.300.2.A In-State Hospitals 1. In order to qualify as an in-state Hospital, a Hospital must:

a. be located in Colorado b. be certified for participation as a Hospital in the Medicare Program;

c. have an approved Application for Participation with the Department; and d. have a fully executed contract with the Department.

A border-state Hospital (located outside of Colorado) which is more accessible to clients who require Hospital services than a Hospital located within the state may be an in-state Hospital by meeting the requirements of 10 CCR 2505-10 Section 8.300.2.A.1.b – c. The Department shall make the proximity determination for Hospitals to enroll as a border-state Hospital.
In-state Hospitals located in Colorado shall be surveyed by the CDPHE.

Failure to satisfy the requirements of CDPHE may cause the Department to institute corrective action as it deems necessary. 8.300.2.B Out-of-State Hospitals An out-of-state Hospital may receive payment for emergency Hospital services if:

the services meet the definition of Emergency Care;
the services are covered benefits;
the Hospital agrees on an individual case basis not to charge the client, or the client’s relatives, for items and services which are covered Medicaid benefits, and to return any monies improperly collected for such covered items and services; and 4. the Hospital has an approved Application for Participation with the Department.

Out-of-state Hospitals may receive reimbursement for Outpatient Hospital Services if they meet the conditions specified in 10 CCR 2505-10 Section 8.300.2.B.2 – 4.

Out-of-state Hospitals may receive reimbursement for non-emergent Inpatient Hospital Services if they meet the conditions specified in 10 CCR 2505-10

Section 8.300.2.B.2 – 4, and the Department has issued a prior authorization. 8.300.2.C Hospitals with Swing-Bed Designation 1. Hospitals which intend to designate beds as swing beds shall apply to CDPHE for certification of swing beds and to the Department for participation as a Medicaid provider of nursing facility services. The criteria in 10 CCR 2505-10 Section 8.430 must be met in order to become a Medicaid provider.

Hospitals providing nursing facility services in swing beds shall furnish within the per diem rate the same services, supplies and equipment which nursing facilities are required to provide.
Clients and/or their responsible parties shall not be charged for any of these required items or services as specified in 10 CCR 2505-10 Sections 8.440 and 8.482.
Hospitals providing nursing facility services to swing-bed clients shall be in compliance with the following nursing facility requirements.

a. Client rights: 42 C.F.R. Section 483.10(b)(3), (b)(4), (b)(5), (b)(6), (d), (e), (h), (i), (j)(1)(vii), (j)(1)(viii), (l), and (m).

b. Client Admission, transfer and discharge rights: 42 C.F.R. Section 483.12 (a)(1) through (a)(7).

c. Client behavior and facility practices: 42 C.F.R. Section 483.13.

d. Client activities: 42 C.F.R. Section 483.15(f).

e. Social Services: 42. C.F.R. Section 483.15(g).

f. Discharge planning: 42 C.F.R. Section 483.20(e)

g. Specialized rehabilitative services: 42 C.F.R. Section 483.45.

h. Dental services: 42 C.F.R. Section 483.55.

Personal Needs Funds and Patient Payments Swing-bed Hospitals shall maintain personal needs accounts, submit AP- 5615 forms, and be responsible for collecting patient payment amounts in accordance with the requirements established for nursing facilities in 10 CCR 2505-10 Section 8.482. 8.300.3 Covered Hospital Services 8.300.3.A Covered Hospital Services - Inpatient Inpatient Hospital Services are a covered Medicaid benefit, when provided by or under the direction of a physician, for as many days as determined Medically Necessary.
To support the Medical Necessity of an Inpatient admission, the provider must adequately document in the member’s medical record that a provider with applicable expertise expressly determined that, based on the client’s severity of illness, the client required services involving the intensity of services that cannot be provided safely and effectively in an Outpatient setting. Such determination may take into account the amount of time the client is expected to require Inpatient Hospital Services. However, the decision to admit a client to Inpatient may not be based solely on the expected length of stay. The decision to admit a client to Inpatient is a medical determination that is based on a multitude of clinical factors, including, but not limited to the:

a. Client’s current medical needs;

b. Client’s medical history;

c. Severity of the signs and symptoms exhibited by the client at the time of presentation to the hospital, and at the point of admission decision;

d. Medical predictability of an adverse clinical event occurring with the client;

e. Results of diagnostic studies, laboratory tests, and other clinical tests and examinations; and f. Types of services available to Inpatients and Outpatients at the specific hospital of admission 2. Inpatient Hospital services include:

a. bed and board, including special dietary service, in a semi-private room to the extent available;

b. professional services of Hospital staff;

c. laboratory services provided within the Hospital, therapeutic or Diagnostic Services involving use of radiology & radioactive isotopes;

d. related outpatient services, including but not limited to emergency department services, provided prior to Inpatient admission;

e. drugs, blood products; and f. medical supplies, equipment and appliances as related to care and treatment 3. Medical treatment for the acute effects and complications of substance abuse toxicity is a covered benefit.

Prior to July 1, 2020, Medicaid payments on behalf of a newborn are included in reimbursement for the period of the mother’s hospitalization for the delivery. If there is a Medical Necessity requiring that the infant remain hospitalized following the mother’s discharge, services are reimbursed under the newborn’s identification number, and separate from the payment for the mother’s hospitalization.

Beginning July 1, 2020, reimbursement for a mother's hospitalization for delivery does not include reimbursement for the newborn's hospitalization.

Services shall be reimbursed under the identification number of each client. 5 Psychiatric Hospital Services Inpatient Hospital psychiatric care is a Medicaid benefit for individuals age 20 and under when provided as a service of an in-state Hospital.

a. Inpatient care in a Psychiatric Hospital may require priorauthorization by the Department’s utilization review vendor or other Department representative, and includes physician services, as well as all services identified in 8.300.3.A.1, above.

b. Inpatient psychiatric care in Psychiatric Hospitals is a Medicaid benefit only when i. services involve active treatment which a team has determined is necessary on an Inpatient basis and can reasonably be expected to improve the condition or prevent further regression so that the services shall no longer be needed; the team must consist of physicians and other personnel qualified to make determinations with respect to mental health conditions and the treatment thereof; and ii. services are provided prior to the date the individual attains age 21 or, in the case of an individual who was receiving such services in the period immediately preceding the date on which he/she attained age 21, the date such individual no longer requires such services or, if earlier, the date such individual attains age 22.

c. Medicaid clients obtain access to inpatient psychiatric care through the Community Mental Health Services Program defined in 10 CCR 2505-10, Section 8.212. 6 Inpatient Hospital Dialysis Inpatient Hospital dialysis treatment is a Medicaid benefit at in-state DRG Hospitals for eligible recipients who are Inpatients only in those cases where hospitalization is required for:

a. an acute medical condition for which dialysis treatments are required; or b. any other medical condition for which the Medicaid Program provides payment when the eligible recipient receives regular maintenance treatment in an Outpatient dialysis program; or c. placement or repair of the dialysis route. 7 Inpatient Subacute Care Administration of subacute care by an enrolled hospital in its inpatient hospital or alternate care facilities is covered for the duration of the Coronavirus Disease 2019 (COVID-19) public health emergency.

Subacute care in a hospital setting shall be equivalent to the level of care administered by a skilled nursing facility for skilled nursing and intermediate care services as defined in 10 CCR 2505-10, Sections 8.406 and 8.409. Members may be admitted to subacute care after an inpatient admission, or directly from an emergency department, observation status, or primary care referral to the administering hospital. 8.300.3.B Covered Hospital Services – Outpatient Outpatient Hospital Services are a Medicaid benefit when determined Medically Necessary and provided by or under the direction of a physician. Outpatient Hospital Services are limited to the scope of Outpatient Hospital Services as defined in 42 C.F.R. Section 440.20. Outpatient Hospital Services include:

Observation Stays Observation Stays are a covered Medicaid benefit when provided by or under the direction of a physician, for as many days as determined Medically Necessary. The physician must adequately document in the client’s medical records that Observation Stay is Medically Necessary for the purposes of evaluating a client for possible Inpatient admission, treating a client expected to be stabilized and released without the need for Inpatient admission, or allowing extended recovery following a complication of an Outpatient procedure. In a majority of cases, the decision whether to admit a client to Inpatient admission or discharge from the hospital can be made in less than twenty-four hours. Only rarely shall Observation Stay exceed forty-eight hours in length.

Observation Stays end when a physician orders either Inpatient admission or discharge from the hospital. An Inpatient admission cannot be converted to an Outpatient Observation Stay after the client is discharged unless for purposes of rebilling after an audit finding as specified in 10 CCR 2505-10 8.043.

The decision to admit a client to Observation Stay is a medical determination that is based on a multitude of factors, including, but not limited to the:

a. Client’s current medical needs;

b. Client’s medical history;

c. Severity of the signs and symptoms exhibited by the client at the time of presentation to the hospital, and at the point of the admission to observation status;

d. Medical predictability of an adverse clinical event occurring with the client;

e. Results of diagnostic studies, laboratory tests, and other clinical tests and examinations; and f. Types of services available to Inpatient and Outpatients at the specific hospital of admission 2. Outpatient Hospital Psychiatric Services Outpatient psychiatric services, including prevention, diagnosis and treatment of emotional or mental disorders, are Medicaid benefits at non- Psychiatric Hospitals..

a. Psychiatric outpatient services are not a Medicaid benefit in Psychiatric Hospitals.

Emergency Care a. Emergency Care Services are a Medicaid benefit, and are exempt from primary care provider referral.

b. An appropriate medical screening examination and ancillary services such as laboratory and radiology shall be available to any individual who comes to the emergency treatment facility for examination or treatment of an emergent or apparently emergent medical condition and on whose behalf the examination or treatment is requested. 8.300.3.C. Metabolic and Bariatric Surgery 1. Eligible Members a. All currently enrolled Health First Colorado members ages thirteen (13) years and older are eligible for metabolic and bariatric surgery services when:

i. The member has clinical obesity; and ii. It is medically necessary, as defined at Sections 8.076.1.8 and 8.280.4.E.2.

Eligible Providers a. Providers must be enrolled in Health First Colorado.

b. Surgeons must be trained and credentialed in metabolic and bariatric surgery procedures.

c. Preoperative evaluations and treatment may be performed by:

i. Physician (MD/DO), ii. Nurse Practitioner (NP), iii. Physician Assistant (PA), iv. Registered dietitian (RD), or v. Behavioral health provider.

Eligible Places of Service a. All surgeries shall be performed at a Hospital, as defined at Section 8.300.1.L.

i. Facilities must have safety protocols in place specific to the care and treatment of bariatric members and the patient population being treated.

b. Pre- and Post- operative care may be performed at a physician’s office, clinic, or other medically appropriate setting.

Covered Services and Limitations a. Health First Colorado covers participating providers for one metabolic and bariatric procedure per member lifetime unless a revision is appropriate based on one of the identified complications.

i. Appropriate revision procedures are identified at section 8.300.3.C.4.d.

b. Covered primary procedures are indicated by the Health First Colorado Fee Schedule.

c. Criteria for Primary Procedures i. The member is clinically obese with one of the following:

BMI of 40 or higher, or 2. BMI of 35-40 with objective measurements documenting one or more of the following co-morbid conditions:

a. Severe cardiac disease;

b. Type 2 diabetes mellitus;

c. Obstructive sleep apnea or other respiratory disease;

d. Pseudo-tumor cerebri;

e. Hypertension;

f. Hyperlipidemia;

g. Severe joint or disc disease that interferes with daily functioning;

h. Intertriginous soft-tissue infections, nonalcoholic steatohepatitis, stress urinary incontinence, recurrent or persistent venous stasis disease, or significant impairment in Activities of Daily Living (ADL).

For members under the age of eighteen (18) years:

a. BMI greater than 120% of the 95 th percentile (class II obesity) and major co-morbidity; or b. BMI greater than 140% of the 95 th percentile (class III obesity).

ii. Contraindications must be ruled out through the pre-surgical evaluation in accordance with nationally recognized standards of care.

iii) The member has attempted nonsurgical weight loss and weight management without sufficient clinical improvement.

iv) The member has received nutritional counseling comprised of at least three (3) visits with a provider with documented expertise in nutrition including education that, at a minimum:

Is individualized and customized for the member’s health related social needs, 2) Identifies any maladaptive eating behaviors and patterns and gives recommendations, 3) Covers nutritional and dietary needs for postoperative success, and 4) Covers managing the member’s modifiable risk factors and correction of any micronutrient deficiencies.
This nutritional counseling can be provided in person or via telemedicine.

v) Medical and psychiatric contraindications to the surgical procedure must have been ruled out through:

A complete history and physical conducted by or in consultation with the requesting surgeon; and 2) A psychiatric or psychological assessment, conducted by a licensed behavioral health professional, no more than twelve (12) months prior to the requested authorization. The assessment must address both potential psychiatric contraindications and the member’s ability to comply with the long-term postoperative care plan.
The multidisciplinary team must document that the member understands and is willing to comply with a long-term postoperative care plan created by the team.

a) For members under the age of eighteen (18) years, this plan and related education must be developmentally appropriate and tailored to the member’s needs.

d. Revision Procedures i. Health First Colorado covers revision of a surgery for clinical obesity if it is used to correct complications such as slippage of an adjustable gastric band, intestinal obstruction, or stricture following a primary procedure, or if it is otherwise medically necessary as defined at Sections 8.076.1.8 and 8.280.4.E.2.

ii. Planned multi-stage procedures are not considered a revision and will be evaluated under the primary procedure criteria listed at 8.300.3.C.4.c.

iii. Unplanned multi-stage procedures are covered when the second stage is medically necessary as defined at Sections 8.076.1.8 and 8.280.4.E.2.

e. Non-Covered Services:

i. Repeat procedures that are not medically necessary.

ii. Procedures performed solely for cosmetic purposes.

Prior Authorization Requirements All metabolic and bariatric surgical procedures require prior authorization, which must include:

a. The member’s height , weight, BMI w.

b. A list and description of each co-morbid condition, with attention to any contraindication which might affect the surgery including all objective measurements.

c. A detailed account of the member’s nonsurgical weight loss and weight management attempt(s)..

d. A detailed account of the nutritional counseling provided by a provider with documented expertise in nutrition, as described in 8.300.3.C.4.c.iv.

e. A current psychiatric or psychological assessment regarding contraindications for metabolic and bariatric surgery, as described in 8.300.3.C.4.c.iv..

g. A description of the post-surgical follow-up program. 8.300.4 Non-Covered Services The following services are not covered benefits:

Inpatient Hospital Services defined as experimental by the United States Food and Drug Administration.
Inpatient Hospital Services which are not a covered Medicare benefit.
Court-ordered psychiatric Inpatient care which does not meet the Medical Necessity criteria established for such care by the Department’s utilization review vendor or other Department representative.
Substance abuse rehabilitation treatment is not covered unless individuals are aged 20 and under. Services must be provided by facilities which attest to having in place rehabilitation components required by the Department. These facilities must be approved by the Department to receive reimbursement. 8.300.5 Payment for Inpatient Hospital Services 8.300.5.A Payments to DRG Hospitals for Inpatient Hospital Services 1. Peer Groups For the purposes of Inpatient reimbursement, DRG Hospitals are assigned to one of the following peer groups. Hospitals which do not fall into the peer groups described in a and b shall default to the peer groups described in c and d based on geographic location.:

a. Pediatric Hospitals b. Rural Hospitals c. Urban Hospitals 2. Base Payment and Outlier Payment DRG Hospitals shall be reimbursed for Inpatient Hospital Services based on a system of DRGs and a hospital-specific Medicaid Inpatient base rate.

The reimbursement for Inpatient Hospital Services shall be referred to as the DRG base payment.

a. The DRG base payment shall be equal to the DRG Relative Weight multiplied by the Medicaid Inpatient base rate as calculated in

Section 8.300.5.A.3 – 6.

b. Outlier days shall be reimbursed at 80% of the DRG per diem rate.

The DRG per diem rate shall be the DRG base payment divided by the DRG average length of stay.

c. The DRG base payment plus any corresponding outlier payment is considered the full reimbursement for an Inpatient Hospital stay where the client was Medicaid-eligible for the entire stay.

d. When a client was not Medicaid-eligible for an entire Inpatient Hospital stay, reimbursement shall be equal to the DRG per diem rate for every eligible day, with payment up to the full DRG base payment. If applicable, the Hospital shall receive outlier reimbursement.

Medicaid Inpatient Base Rate for In-network Colorado DRG Hospitals a. Calculation of the Starting Point for the Medicaid Inpatient Base Rate Medicaid Inpatient Base rates for DRG Hospitals are calculated based in part on CMS data. The CMS named files are used as inputs to calculate the inpatient base rates. For the purpose of calculating the starting point for the Medicaid inpatient base rate, the CMS named files will be whatever file is the most recently deposited “adjustment” of the CMS Tables and IMPACT file data effective October 1 and available as of the end of the first full week in January of rebasing years. Similarly, the most recently available Medicare and Medicaid full year cost reports on the CMS Healthcare Provider Cost Reporting Information System (HCRIS) will be utilized by the end of the first full week in January of rebasing years. One exception to the timeframe is the Hospital Acquired Conditions (HAC) Reduction file. The data for the current year is published within the first quarter of each calendar year.

Since the reports available at the end of the first full week of January contain the previous year’s HAC data, the Department will utilize the newest file available between January through March of rebasing years to assign HAC Reduction to Inpatient Base Rates.

For in-state Colorado DRG Hospitals (both PPS and non-PPS), the starting point shall be the hospital-specific Medicare Federal base rate with the specific adjustments listed. The Operating Federal Portion and Federal Capital Rate (source: CMS Tables 1A-1B & IE) will be adjusted by the Wage Index and Geographic Adjustment Factor (GAF) from the CMS IMPACT File.

For CAH and Pediatric hospitals (non-PPS Medicare hospitals), both adjustment factors as listed above will be set to 1.0 and the corresponding labor and non-labor related amounts will be applied because these factors are not available from CMS. Additionally, the Quality and Meaningful Electronic Health Records (EHR) User adjustments will be applied to all PPS hospitals as indicated on the CMS IMPACT file, while all non-PPS hospitals are assumed to have submitted Quality Data and be meaningful EHR users since no data exists for them. The Medicare base rate IMPACT File shall be used to set the Federal Base Rate and other adjustments detailed above.

b. Policy Adjustments Indirect Medical Education (IME) / Value Based Purchasing Adjustment (VBP) Factor / Readmission Adjustment Factor and Hospital Acquired Conditions (HAC) Reduction:

For PPS hospitals, Operating IME% will be multiplied by Adjusted Operating Federal Portion and the Capital IME% will be multiplied by the Adjusted Federal Capital Rate. The VBP Adjustment Factor and Readmission Adjustment Factor taken from CMS Tables 16B and 15 respectively will be multiplied by the Adjusted Operating Federal Portion. The Hospital Acquired Conditions Reduction taken from the CMS.gov Data Set as detailed in 8.300.5.A.3.a will be applied against the Medicare Federal Base Rate with Wage Index/GAF Adjustments.
For non-PPS hospitals, Operating & Capital IME % are not calculated in the IMPACT File so the Department’s Contractor will compute their Operating and Capital IME using the most recently available HCRIS cost report data in rebasing years and will require that hospitals have a CMS approved teaching program as detailed in Section 8.300.5.A.3.e. Additionally, non-PPS Hospitals will have the opportunity to review their calculated Operating and Capital IME percent during a 30-day review period and request changes if necessary. The VBP Adjustment Factor, Readmission Adjustment Factor and HAC Reduction will not be applied to non-PPS hospitals since they are not calculated by CMS.

c. Mutually Exclusive Medicaid Add-ons:

Four Add-ons will be mutually exclusive and applied as described here and will be applied as a percentage against the Medicare Federal Base Rate w/Wage Index/GAF Adjustments as detailed below.

Critical Access Hospital (CAH) Add-on will be set at 25% and is only open to those hospitals categorized as CAH by Medicare, 2) Sole Community Hospital (SCH)/Medicare Dependent Hospital (MDH) will be set at 20% and is only open those hospitals categorized as SCH/MDH in Section 8.300.1.L, 3) Low Discharge Add-on based on the average of up to three years of Total Discharges from cost reports on HCRIS in rebasing years and excludes hospitals that are classified as Pediatric, SCH/MDH or CAH. For hospitals with subunits of Psychiatric, Rehabilitation and other subunits discharges in those subunits with be added to total discharges. The percentage add-on is set at 10% and distributed on a sliding scale with a ceiling of 2,500 and floor of 500 discharges, 4) The Pediatric Add-on is open only to hospitals defined as Pediatric in Section 8.300.1.L.3 and the percentage add-on is set at 25%.

d. Remaining Medicaid Add-ons:

The remaining add-ons are open to all hospitals who qualify and are applied as a percentage of the Medicare Federal Base Rate with Wage Index/GAF Adjustments and distributed on a sliding scale between the respective ceiling and floor.

Payer Mix Add-on is based on the percentage of Medicaid patient days treated at the hospital using up to three years of the most recently available HCRIS cost reports. The add-on is set at up to 10% with a ceiling and floor of 50% and 35% respectively. For hospitals with subunits of Psychiatric, Rehabilitation and other subunits Payer Mix utilization in those subunits with be added to the calculations.
Operating Cash Flow Margin Percent Add-on (also known as the solvency metric) is set at 20% with a ceiling of 8% and floor of 0%. The source for this data is up to 3 years of Hospital Transparency Data that is generated by each hospital and sent into the Department. The Operating Cash Flow Margin Percent Add-on is calculated for all hospitals and is based on the maximum of the hospital or the hospital system’s operating cash flow margin percent. System hospital list can be found on the Department’s website.

Operating Cash Flow Margin Percent is calculated by taking (Total Operating Net Income + Depreciation Expense) / Total Operating Revenue.

e. Application of Graduate Medical Education (GME) Cost Add-on to Determine Medicaid Inpatient Base Rate:

The Medicaid Inpatient base rate shall be equal to the rate as calculated in Sections 8.300.5.A.3.a-b plus the GME Medicaid hospital-specific cost add-on. The GME Medicaid hospital-specific cost add-on is calculated from the most recently available HCRIS Medicare/Medicaid cost report (CMS 2552) worksheet B, Part I. Partial year cost reports shall not be used to calculate the GME cost add-on. The GME cost add-on shall not be applied to the Medicaid Inpatient base rates for State University Teaching Hospitals.

State University Teaching Hospitals shall receive reimbursement for GME costs as described in Section 8.300.9.B.

The GME Medicaid hospital-specific cost add-on shall be an estimate of the cost per discharge for GME based on:

Medicare approved GME program where legitimate GME expenses have been reported in accordance with Medicare's rules detailed in 42 C.F.R. § 413.75, et. seq. (2025) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This regulation is available for public inspection at the Department of Health Care Policy and Financing, 303 E.17th Ave, Denver, CO 80203. Pursuant to C.R.S § 24-4-410(12.5)(V)(b), the Department shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule.

GME will be calculated when the following two criteria are met:

i. Hospitals that appear on the most recent list as of the end of the first full week in January of CMS qualified teaching hospitals on the CMS Open Payments website or the hospital will need to provide documentation to the State by proving Medicare approval of the GME program.

ii. Have countable GME costs in the most recent HCRIS cost report available as of the end of the first full week in January of rebasing years in worksheet B, part 1 and discharges from worksheet S-3, part I.

Ten percent of the GME Medicaid hospital-specific cost addon shall be applied.

f. Application of Adjustment Based on General Assembly Funding In rebasing years, for all in-state, Colorado DRG Hospitals (both PPS and non-PPS), the starting point for the Medicaid Inpatient base rate, as determined in Section 8.300.5.A.3.a - e, shall be adjusted by an equal percentage. This percentage shall be determined by the Department as required by the available funds appropriated by the General Assembly. Additionally, a 10% corridor has been implemented to prevent any hospital’s inpatient base rate from increasing or decreasing more than 10% each rebasing year.

g. Annual Adjustments The Medicaid Inpatient base rates are rebased every other year as described in Section 8.300.5.A.3.a - f and are effective each July 1.

In non-rebasing years, the Medicaid Inpatient base rates will be adjusted by the State Budget Action as set by Legislature and are effective each July 1. The Medicaid base rate shall be adjusted during the fiscal year, if necessary, based on appropriations available to the Department and/or adjustments necessary to balance the DRG payment equation. Medicaid inpatient base rates may be reduced during the state fiscal year in response to a Governor’s Executive Order issued pursuant to C.R.S § 24-75- 201.5.

Medicaid Inpatient Base Rate for New In-State Colorado DRG Hospitals The Medicaid Inpatient base rate for new in-state Colorado DRG Hospitals shall be the average Colorado Medicaid Inpatient base rate for their corresponding peer group. A Hospital is considered “new” until the next Inpatient rate rebasing year after the Hospital’s contract effective date. For the next Inpatient rate rebasing year, the Hospital’s Medicaid Inpatient base rate shall be equal to the rate as determined in Section 8.300.5.A.3- 6. If the Hospital does not have a Medicare Inpatient base rate or a full year Medicare/Medicaid cost report to compute a starting point as described in Section 8.300.5.A.3.a, their initial rate shall be equal to the average Colorado Medicaid Inpatient base rate for their corresponding peer group.
Medicaid Inpatient Base Rate for Border-state Hospitals The Medicaid Inpatient base rate for border-state Hospitals shall be equal to the average Medicaid Inpatient base rate for the corresponding peer group.
Medicaid Inpatient Base Rate for Out-of-state Hospitals a. The Medicaid Inpatient base rate for out of state Hospitals shall be equal to 90% of the average Medicaid Inpatient base rate for the corresponding peer group.

b. The Department may reimburse an out-of-state Hospital for nonemergent services at an amount higher than the DRG base payment when the needed services are not available in a Colorado Hospital. Reimbursement to the out-of-state Hospital shall be made at a rate mutually agreed upon by the parties involved.

Reimbursement for Inpatient Hospital claims that (a) include serious reportable events identified by the Department in the Provider Bulletin with (b) discharge dates on or after October 1, 2009, may be adjusted by the Department. 8.300.5.B Abbreviated Client Stays 1. DRG Hospitals shall receive the DRG base payment and any corresponding outlier payment for Abbreviated Client Stays. The DRG base payment and outlier payment shall be subject to any necessary reduction for ineligible days. 8.300.5.C Transfer Pricing 1. Reimbursement for a client who is transferred from one DRG Hospital to another DRG Hospital is calculated at a DRG per diem rate for each Hospital with payment up to the DRG base payment to each DRG Hospital. If applicable, both Hospitals may receive outlier reimbursement.
Reimbursement for a client who is transferred from one DRG Hospital to a Non-DRG Hospital, or the reverse, is calculated at the DRG per diem rate for the DRG Hospital with payment up to the DRG base payment.

Reimbursement for the Non-DRG Hospital shall be calculated based on the assigned per diem rate. If applicable, the DRG Hospital may receive outlier reimbursement.

For transfers within the DRG Hospital, the Hospital is required to submit one claim for the entire stay, regardless of whether or not the client has been transferred to different parts of the Hospital. Since the Colorado Medicaid program does not recognize distinct part units, Hospitals may not submit two claims for a client who is admitted to the Hospital and then transferred to the distinct part unit or vice versa. 8.300.5.D APR-DRG Payment Methodology Exclusions 1. Long-acting reversible contraceptives (LARC) devices, inserted following a delivery, are excluded from the DRG Relative Weight calculation and are paid according to the Department’s fee schedule.
Pursuant to § 25.5-5-509, C.R.S. payments for select Inpatient Hospital Opioid Antagonist Drugs that would have otherwise been compensated through the APR-DRG methodology will be reimbursed at either the lower of the billed charges or the fee schedule rate.
Effective January 1, 2024, for services meeting the criteria of an Inpatient Hospital Specialty Drug that would have otherwise been compensated through the APR-DRG methodology, a hospital must submit a request for authorization to the Department prior to administration of the drug. If the request is approved, then the payment will be negotiated between the Department and the hospital on a case-by-case basis. 8.300.5.E Payments to Non-DRG Hospitals for Inpatient Services 1. Payments to Psychiatric Hospitals a. The Department shall reimburse Psychiatric Hospitals for inpatient services provided to Medicaid clients on a per diem basis. The per diem rates shall follow a step-down methodology. Each step has a corresponding per diem rate based on historical Medicaid payment rates and evaluation of Hospital data concerning the relationship between Hospital costs and client length of stay. Criteria for each step are described below: i Step 1: Day 1 through Day 7 ii Step 2: Day 8 through remainder of care at acute level b. Hospital rates may be adjusted annually on July 1 to account for changes in funding by the General Assembly and inflationary adjustments as determined by the Medicare Economic Index.

Hospital rates may be reduced during the state fiscal year in response to a Governor’s Executive Order issued pursuant to C.R.S § 24-75-201.5.

Payment to State-Owned Psychiatric Hospitals The Department shall reimburse State-Owned Psychiatric Hospitals on an interim basis according to a per diem rate. The Department will determine the per diem rate based on an estimate of 100% of Medicaid costs from the Hospital’s Medicare cost report. Periodically, the Department will audit actual costs and may require a cost settlement to insure reimbursement is 100% of actual audited Medicaid costs.
Payments to Long-Term Care and Rehabilitation Hospitals (excludes distinct part units and satellite locations as defined under Section 8.300) shall be divided into three (3) subgroups: Long-Term Care Hospital, Rehabilitation Hospital and Spine/Brain Injury Treatment Specialty Hospital.

The Department shall reimburse Long-Term Care, Rehabilitation, and Spine/Brain Injury Treatment Specialist Hospitals for inpatient services provided to Medicaid patients on a per diem basis. The per diem rates shall follow a step-down methodology based on length of stay, with a decrease of five (5) percent with each step. Each step shall be assigned a corresponding per diem rate based on historical Medicaid payment rates and evaluation of Hospital data concerning the relationship between Hospital costs and client length of stay. The Department may adjust hospital rates annually on July 1 to account for changes in funding by the General Assembly. The criteria for each of the steps are described below:

a. Payments to Long-Term Care Hospitals:

i. Step 1: Day 1 through Day 21 ii. Step 2: Day 22 through Day 35 iii. Step 3: Day 36 through Day 56 iv. Step 4: Day 57 through remainder of stay b. Payments to Rehabilitation Hospitals:

i. Step 1: Day 1 through Day 6 ii. Step 2: Day 7 through Day 10 iii. Step 3: Day 11 through Day 14 iv. Step 4: Day 14 through remainder of stay c. Payments to Spine/Brain Injury Treatment Specialty Hospitals:

i. Step 1: Day 1 through Day 28 ii. Step 2: Day 29 through Day 49 iii. Step 3: Day 50 through Day 77 iv. Step 4: Day 78 through remainder of stay d. The Classification-specific per diem for 2019, the year of this methodology implementation shall be calculated using the following method:

i. The Department shall assign the claims submitted by each hospital for fiscal year 2017 to one of the following peer groups:

Long-Term Care Hospital 2) Rehabilitation Hospital 3) Spine/Brain Injury Treatment Specialty Hospital ii. The Department shall process Medicaid inpatient hospital claims from state fiscal year 2017 through the methodology described in Section 8.300.5.D.3 a-c. This will create per diems that are budget neutral to fiscal year 2017.

iii. The Department shall adjust the per diems annually to reflect budget changes. For state fiscal year 2018, rates shall be increased 1.4%. For state fiscal year 2019, rates shall be increased 1%. The Department shall adjust rates in subsequent years by the percentage changes in the budget as appropriated by the General Assembly. Hospital rates may be reduced during the state fiscal year in response to a Governor’s Executive Order issued pursuant to C.R.S § 24- 75-201.5. 8.300.5.F [Emergency rule expired 04/10/2021] 8.300.5.G Payment for Inpatient Subacute Care 1. Inpatient Subacute Care days shall be paid at a rate equal to the estimated adjusted State-wide average rate per patient-day paid for services provided in skilled nursing facilities under the State plan approved by the Centers for Medicare and Medicaid Services (CMS), for the State in which such hospital is located. 8.300.5.H Payment for High Acuity In-State Services 1. The Department may negotiate a higher reimbursement rate for in-state inpatient hospital services up to, but no greater than, 100% of the costs anticipated by the hospital—which must be demonstrated by evidence, including but not limited to an anticipated cost report submitted to the Department for review—where, as determined by the Department, all of the following conditions are fulfilled:

a. The in-state inpatient payment methodology insufficiently accounts for the level of acuity;

b. All other placement options have been exhausted; and c. The services have been reviewed and authorized by the Medical Director for the Department. 8.300.6 Payments For Outpatient Hospital Services 8.300.6.A Payments to DRG Hospitals for Outpatient Services 1. Payments to In-Network Colorado DRG Hospitals Excluding items that are reimbursed according to the Department’s fee schedule, Outpatient Hospital Services are reimbursed on an interim basis at actual billed charges multiplied by the Medicare cost-to-charge ratio less 28%. When the Department determines that the Medicare cost-tocharge ratio is not representative of a Hospital’s Outpatient costs, the cost-to-charge ratio may be calculated using historical data. A periodic cost audit is done and any necessary retrospective adjustment is made to bring reimbursement to the lower of actual audited Medicaid cost less 28% or billed charges less 28%.

Effective September 1, 2009, Outpatient Hospital Services are reimbursed on an interim basis at actual billed charges times the Medicare cost-tocharge ratio less 29.1 percent (29.1%). When the Department determines that the Medicare cost-to-charge ratio is not representative of a hospital's actual audited cost less 29.1 percent (29.1%) or billed charges less 29.1 percent (29.1%).

Effective January 1, 2010, Outpatient Hospital Services are reimbursed on an interim basis at actual billed charges times the Medicare cost-to-charge ratio less 30 percent (30%). When the Department determines that the actual audited cost less 30 percent (30%) or billed charges less 30 percent (30%).

Effective July 1, 2010, Outpatient Hospital Services are reimbursed on an ratio less 30.7 percent (30.7%). When the Department determines that the actual audited cost less 30.7 percent (30.7%) or billed charges less 30.7 percent (30.7%).

Effective July 1, 2011, Outpatient Hospital Services are reimbursed on an ratio less 31.2 percent (31.2%). When the Department determines that the actual audited cost less 31.2 percent (31.2%) or billed charges less 31.2 percent (31.2%).

Effective July 1, 2013, Outpatient Hospital Services are reimbursed on an ratio less 29.8 percent (29.8%). When the Department determines that the actual audited cost less 29.8 percent (29.8%) or billed charges less 29.8 percent (29.8%).

Effective July 1, 2014, Outpatient Hospital Services are reimbursed on an ratio less 28.4 percent (28.4%). When the Department determines that the actual audited cost less 28.4 percent (28.4%) or billed charges less 28.4 percent (28.4%).

Effective July 1, 2015, Outpatient Hospital Services are reimbursed on an ratio less 28 percent (28%). When the Department determines that the actual audited cost less 28 percent (28%) or billed charges less 28 percent (28%).

Effective October 31, 2016, DRG Hospitals will be reimbursed for Outpatient Hospital Services based on a system of Enhanced Ambulatory Patient Grouping and a Hospital-specific Medicaid Outpatient base rate.

The reimbursement for Outpatient Hospital Services shall be referred to as the EAPG Payment.

a. The EAPG Payment will be equal to the EAPG Weight multiplied by the Hospital-specific Medicaid Outpatient base rate for that hospital as calculated in 10 CCR 2505-10, Section 8.300.6.A.1.k. If the EAPG Weight is modified due to any action impacting payment as described in sections 8.300.6.A.1.d-j, the modified EAPG Weight will be referred to as the EAPG Adjusted Weight. EAPG Payment will then be equal to the EAPG Adjusted Weight multiplied by the Hospital-specific Medicaid Outpatient base rate. If the billed amount is less than the EAPG Payment, reimbursement will be the billed amount.

b. The EAPG Payment is calculated for each detail on the claim.

Claim details with the same dates of service are grouped into a visit. Claims containing details describing charges for emergency room, treatment room services or patients placed under observation will have all its details grouped into a single visit.

c. Each detail on a claim is assigned an EAPG. EAPGs can have the following types:

(1) Per Diem (2) Significant Procedure. Subtypes of Significant Procedures Are:

(a) General Significant Procedures (b) Physical Therapy and Rehabilitation (c) Behavioral Health and Counseling (d) Dental Procedure (e) Radiologic Procedure (f) Diagnostic or Therapeutic Significant Procedure (3) Medical Visit (4) Ancillary (5) Incidental (6) Drug (7) Durable Medical Equipment (8) Unassigned d. A detail will be subject to EAPG Consolidation when it is assigned the same Significant Procedure EAPG as a detail not already subjected to EAPG Consolidation for that visit. EAPG Consolidation will also occur for details assigned EAPGs considered to be clinically similar to another EAPG during the visit. Details subject to EAPG Consolidation will have an EAPG Payment calculated using an EAPG Weight of 0.

e. A detail will be subject to EAPG Packaging when its assigned EAPG is considered an ancillary service to a Significant Procedure EAPG or Medical Visit EAPG present on the claim for that visit.

Details describing additional undifferentiated medical visits and services will be exempt from EAPG Packaging. A detail is also subject to EAPG Packaging when it is assigned a Medical Visit EAPG while a Significant Procedure EAPG is present on the claim for that visit. Details assigned Significant Procedure EAPGs that are not General Significant Procedures do not cause details with Medical Visit EAPGs to be subject to EAPG Packaging. Details subject to EAPG Packaging will be calculated using an EAPG Weight of 0.

f. A detail will qualify for Multiple Significant Procedure Discounting when a Significant Procedure of the same subtype is present on the claim for that visit. Details qualifying for Multiple Significant Procedure Discounting are ordered by their EAPG Weight, by visit.

Per visit, the qualifying detail with the greatest EAPG Weight will have its EAPG Payment calculated at 100 percent (100%) of its EAPG Weight. The qualifying detail for that visit with the next greatest EAPG Weight will have its EAPG Payment calculated at 50 percent (50%) of its EAPG Weight. All other qualifying details for that visit will have its EAPG Payment calculated at 25 percent (25%) of its EAPG Weight.

g. Details assigned the same Ancillary EAPG on the same visit will qualify for Repeat Ancillary Discounting. EAPG Payment for the first occurrence of a detail qualifying for Repeat Ancillary Discounting for that visit and EAPG is calculated using 100 percent (100%) of its EAPG Weight. EAPG Payment for the second occurrence of a detail qualifying for Repeat Ancillary Discounting for that visit and EAPG is calculated using 50 percent (50%) of its EAPG Weight.

EAPG Payment for all other details qualifying for Repeat Ancillary Discounting for that visit and EAPG will be calculated using 25 percent (25%) of their EAPG Weights.

h. Details describing terminated procedures will be subject to Terminated Procedure Discounting. EAPG Payment for a detail subject to Terminated Procedure Discounting is calculated using 50 percent (50%) of the EAPG Weight. Terminated procedures are not subject to other types of discounting.

i. Details describing bilateral services will have EAPG Payment calculated using 150 percent (150%) of the EAPG Weight or the EAPG Payment not resulting from Terminated Procedure Discounting.

j. Details describing 340B Drugs will have an EAPG Payment calculated using 65 percent (65%) of the EAPG Weight or the EAPG Payment not resulting from Terminated Procedure Discounting.

k. The Hospital-specific Medicaid Outpatient base rate for January 1, 2022 for each hospital is calculated using the following method.

(1) Assign each hospital to one of the following groups based on hospital type and location:

(a) Pediatric Hospitals (b) Critical Access Hospitals (c) Non-Critical Access, System Hospitals (d) Independent Hospitals (e) Rehabilitation, Long-term Acute Care, and Brain/Spine Injury Hospitals (2) Rehabilitation, Long-term Acute Care, and Brain/Spine Injury Hospitals are assigned their same hospital-specific base rate as effective immediately prior to January 1, 2022.

(3) Process Medicaid outpatient hospital claims from calendar year 2019 through the methodology described in 8.300.6.A.1.a-j using 3M’s EAPG Relative Weights, scaled for budget neutrality purposes, and version 3.16 of the Enhanced Ambulatory Patient Grouping methodology.

Hospital payment rates from version 3.10 of the methodology are then compared to the version 3.16 payment rates using the hospital-specific base rates immediately prior to January 1, 2022.

(4) For Critical Access Hospitals, a weighted average base rate by outpatient hospital visit is calculated EAPG payments for Critical Access Hospitals under version 3.10 and 3.16 are calculated using this weighted average base rate, then an inflation factor is applied to determine a revenue neutral rate for the Critical Access Hospital group. This inflation factor is then applied to all Critical Access Hospital rates effective immediately prior to January 1, 2022. For all other hospitals, with the exception of Rehabilitation, Long-term Acute Care, and Spine/Brain Injury Hospitals, a revenue neutral rate is calculated which aligns payment under version 3.16 of EAPGs to payments calculated under version 3.10.

(5) For Critical Access Hospitals, the average and standard deviation of their rates with the inflation factor applied is calculated. All Critical Access Hospitals with a rate falling below 1 standard deviation of the average is given a rate at 1 standard deviation below the average. For Critical Access Hospitals with a rate above 2 standard deviations of the average is given a rate at 2 standard deviations above the average. For each other hospital group, except Rehabilitation, Long-term Acute Care, and Spine/Brain Injury Hospitals, the average and standard deviation of their rates are calculated. For hospitals that have a rate below 1.5 standard deviations of the average rate of their assigned group, the hospital is assigned a rate at 1.5 standard deviations below the group’s average rate. For hospitals that have a rate above 1.5 standard deviations of the average rate of their assigned group, the hospital is assigned a rate at 1.5 standard deviations above the group’s average rate.

(6) For new, in-state hospitals, such hospitals will be assigned to a Pediatric, Long Term Acute Care, or Rehabilitation peer group depending on hospital type. If a provider does not meet the criteria for any of the above peer groups, it will be assigned to a Rural or Urban peer group based on location.

The hospital will receive a base rate of the average peergroup rate as calculated from Colorado hospitals base rate statistics.

(7) For all hospitals, the Medicaid Outpatient base rate, as determined in 8.300.6.A.k.(1)-(6), shall be adjusted by an equal percentage, when required due to changes in the available funds appropriated by the General Assembly. The application of this change to the Medicaid Outpatient base rate shall be determined by the Department. Medicaid outpatient base rates may be reduced during the state fiscal year in response to a Governor’s Executive Order issued pursuant to C.R.S § 24-75-201.5.

l. Effective June 1, 2020, by the modification of the EAPG Weights, the allowed reimbursement of outpatient hospital drugs shall be increased by 42.93% for drugs provided at Critical Access Hospitals and Medicare Dependent Hospitals, and decreased by 3.47% for drugs provided at non-independent urban hospitals.

Payments to Out-of-Network DRG Hospitals Excluding items that are reimbursed according to the Department’s fee schedule, border-state Hospitals and out-of-network Hospitals, including out-of-state Hospitals, shall be paid 30% of billed charges for Outpatient Hospital Services. Consideration of additional reimbursement shall be made on a case-by-case basis in accordance with supporting documentation submitted by the Hospital.

Out-of-Network DRG Hospitals will be reimbursed for Outpatient Hospital Services based on the system of Enhanced Ambulatory Patient Grouping described in Section 8.300.6.A.1. Such hospitals will be assigned to a Pediatric, Long Term Acute Care, or Rehabilitation peer group depending on hospital type. If a provider does not meet the criteria for any of the above peer groups, it will be assigned to a Rural or Urban peer group based on location. The hospital will receive a base rate of 90% of the average peer group rate as calculated from Colorado hospitals base rate statistics. Out-of-Network DRG Hospitals will periodically have their Medicaid Outpatient base rates adjusted as determined in Section 8.300.6.A.k.7.

Payments for Outpatient Hospital Specialty Drugs Effective August 11, 2018, for services meeting the criteria of an Outpatient Hospital Specialty Drug that would have otherwise been compensated through the EAPG methodology, a hospital must submit a request for authorization to the Department prior to administration of the drug. If the request is approved, then the payment will be negotiated between the Department and the hospital on a case-by-case basis.
Payments for Select Outpatient Hospital Opioid Antagonist Drugs Pursuant to C.R.S. § 25.5-5-509, effective July 8, 2022, payments for select Outpatient Hospital Opioid Antagonist Drugs that would have otherwise been compensated through the EAPG methodology will be reimbursed at either the lower of the billed charges or the fee schedule rate. 8.300.7 Graduate Medical Education (GME) Payments to Hospitals for Medicaid Managed Care GME costs for Medicaid managed care clients shall be paid directly to qualifying Hospitals rather than to managed care organizations (MCOs). 8.300.7.A GME for Medicaid Managed Care – Inpatient Services 1. The Hospital cost report used for the most recent rebasing year shall be used to determine the Medicaid Inpatient GME cost per day for each Hospital that has GME costs in its fee-for-service base rate, excluding State University Teaching Hospitals. Each Hospital’s GME cost per day shall be computed when Hospital rates are rebased according to the schedule outlined in Section 8.300.5.A.3.e. Years when rates are updated with the State Budget Action as set by Legislature, GME cost per day will remain unchanged from the cost report rebasing year.
MCOs shall provide to the Department Inpatient days by Hospital for discharges (net of adjustments) during each quarter of the calendar year.

This information shall be provided within 120 days after the close of each calendar year quarter.

The Medicaid managed care Inpatient days for each Hospital shall be the total of the Inpatient days for each Hospital received from the MCOs for each quarter. That total shall be multiplied by the GME cost per day to determine the Inpatient GME reimbursement for each Hospital per quarter.

The GME reimbursement will be paid at least annually through a gross adjustment process to each Hospital by June 30th of each year. 8.300.7.B GME for Medicaid Managed Care – Outpatient Services 1. The Hospital cost report used for the most recent rebasing year shall be used to determine the Outpatient GME cost-to-charge ratio for each Hospital that has a graduate medical education program. Each Hospital’s GME cost-to-charge ratio shall be computed when Hospital rates are rebased according to the schedule outlined in Section 8.300.5.A.3.e.

Years when rates are updated with the State Budget Action as set by Legislature, GME cost-to-charge ratio will remain unchanged from the cost report rebasing year.

MCOs shall provide to the Department Outpatient charges for Medicaid clients by Hospital for Outpatient dates of service during each quarter of the calendar year. This information shall be provided within 120 days after the close of each calendar year quarter.
The Medicaid managed care Outpatient charges for each Hospital shall be the total of the Outpatient charges for each Hospital received from the MCOs for each quarter. That total shall be multiplied by the cost-to-charge ratio and reduced by 28 percent to determine the Outpatient GME reimbursement for each Hospital per quarter. The GME reimbursement shall be paid at least annually through a gross adjustment process to each Hospital by June 30th of each year. 8.300.8 Disproportionate Share Hospital Adjustment 8.300.8.A Federal regulations require that Hospitals which provide services to a disproportionate share of Medicaid recipients shall receive an additional payment amount to be based upon the following minimum criteria:
A Hospital must have a Medicaid Inpatient utilization rate at least one standard deviation above the mean Medicaid Inpatient utilization rate for Hospitals receiving Medicaid payments in the State, or a low income utilization rate that exceeds 25 percent; and 2. A Hospital must have at least two obstetricians with staff privileges at the Hospital who agree to provide obstetric services to individuals entitled to such services under the State Plan.

a. In the case where a Hospital is located in a rural area (that is, an area outside of a metropolitan statistical area, as defined by the Executive Office of Management and Budget), the term “obstetrician” includes any physician with staff privileges at the Hospital to perform non-emergency obstetric procedures.

Number (2) above does not apply to a Hospital in which:

a. the Inpatients are predominantly under 18 years of age; or b. does not offer non-emergency obstetric services as of December 21, 1987.

The Medicaid Inpatient utilization rate for a Hospital shall be computed as the total number of Medicaid Inpatient days for a Hospital in a cost reporting period, divided by the total number of Inpatient days in the same period.
The low income utilization rate shall be computed as the sum of:

a. The fraction (expressed as a percentage), i. the numerator of which is the sum (for a period) of 1) total revenues paid the Hospital for client services under a State Plan under this title and 2) the amount of the cash subsidies for client services received directly from state and local governments; and ii. the denominator of which is the total amount of revenues of the Hospital for client services (including the amount of such cash subsidies) in the period; and b. a fraction (expressed as a percentage), i. the numerator of which is the total amount of the Hospital’s charge for Inpatient Hospital services which are attributable to charity care in a period less the portion of any cash subsidies described in clause (I) (ii) of subparagraph a) of

Section 1923 of the Social Security Act, in the period reasonably attributable to Inpatient Hospital services, and ii the denominator of which is the total amount of the Hospital’s charges for Inpatient Hospital services in the Hospital in the period.

The numerator under subparagraph (b)(i) shall not include contractual allowances and discounts. 8.300.8.B Colorado Determination of Individual Hospital Disproportionate Payment Adjustment 1. Eligible hospitals will receive a Disproportionate Share Hospital Supplemental Payment according to the terms defined in 10 CCR 2505-10

section 8.3004.D. 8.300.9 Supplemental Inpatient Hospital Payments 8.300.9.A Family Medicine Residency Training Program Payment A Hospital qualifies for a Family Medicine Residency Training Program payment when it is recognized by the Commission on Family Medicine and has at least 10 residents and interns. The Family Medicine Residency Training Program payment will only be made to Medicaid in-network Hospitals. For each program which qualifies under this section, the additional Inpatient Hospital payment will be calculated based upon historical data and paid in 12 equal monthly installments. The Family Medicine Residency Training Program payment is a fixed amount subject to annual appropriation by the General Assembly. 8.300.9.B State University Teaching Hospital Payment State University Teaching Hospitals shall receive a supplemental Inpatient Hospital payment for GME costs associated with Inpatient Hospital Services provided to Medicaid fee-for-service and managed care clients. The State University Teaching Hospital payment is calculated based on GME costs and estimated Medicaid discharges using the same methodology as that used to calculate the GME add-on to the Medicaid Inpatient base rate described in 10 CCR 2505-10 Section 8.300.5.A.3.c., and the GME payments to Hospitals for Medicaid managed care described in 10 CCR 2505-10 Section 8.300.7. The State University Teaching Hospital payment is a fixed amount subject to annual appropriation by the General Assembly. 8.300.10 Patient Payment Calculation for Nursing Facility Clients Who are Hospitalized 8.300.10.A When an eligible client is admitted to the Hospital from a nursing facility, the nursing facility shall, at the end of the month, apply all of the available patient payment to the established Medicaid rate for the number of days the client resided in the nursing facility. The nursing facility shall notify the county department of any amount of patient payment that applies, using form AP-5615.

An allowed exception to the usual five (5) day completion requirement is that the AP-5615 for hospitalized clients may be completed at the end of the month. If the nursing facility has calculated an excess amount, the county will notify the Hospital of the amount. If directed by the county department, the nursing facility shall transfer the excess amount to the Hospital and this payment will be shown as a patient payment when the Hospital submits a claim to the Medicaid Program. 8.300.10.B The Hospital is responsible for collecting the correct amount of patient payment due from the client, the client’s family, or representatives. Failure to collect patient payment, in whole or in part, does not allow the Hospital to bill Medicaid for the patient payment. 8.300.11. Payment for Hospital Beds Designated as Swing Beds 8.300.11.A Swing Bed Payment Rates 1. Payment for swing-bed services will be made at the average rate per client day paid to Class I nursing facilities for services furnished during the previous calendar year.

Oxygen provided to swing-bed clients shall be reimbursed as specified in 10 CCR 2505-10, Sections 8.580 and 8.585.
Clients shall be required to contribute their patient payment to the cost of their nursing care. Collection as well as determination of the patient payment amount shall be in accordance with 10 CCR 2505-10, Section 8.482. 8.300.11.B Swing Bed Claim Submission 1. Hospitals shall submit claims for swing-bed routine services as nursing facility claims.
Ancillary services (services not required to be provided by nursing facilities participating in the Medicaid program within their per diem rate, but reimbursable under Medicaid, including but not limited to laboratory and radiology) shall be billed separately on the appropriate claim form. 8.300.12 Utilization Management and Reviews All participating Hospitals are required to comply with utilization management and review, prior authorization requirements, audit and/or program integrity, and quality improvement activities administered by the Department’s utilization review vendor, external quality review organization or other representative. 8.300.12.A Conduct of Reviews 1. All reviews will be conducted in compliance with 10 CCR 2505-10, Sections 8.058 Request for Prior Authorization, 8.076, Program Integrity, and 8.079, Quality Improvement.
Reviews will be conducted relying on the professional expertise of health professionals, prior experience and professional literature; and nationally accepted evidence-based utilization review screening criteria whenever possible. These criteria shall be used to determine the quality, Medical Necessity and appropriateness of a health care procedure, treatment or service under review.
The types of reviews conducted may include, but are not limited to the following:

a. Prospective Reviews;

b. Concurrent Reviews;

c. Reviews for continued stays and transfers;

d. Retrospective Reviews.

These reviews, for selected Inpatient or Outpatient procedures and/or services, shall include but are not limited to:

a. Medical Necessity;

b. Appropriateness of care;

c. Service authorizations;

d. Payment reviews;

e. DRG validations;

f. Outlier reviews;

g. Second opinion reviews; and h. Quality of care reviews.

If criteria for Inpatient hospitalization or outpatient Hospital services are not met at any point in a hospitalization (i.e., at the point-of-admission review, Continued Stay Review or Retrospective Review) the provider will be notified of the finding.

a. When appropriate, payment may be adjusted, denied or recouped.

When the justification for services is not found, a written notice of denial shall be issued to the client, attending physician and Hospital. Clients and providers may follow the Department’s procedures for appeal. See 10 CCR 2505-10 Sections 8.050, Provider Appeals, and 8.057, Recipient Appeals. 8.300.12.B Corrective Action 1. The Department may require or recommend Corrective Action when documentation indicates a pattern of inappropriate behavior, including, but not limited to, improper billing, unwarranted utilization, or questionable quality of care.
The Department may initiate sanctions, as set forth in 10 CCR 2505-10,

Section 8.076 and Section 8.130 if the required Corrective Action is not implemented or the implemented Corrective Action fails to resolve the pattern of inappropriate behavior.

Requirement to self-audit, Retrospective Reviews, and other actions as determined appropriate by the Department may be required or performed as a type of Corrective Action for an identified Hospital or client. 8.300.12.C Prior Authorization of Swing-Bed Care Care for Medicaid clients in hospital beds designated as swing beds shall be prior authorized and subject to the Continued Stay Review process in accordance with the criteria and procedures found in 10 CCR 2505-10, Sections 8.393 and 8.400 through 8.415. Prior authorization requires a level of care determination using the Uniform Long Term Care 100.2 and a Pre-Admission Screening and Resident Review (PASRR) screening. 8.300.13 – 8.375.60 [Repealed effective 11/30/2009]

8.310 DIALYSIS TREATMENT CENTERS 8.310.1 Definitions Acute Kidney Injury (AKI) is the sudden loss of kidney function, the ability of the kidneys to remove waste and excess fluid. AKI is typically a condition in which kidney function can be expected to recover after a short period of time with treatment (i.e. pharmaceuticals or dialysis). However, AKI can progress to a complete recovery of kidney function, development of Chronic Kidney Disease (CKD) or End Stage Renal Disease (ESRD).

Chronic Kidney Disease (CKD) is the slow loss of kidney function over time until the kidneys reach ESRD.

Dialysis is the process of cleaning the blood when the kidneys have failed and are no longer filtering the blood to remove waste and excess fluid. Kidney failure can stem from AKI or CKD. Dialysis includes both peritoneal dialysis and hemodialysis.

End Stage Renal Disease (ESRD) is defined as irreversible and permanent damage to the kidneys that requires either a regular course of dialysis treatment or kidney transplantation to maintain life.

Provider means a Dialysis Treatment Center that is hospital-affiliated or independent of a licensed hospital, and licensed by the Colorado Department of Public Health and Environment to provide outpatient dialysis services or training for home or self-dialysis.

Home Dialysis Training is a program that trains Clients to perform dialysis in the client’s home with little or no professional assistance, and trains other individuals to assist clients in performing home dialysis.

Self-Dialysis Training is a program that trains Clients to perform self-dialysis in the treatment facility with little or no professional assistance, and trains other individuals to assist Clients in performing self-dialysis. 8.310.2. Eligibility 8.310.2.A. Client Eligibility 1. Any Colorado Medicaid Client diagnosed with CKD, AKI or ESRD, which requires dialysis treatments to restore kidney function or maintain life shall be eligible. 8.310.2.B. Provider Eligibility 1. To provide services, a Dialysis Treatment Center must be:

a. Enrolled in the Colorado Medical Assistance Program;

b. Certified by the Centers for Medicare and Medicaid Services (CMS) to participate in the Medicare program as a dialysis treatment center;

c. Certified by the Colorado Department of Public Health and Environment 8.310.2.C. Prior Authorization 1. Prior Authorization is not required for services listed at Section 8.310.3.B. 8.310.3. General Services 8.310.3.A. Provider Requirements 1. The Provider must utilize the most cost efficient method of dialysis treatment appropriate for each client, as assessed through an evaluation for peritoneal dialysis based upon an individual medical diagnosis and condition.

The Provider Facility must develop and implement a written, individualized comprehensive plan of care for each patient, which must include:

a. The services necessary to address the patient’s needs;

b. The comprehensive assessment and changes in the patient’s condition;

c. Measurable and expected outcomes, and estimated timetables to achieve these outcomes;

d. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards; and e. The plan of care must represent the selection of a suitable treatment modality (e.g., dialysis or transplantation) and dialysis setting (e.g., home, self-care) for each patient (42 CFR 405, 410, 413, 414, 488 and 494). 8.310.3.B. Covered Dialysis Services The following are covered services under the Colorado Medicaid Dialysis Center Program:

In-Center Dialysis a. Dialysis treatments completed by facility staff, and all necessary equipment and supplies.

b. In-Center dialysis is a benefit when the client meets one of the following conditions:

i) The client requires dialysis treatments prior to completing home dialysis training;

ii) Training to perform self-treatment in the home environment is contraindicated;

iii) The client is otherwise not a proper candidate for selftreatment in a home environment;

iv) The home environment of the eligible client contraindicates self-treatment; or v) The eligible client is awaiting a kidney transplant.

c. Self-dialysis may be performed within the facility with limited professional assistance, if the client has completed an appropriate course of training.

i) The benefit includes training of the client by qualified personnel.

Home Dialysis a. To be eligible for home dialysis a client or client’s caregiver must receive appropriate training to perform dialysis at home.

b. The benefit includes training by qualified personnel, necessary supplies, and equipment for dialysis services.

c. The Benefit includes delivery, installation, and maintenance of equipment for home dialysis 3. The following are included in the Dialysis Center reimbursement and should not be billed separately:

a. Costs associated with home dialysis other than necessary delivery, equipment, installation, maintenance, supplies, or training.

b. Blood and blood products.

c. Additional staff time or personnel costs.

d. Routine Laboratory Services i) All laboratory services considered routine for dialysis treatment, and performed by a dialysis treatment facility, are included as part of the dialysis treatment reimbursement.

ii) A Provider performing routine laboratory services must be a certified clinical laboratory.

e. Routine Pharmaceuticals for Dialysis Treatment i) All pharmaceuticals considered routine for dialysis treatment, and dispensed by a dialysis treatment facility, are included as part of the dialysis treatment reimbursement.

ii) Pharmaceuticals not dispensed by the dialysis provider are billed by and reimbursed to the dispensing pharmacy. 8.310.3.C. Non-Covered Services The following are non-covered services under the Colorado Medicaid Dialysis Center benefit:

Personal care items such as slippers or toothbrushes.

8.320 COMMUNITY CLINIC, INCLUDING FREESTANDING EMERGENCY

DEPARTMENTS 8.320.1 Definitions A. Community Clinic (CC) means a hospital-owned health care facility, licensed as a Community Clinic under 6 CCR 1011-1, Chapter IX or as a Freestanding Emergency Department (FSED) under 6 CCR 1011-1, Chapter XIII and enrolled as a CC provider type, that provides health care services on an ambulatory

basis.

B. CMS means the Centers for Medicare and Medicaid Services.

C. Department means the Department of Health Care Policy and Financing.

D. Emergency Care Services, for the purposes of this rule, has the same meaning as Section 8.300.1.I.

E. Observation Stay, for the purposes of this rule, has the same meaning as Section 8.300.1.Q. 8.320.2 Requirements for Enrollment as a CC 8.320.2.A.

The facility is licensed as a Community Clinic or FSED by the Colorado Department of Public Health and Environment (CDPHE) in accordance with CDPHE rule at 6 CCR 1011-1, Chapter IX or Chapter XIII; and 2. The facility location is certified by CMS under the operating hospital’s Medicare certification. 8.320.3 Services 8.320.3.A The following services provided by a CC are eligible for reimbursement:
Outpatient services, as defined in the Department’s rule at 10 CCR 2505- 10, section 8.300.3.B, section 8.300.B.2, 8.300.B.3; and 2. Observation stays, as defined in the Department’s rule at 10 CCR 2505- 10, section 8.300.3.B.1. 8.320.4 Reimbursement 8.320.4.A CC services are reimbursed as:
Outpatient services, in accordance with the Department’s rule at 10 CCR 2505-10, section 8.300.6, using the hospital base rate for the hospital that is identified in the CMS certification of the CC. ______________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.400 MEDICAL ASSISTANCE - SECTION 8.400 Long Term Care, Nursing Facility Care, Adult Day Care Services {#sec-10-ccr-2505-10-8.400 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.400}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE - SECTION 8.400 LONG TERM CARE, NURSING FACILITY CARE, ADULT DAY CARE SERVICES 10 CCR 2505-10 8.400 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

8.400 LONG-TERM CARE .10 Long-term care includes nursing facility care as part of the standard Medicaid benefit package, and Home and Community Based Services provided under waivers granted by the Federal government. .101 Nursing facility services and Home and Community Based Services are benefits only under Medicaid. Nursing Facility Services and Home and Community Based Services are non-benefits under the Modified Medical Program. .102 State only funding will pay for nursing facility services for October 1988 and November 1988 for clients under the Modified Medical Program who were residing in a nursing facility October 1, 1988. This is intended to give clients time to qualify for Medicaid. .11 Standard Medicaid long-term care services are services provided in:

Skilled care facilities (SNF)
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
Long-Term Care Hospitals - Inpatient Psychiatric Institution for Individuals under 21. .12 Home and Community Based Services (HCBS) under the Medicaid Waivers include distinct service programs designed as alternatives to standard Medicaid nursing facility or hospital services for discrete categories of clients. These waivers are Home and Community Based Services Waiver for Persons Who Are Elderly, Blind and Disabled (HCBS-EBD), Home and Community Based Services Waiver for Complementary and Integrative Health (HCBS-CHI), Community Mental Health Supports Waiver (HCBS-CMHS), Home and Community Based Services Waiver for Persons With Brain Injury (HCBS-BI); Home and Community Based Services Waiver for Persons with Developmental Disabilities (HCBS-DD), Supportive Living Services Waiver (HCBS-SLS); Children with Complex Health Needs Waiver (HCBS-CwCHN), Children’s Habilitation Residential Program Waiver (HCBS-CHRP), and Children Extensive Supports Waiver (HCBS-CES). .13 Unless specified by reference to the specific programs described above, the term Home and Community Based Services where it appears in these rules and regulations shall refer to the programs described herein above, and the rules and regulations within this section shall be applicable to all Home and Community Based Services programs. .14 Nursing facilities are prohibited from admitting any new client who has mental illness or intellectual or developmental disability, as defined in Section 8.401.18 Determination Criteria for Mentally Ill or Individuals with an Intellectual or Developmental Disability unless that client has been determined to require the level of services provided by a nursing facility as defined in Section 8.401.19. .15 Clients eligible for Home and Community Based Services are eligible for all Medicaid services including home health services. .16 Target Population Definitions. For purposes of determining appropriate type of long-term services, including home and community-based services, as well as providing for a means of properly referring clients to the appropriate community agency, the following target group designations are established:

A. Developmentally Disabled - includes all clients whose need for long-term care services is based on a diagnosis of Developmental Disability and Related Conditions, as defined in Section 8.401.18.

B. Mentally Ill - includes all clients whose need for long-term care is based on a diagnosis of mental disease as defined in Section 8.401.18.

C. Functionally Impaired Elderly - includes all clients who meet the level of care for SNF or ICF care, as determined by the LOC Screen and who are age 65 or over.

D. Physically Disabled or Blind Adult - includes all clients who meet the level of care for SNF or ICF care, as determined by the LOC Screen and who are age 18 through 64.

E. Persons Living with AIDS - includes all clients of any age who meet either the nursing home level of care or acute level of care for nursing facilities or hospitals and have the diagnosis of Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS). Clients who are diagnosed with HIV or AIDS may alternatively request to be designated as any other target group for which they meet the definitions above. .17 Services in Home and Community Based Services programs established in accordance with federal waivers shall be provided to clients in accordance with the URC determined target populations as defined herein above.

8.401 LEVEL OF CARE SCREEN

The Level of Care Screen assesses whether applicants require an institutional level of care typically provided in the following settings:

Nursing Facility - Hospital - Inpatient Psychiatric Institution for Individuals under the age of 21 - Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) .01 The client must have been found by the Case Management Agency to meet the applicable level of care for the type of services to be provided. .02 The Case Management Agency shall not make a Level of Care Eligibility Determination unless the recipient has been determined to be Medicaid eligible or an application for Medicaid services has been filed with the County Department of Social/Human services. .03 Payment for skilled (SNF) and intermediate nursing home care (ICF) Payment for skilled (SNF) and intermediate nursing home care (ICF) will only be made for clients whose Level of Care Eligibility Determination and frequency of need for skilled and maintenance services meet the level of care for long-term care. .04 Payment for care in an intermediate care facility for individuals with intellectual disabilities (ICF/IID) will only be made for developmentally disabled clients whose programmatic and/or health care needs meet the level of care for the appropriate class of ICF/IIDs. .05 Services provided by nursing facilities are available to those individuals who meet the level of care below and are not identified as mentally ill or individuals with an intellectual or developmental disability by the Determination Criteria for Mentally Ill or Individuals with an Intellectual or Developmental Disability in

Section 8.401.18.

8.401.1 GUIDELINES FOR LONG TERM CARE SERVICES .11 Eligibility for long-term care is based on a LOC Screen, as defined in Section 8.390.1, in which an individual’s needs are evaluated in at least the following areas of activities of daily living:

Mobility - Bathing - Dressing - Eating - Toileting - Transferring - Need for supervision .12 Skilled services shall be defined as those services which can only be provided by a skilled person such as a nurse or licensed therapist or by a person who has been extensively trained to perform that service. .13 Maintenance services shall be defined as those services which may be performed by a person who has been trained to perform that specific task, e.g., a family member, a nurses’ aide, a therapy aide, visiting homemaker, etc. .14 Skilled and maintenance services are performed in the following areas:
Skin care - Medication - Nutrition - Activities of daily living - Therapies - Elimination - Observation and monitoring .15 A. The case management agency shall certify as to the need for the nursing facility level of care, as demonstrated by the Level of Care Eligibility Determination Screen outcome using criteria outlined in 10 CCR 2505-10

Section 8.401.

B. A person's need for Medicaid state plan benefits is not a proper consideration in determining whether a person needs long-term care services (including Home and Community Based Services).

.16 LONG-TERM CARE ELIGIBILITY ASSESSMENTS

The Department is implementing a new Level of Care Eligibility Determination Screen instrument- the Colorado Single Assessment Level of Care Screen, or CSA LOC Screen. The new LOC Screen will replace the current instrument, the Uniform Long- Term Care (ULTC) 100.2. The intent of the new instrument is to better understand individual needs, obtain objective and consistent assessment data, including standardized Functional Assessment Standardized Items (FASI), and is not intended to reduce eligibility or services. The Department will implement the new LOC Screen gradually, meaning the ULTC 100.2 and the new CSA LOC Screen instruments will both be in use concurrently for Level of Care Eligibility Determination Screens until the new CSA LOC Screen has been fully implemented across Colorado. During the transition, Case Management Agencies will use one of the two instruments, as determined by the Department, for initial and ongoing Level of Care Eligibility Determinations.

A. UNIFORM LONG-TERM CARE 100.2

To qualify for Medicaid long-term care services using the ULTC 100.2, the member/Applicant must have deficits in 2 of 6 Activities of Daily Living (ADL), (2+ score) or require at least moderate (2+ score) in Behaviors or Memory/Cognition under Supervision as outlined below. The needs of an individual ages 18 and under shall be assessed in accordance with Appendix A, the Age-Appropriate Guidelines for the Use of ULTC 100.2 on Children. Specific ULTC scoring criteria is as follows:

BATHING

Definition: The ability to shower, bathe or take sponge baths for the purpose of maintaining adequate hygiene. 0=The client is independent in completing the activity safely. 1=The client requires oversight help or reminding; can bathe safely without assistance or supervision, but may not be able to get into and out of the tub alone. 2=The client requires hands on help or line of sight standby assistance throughout bathing activities in order to maintain safety, adequate hygiene and skin integrity. 3=The client is dependent on others to provide a complete bath.

Due To: (Score must be justified through one or more of the following conditions)

Falls Open Wound Stoma Site Supervision:

DRESSING

Definition: The ability to dress and undress as necessary. This includes the ability to put on prostheses, braces, anti-embolism hose or other assistive devices and includes fine motor coordination for buttons and zippers. Includes choice of appropriate clothing for the weather. Difficulties with a zipper or buttons at the back of a dress or blouse do not constitute a functional deficit. 1= The client can dress and undress, with or without assistive devices, but may need to be reminded or supervised to do so on some days. 2= The client needs significant verbal or physical assistance to complete dressing or undressing, within a reasonable amount of time. 3= The client is totally dependent on others for dressing and undressing.

Due To: (Score must be justified through one or more of the following conditions)

Open Wound Supervision:

Bladder Incontinence Bowel Incontinence TOILETING Definition: The ability to use the toilet, commode, bedpan or urinal. This includes transferring on/off the toilet, cleansing of self, changing of apparel, managing an ostomy or catheter and adjusting clothing. 1=The client may need minimal assistance, assistive device, or cueing with parts of the task for safety, such as clothing adjustment, changing protective garment, washing hands, wiping and cleansing. 2=The client needs physical assistance or standby with toileting, including bowel/bladder training, a bowel/bladder program, catheter, ostomy care for safety or is unable to keep self and environment clean. 3=The client is unable to use the toilet. The client is dependent on continual observation, total cleansing, and changing of garments and linens. This may include total care of catheter or ostomy. The client may or may not be aware of own needs.

Due To: (Score must be justified through one or more of the following conditions)

Bladder Incontinence Bowel Incontinence Physiological defect Balance Impaction Ostomy Catheter MOBILITY Definition: The ability to move between locations in the individual’s living environment inside and outside the home. Note: Score client’s mobility without regard to use of equipment other than the use of prosthesis. 1=The client is mobile in their own home but may need assistance outside the home. 2=The client is not safe to ambulate or move between locations alone; needs regular cueing, stand-by assistance, or hands on assistance for safety both in the home and outside the home. 3=The client is dependent on others for all mobility.

Due To: (Score must be justified through one or more of the following conditions)

Fine or Gross Motor Impairment Balance

History of Falls TRANSFERRING Definition: The physical ability to move between surfaces: from bed/chair to wheelchair, walker or standing position; the ability to get in and out of bed or usual sleeping place; the ability to use assisted devices, including properly functioning prosthetics, for transfers. Note: Score Client’s ability to transfer without regard to use of equipment. 1=The client transfers safely without assistance most of the time, but may need standby assistance for cueing or balance; occasional hands on assistance needed. 2=The client transfer requires standby or hands on assistance for safety; client may bear some weight. 3=The client requires total assistance for transfers and/or positioning with or without equipment.

Due To: (Score must be justified through one or more of the following conditions)

Falls EATING Definition: The ability to eat and drink using routine or adaptive utensils. This also includes the ability to cut, chew and swallow food. Note: If a person is fed via tube feedings or intravenously, check box 0 if they can do independently, or box 1, 2, or 3 if they require another person to assist. 1=The client can feed self, chew and swallow foods but may need reminding to maintain adequate intake; may need food cut up; can feed self if food brought to them, with or without adaptive feeding equipment. 2=The client can feed self but needs line of sight standby assistance for frequent gagging, choking, swallowing difficulty; or aspiration resulting in the need for medical intervention. The client needs reminder/assistance with adaptive feeding equipment; or must be fed some or all food by mouth by another person. 3=The client must be totally fed by another person; must be fed by another person by stomach tube or venous access.

Due To: (Score must be justified through one or more of the following conditions)

Poor Dentition Tremors Swallowing Problems Choking Aspiration Tube Feeding IV Feeding SUPERVISION Behaviors Definition: The ability to engage in safe actions and interactions and refrain from unsafe actions and interactions (Note, consider the client’s inability versus unwillingness to refrain from unsafe actions and interactions).

SCORING CRITERIA 0=The client demonstrates appropriate behavior; there is no concern. 1=The client exhibits some inappropriate behaviors but not resulting in injury to self, others and/or property. The client may require redirection. Minimal intervention is needed. 2=The client exhibits inappropriate behaviors that put self, others or property at risk.

The client frequently requires more than verbal redirection to interrupt inappropriate behaviors. 3=The client exhibits behaviors resulting in physical harm to self or others. The client requires extensive supervision to prevent physical harm to self or others.

Due To: (Score must be justified through one or more of the following conditions)

Chronic Medical Condition Acute Illness Choking Communication Impairment (not inability to speak English)

Mood Instability Supervision needs:

Short Term Memory Loss Long Term Memory Loss Agitation Aggressive Behavior Verbal Abusiveness Constant Vocalization Sleep Deprivation Self-Injurious Behavior Impaired Judgment Disruptive to Others Disassociation Wandering Self Neglect Medication Management Memory/Cognition Deficit Definition: The age appropriate ability to acquire and use information, reason, problem solve, complete tasks or communicate needs in order to care for oneself safely.

SCORING CRITERIA 0= Independent no concern 1= The client can make safe decisions in familiar/routine situations, but needs some help with decision making support when faced with new tasks, consistent with individual’s values and goals. 2= The client requires consistent and ongoing reminding and assistance with planning, or requires regular assistance with adjusting to both new and familiar routines, including regular monitoring and/or supervision, or is unable to make safe decisions, or cannot make their basic needs known. 3= The client needs help most or all of time.

Due To: (Score must be justified through one or more of the following conditions)

Metabolic Disorder Medication Reaction Acute Illness Alzheimer’s/Dementia Chronic Medical Condition Communication Impairment (does not include ability to speak English)

Self-Injurious Behavior Impaired Judgment Unable to Follow Directions Constant Vocalizations Perseveration Receptive Expressive Aphasia Agitation Disassociation Wandering Abnormal Oxygen Saturation Supervision Needs:

Disorientation Medication Management Mood Instability B. COLORADO SINGLE ASSESSMENT (CSA) LEVEL OF CARE SCREEN The Level of Care Eligibility Determination outcome is based on an individual’s performance level as documented in the LOC Screen, in areas including, but not limited to, completing Activities of Daily Living, memory and cognition, sensory and communication, and behavior, as well as other criteria specific to applicable program.

The eligibility criteria and thresholds are as follows:

Nursing Facility Level of Care Eligibility for ages four (4) and older a. Participants four (4) years of age or older must meet the Nursing Facility Level of Care criteria and thresholds outlined in 10 CCR 2505-10 Section 8.401.16.B.1 to be determined eligible for Long-Term Services and Supports.

i. Eligibility Criteria 1. Meets one or more ADL and Health Condition criteria thresholds in at least two areas to include Mobility, Transferring, Bathing, Dressing, Toileting, Eating (ADLs) or Health Condition; or 2. Meets one or more Behavior threshold(s); or 3. Meets one or more Memory and Cognition threshold(s); or 4. Meets the Sensory & Communication threshold.

ii. Criteria Thresholds 1. ADL and Health Condition criteria thresholds are as follows:

a. Mobility threshold is met with either of the following:

i. Participant does not walk but walking is indicated in the future or Participant does not walk and walking is not indicated in the future;

ii. Participant requires a cane or walker during all mobility activities; or iii. Participant uses a wheelchair or scooter as their primary mechanism for mobility; or iv. Participant requires, at minimum, partial moderate assistance to walk (once standing) 10 feet indoors; or v. Participant requires, at minimum, supervision or touching assistance to walk (once standing) 150 feet indoors; or vi. Participant requires, at minimum, supervision or touching assistance to walk 10 feet outside of the home; or vii. Participant requires, at minimum, supervision or touching assistance to walk 150 feet outside of the home.

b. Transferring threshold is met with either of the i. Participant requires use of a cane or walker during all transfer activities; or ii. Participant requires, at minimum, partial/moderate assistance for the ability to roll left and right: from lying on back to left and right side, and return to lying on back on the bed; or iii. Participant requires, at minimum, partial/moderate assistance for the ability to complete a sit to stand transfer: safely come to a standing position from sitting in a chair or on the side of the bed.

c. Bathing threshold is met with the following:

i. Participant requires, at minimum, partial/moderate assistance for the ability to shower/bathe self in shower or tub, including washing, rinsing, and drying self. Does not include transferring in/out of tub/shower d. Dressing threshold is met with either of the following:

i. Participant requires, at minimum, partial/moderate assistance with upper body dressing; or ii. Participant requires, at minimum, partial/moderate assistance with lower body dressing; or iii. Participant requires, at minimum, partial/moderate assistance with putting on/taking off footwear.

e. Toileting threshold is met with either of the following:

i. Participant requires, at minimum, partial/moderate assistance with toilet hygiene;

ii. Participant requires, at minimum, partial/moderate assistance with toilet transfers; or iii. Participant requires, at minimum, partial/moderate assistance with menses care;

iv. Participant requires assistance with managing equipment related to bladder incontinence; or v. Participant is currently using a bladder program to manage participant’s bladder continence; or vi. Participant requires assistance with managing equipment related to bowel incontinence; or vii. Participant is currently using a bowel program to manage the participant’s bowel continence.

f. Eating threshold is met with either of the following:

i. Participant requires, at minimum, partial/moderate assistance for eating; or ii. Participant requires, at minimum, partial/moderate assistance for tube feeding.

g. Health Condition threshold is met with the following:

i. Participant has a diagnosis of paralysis; or ii. A missing limb.

Behavior criteria thresholds are as follows:

a. Behavior threshold area one is as follows:

i. Participant’s behavior status previously or currently requires interventions or presents symptoms for Injury to Self, Physical Aggression or Property Destruction; and ii. One or more of the following are met:

Cueing frequency, at minimum, is required more than once per month and up to weekly; or 2. Physical intervention frequency, at minimum, is required more than once per month up to weekly; or 3. Planned intervention frequency, at minimum, is required less than monthly up to once per month.

b. Behavior criteria threshold area two is as follows:

i. Participant’s behavior status for Verbal Aggression currently requires interventions or presents symptoms for this behavior; and ii. Participant presents threat(s) to own or other’s safety; and iii. One or more of the following are met:

Cueing frequency, at minimum, is required more than once per month and up to weekly; or 2. Physical intervention frequency, at minimum, is required more than once per month up to weekly; or 3. Planned intervention frequency, at minimum, is required less than monthly up to once per month.

c. Behavior criteria threshold area three is as follows:

i. Injurious to Self, property destruction, physical aggression, or verbal aggression behavior status currently requires intervention and/or displays symptoms and ii. Likelihood behavior would occur and/or escalate if HCBS services were withdrawn is likely or highly likely.

Memory and Cognition criteria thresholds are as follows:

a. Participant has a Level of Impairment of moderately or higher in at least one area (Memory, Attention, Problem Solving, Planning, or Judgment); or b. Participant has a level of impairment of mildly or higher in at least two areas (Problem Solving, Planning, Judgment).

Sensory and Communication criteria threshold is as follows:

a. Participant frequently exhibits difficulty expressing needs and/or ideas with individuals they are familiar with; or b. Participant rarely or never expresses themself or is very difficult to understand.

Nursing Facility Level of Care Eligibility Criteria for individuals zero to three (0-3) years of age a. Participants zero to three (0-3) years of age must meet the Nursing Facility Level of Care criteria and thresholds outlined in 10 CCR 2505-10

Section 8.401.16.B.2, according to age, to be determined eligible for Long- Term Services and Supports.

i. Eligibility Criteria 1. The participant must meet the criteria threshold for two or more Activities of Daily Living, based on participant age.

If the participant meets one or more of the two required ADL thresholds by selecting only “Other Concerns,” a second level review is required to determine eligibility.
Participants may also meet LOC using the behavior criteria for adults in Section 8.401.16.B.1.ii.2.

ii. Activities of Daily Living thresholds by age 0-5 months 1. Bathing:

a. Needs adaptive equipment, or b. Utilizes medical devices that make bathing very c. Other concerns that may affect the amount of support d. at least one of the bathing impairments above is expected to last for at least one year from the date of assessment.

Dressing:

a. Has physical characteristics that make dressing very extreme hypertonia., or b. Utilizes medical devices that make dressing very c. Other concerns that may affect the amount of support d. at least one of the impairments above is expected to 3. Eating:

a. Requires more than one hour per feeding, or b. Receives tube feedings or TPN, or c. Requires more than three hours per day for feeding or eating, or d. Other concerns that may affect the amount of support e. at least one of the impairments above is expected to iii. Activities of Daily Living thresholds by age 6-11 months 1. Bathing:

a. Needs adaptive equipment, or b. Utilizes medical devices that make bathing very c. Other concerns that may affect the amount of support d. at least one of the impairments above is expected to 2. Dressing:

a. Has physical characteristics that make dressing very b. Utilizes medical devices that make dressing very c. Other concerns that may affect the amount of support d. at least one of the impairments above is expected to 3. Eating:

a. Requires more than one hour per feeding, OR b. Receives tube feedings or TPN, OR c. Requires more than three hours per day for feeding or d. Other concerns that may affect the amount of support e. at least one of the impairments above is expected to 4. Mobility:

a. Unable to maintain a sitting position when placed, OR b. Unable to move self by rolling, crawling, or creeping, c. Other concerns that may affect the amount of support d. at least one of the impairments above is expected to iv. Activities of Daily Living thresholds by age 12-17 months 1. Bathing:

a. Needs adaptive equipment, OR b. Utilizes medical devices that make bathing very c. becomes agitated requiring alternative bathing methods OR d. Other concerns that may affect the amount of support e. at least one of the impairments above is expected to 2. Dressing:

a. Unable to sit alone, OR b. Requires a stander or someone to support the child’s c. Unable to crawl or creep, OR d. Other concerns that may affect the amount of support e. at least one of the impairments above is expected to v. Activities of Daily Living thresholds by age 18-23 months 1. Bathing:

a. Needs adaptive equipment, OR b. Utilizes medical devices that make bathing very c. becomes agitated requiring alternative bathing methods OR Other concerns that may affect the amount of support the child needs AND d. at least one of the impairments above is expected to 2. Dressing:

a. Has physical characteristics that make dressing very b. Utilizes medical devices that make dressing very Does not assist with dressing by helping to place arms in sleeves or legs into pants, OR c. Other concerns that may affect the amount of support d. at least one of the impairments above is expected to 3. Eating:

a. Receives tube feedings or TPN, OR b. Requires more than three hours per day for feeding or c. Other concerns that may affect the amount of support d. at least one of the impairments above is expected to 4. Mobility:

a. Requires a stander or someone to support the child’s b. Uses a wheelchair or other mobility device not c. Unable to take steps holding on to furniture, OR d. other concerns that may affect the amount of support e. at least one of the impairments above is expected to vi. Activities of Daily Living thresholds by age 24-35 months 1. Bathing:

a. Has physical characteristics that make dressing very b. Utilizes medical devices that make dressing very Does not assist with dressing by helping to place arms in sleeves or legs into pants, OR c. Unable to pull hats, socks, and mittens, OR d. Other concerns that may affect the amount of support e. at least one of the impairments above is expected to 3. Eating:

a. Receives tube feedings or TPN, OR b. Requires more than three hours per day for feeding or c. Cannot pick up appropriate foods with hands and bring them to his/her mouth, OR d. Other concerns that may affect the amount of support e. at least one of the impairments above is expected to 4. Mobility:

a. Requires a stander or someone to support the child’s b. Does not walk or needs physical help to walk, OR c. Uses a wheelchair or other mobility device not d. Other concerns that may affect the amount of support e. at least one of the impairments above is expected to 5. Transfers:

a. Requires transfer assistance due to physical or cognitive deficits, OR b. Other concerns that may affect the amount of support c. at least one of the impairments above is expected to vii. Activities of Daily Living thresholds by age 36-47 months 1. Bathing:

a. Needs adaptive equipment, OR b. Utilizes medical devices that make bathing very c. Is combative during bathing (e.g., flails, takes two caregivers to accomplish task), OR d. Other concerns that may affect the amount of support e. at least one of the impairments above is expected to 2. Grooming:

a. Is combative during grooming (e.g., flails, clamps mouth shut, takes two caregivers to accomplish task), b. Has physical limitations that prevent completing the task (e.g. limited range of motion, unable to grasp brush), OR c. Other concerns that may affect the amount of support d. at least one of the impairments above is expected to 3. Dressing:

a. Has physical characteristics that make dressing very b. Utilizes medical devices that make dressing very c. Is combative during dressing (e.g., flails, resists efforts to put clothes on, takes two caregivers to accomplish task), OR d. Does not or cannot assist with dressing by helping to place arms in sleeves or legs into pants, OR e. Unable to undress self independently, OR f. Other concerns that may affect the amount of support g. at least one of the impairments above is expected to 4. Eating:

a. Is combative while eating (e.g., flails, throws food so will not have to eat, takes two caregivers to accomplish task), OR b. Receives tube feedings or TPN, OR c. Requires more than three hours per day for feeding or d. Needs to be fed by another individual, OR e. Needs one-on-one monitoring to prevent choking, aspiration, or other serious complications, OR f. Other concerns that may affect the amount of support g. at least one of the impairments above is expected to 5. Toileting:

a. Is combative during toileting (e.g., flails, takes two caregivers to accomplish task), OR b. Has no awareness of being wet or soiled, OR c. Requires caregiver assistance to be placed onto the toilet/potty chair, OR d. Does not use toilet/potty chair when placed there by a caregiver, OR e. Other concerns that may affect the amount of support f. at least one of the impairments above is expected to 6. Mobility:

a. Does not walk or needs physical help to walk, OR b. Uses a wheelchair or other mobility device not c. Other concerns that may affect the amount of support d. at least one of the impairments above is expected to 7. Transfers:

a. Needs physical help with transfers, OR b. Uses a mechanical lift, OR c. Other concerns that may affect the amount of support d. at least one of the impairments above is expected to 3. Nursing Facility Level of Care Eligibility Alternative Criteria a. Alternative ADL criteria shall be applicable for participants four (4) and older whose level of support for Activities of Daily Living (Mobility, Transferring, Bathing, Dressing Toileting, Eating) has varied over the last 30 days; and i. Meet the following alternate ADL thresholds in two or more ADL areas (Mobility, Transferring, Bathing, Dressing Toileting, Eating):

Participant’s performance level is, at minimum, scored at partial/moderate assistance or higher AND 2. Frequency of enhanced support is scored, at minimum, 1-2 times per month in the past 30 days, or ii. Meets at least one Nursing Facility Level of Care ADL (Mobility, Transferring, Bathing, Dressing Toileting, Eating) thresholds as required at 10 CCR 2505-10 Section 8.401.16.B.1.a.ii.1., and iii. Meets the alternate ADL thresholds in at least one ADL area.

b. If the alternative LOC criteria is used, a second level review is required to determine eligibility.

Hospital Level of Care Eligibility Criteria a. Complementary and Integrative Health (CIH), Brain Injury (BI), and Children with Complex Health Needs (CwCHN) have a Hospital Level of Care (H-LOC).

i. CIH and BI may be met through NF-LOC and H-LOC Criteria.

ii. CwCHN has distinct criteria.

b. H-LOC for SCI and BI participants must meet in at least one of the following areas:

i. Transfers:

Participant has met Nursing Facility Level of Care (NF-LOC)

AND 2. Participant’s performance level is, at minimum, substantial/maximum assistance for Chair/Bed -to-Chair Transfers-the ability to safely transfer to and from a bed to a chair.

ii. Bathing:

Participant has met NF-LOC AND 2. Participant’s performance level is, at minimum, substantial/maximum assistance for Shower/bathe self-the ability to bathe self in shower or tub, including washing, rinsing, and drying self. Does not include transferring in/out of tub/shower.

iii. Dressing:

Participant has met NF-LOC AND 2. Participant's performance level is, at minimum, substantial/maximum assistance for Upper Body Dressingthe ability to put on and remove shirt or pajama top. Includes buttoning, if applicable OR 3. Participant's performance level is, at minimum, substantial/maximum for Lower Body Dressing-the ability to dress and undress below the waist, including fasteners.

Does not include footwear.

iv. Toileting:

Participant has met NF-LOC AND 2. Participant's performance level is, at minimum, substantial/maximum assist for Toilet hygiene-the ability to maintain perineal/feminine hygiene, adjust clothes before and after using toilet, commode, bedpan, urinal. If managing ostomy, include wiping opening but not managing equipment. OR 3. Participant's performance level is, at minimum, substantial/maximum assistance for Toilet Transfers: the ability to safely get on and off a toilet or commode.

v. Eating:

Participant has met NF-LOC AND 2. Participant's performance level is, at minimum, substantial/maximum assistance for Eating - the ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. This includes modified food consistency OR 3. Participant's performance level is, at minimum, substantial/maximum assistance for Tube feeding - the ability to manage all equipment/supplies related to obtaining nutrition.

c. H-LOC for CwCHN participants must be met in at least ONE of the following threshold areas:

i. Threshold Area 1:

Participant has met NF-LOC and has one or more ADL at the “substantial/maximal level” (scoring option related to assistance needed with ADL completion)

ii. Threshold Area 2:

Participant has met NF-LOC and one of the following conditions applies to the participant;

a. Participant has been diagnosed with a life limiting illness b. Technologically dependent for life or health-sustaining functions, or c. Complex medication regimen or medical interventions to maintain or improve health status, or d. Need of ongoing assessment or intervention to iii. Threshold Area 3:

Participant has not met NF-LOC or Alt-LOC and one of the following conditions applies to the participant:

a. Technologically dependent for life or health-sustaining functions, or b. Complex medication regimen or medical interventions to maintain or improve health status, or c. Need of ongoing assessment or intervention to iv. Threshold Area 4:

Participant has not met NF-LOC or Alt-LOC, and 2. Participant has been diagnosed with a life limiting illness by a licensed medical professional, and 3. One of the following conditions applies to the participant:

a. Technologically dependent for life or health-sustaining functions, OR b. Complex medication regimen or medical interventions to maintain or improve health status, OR c. Need of ongoing assessment or intervention to 8.401.18 PRE-ADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND SPECIALIZED SERVICES FOR INDIVIDUALS WITH MENTAL ILLNESS OR INDIVIDUALS WITH AN INTELLECTUAL OR DEVELOPMENTAL DISABILITY .181 Purpose of Program A. The PASRR program requires pre-screening or reviewing of all clients who apply to or reside in a Medicaid certified nursing facility regardless of:

The source of payment for the nursing facility services; or 2. The individual's or resident's diagnosis.

B. The purpose of the PASRR Level I Identification screening is to identify for further review all those clients seeking nursing facility admission, for whom it appears a diagnosis of mental illness or intellectual or developmental disability is likely.

C. The purpose of the PASRR Level II evaluation is to evaluate and determine whether nursing facility services are needed, whether an individual has mental illness or intellectual or developmental disability and whether specialized mental health or intellectual or developmental disability services are needed. .182 Definitions A. Serious Mental Illness 1. Serious mental illness (SMI) is defined as: a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.

For the purposes of the PASRR program, a person is considered to have serious mental illness if they meet the diagnosis, level of impairment and recent treatment criteria found at 42 C.F.R. § 483.102.
An individual is considered to not have serious mental illness if they have:

a. a primary diagnosis of dementia (including Alzheimer's disease or a related disorder); or b. a non-primary diagnosis of dementia (including Alzheimer's disease or a related disorder) without a primary diagnosis of serious mental illness, or intellectual or developmental disability or a related condition.

B. Intellectual or developmental disability and Related Conditions 1. Intellectual or developmental disability refers to significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental years.

The provisions of this section also apply to individuals with “related conditions,” as defined by 42 C. F. R. section 435.1010 (2013) which states: “Persons with related conditions” means individuals who have a severe, chronic disability that meets all of the following conditions:

a. It is attributable to:

Cerebral palsy or epilepsy; or 2) Any other condition, other than mental illness, found closely related to intellectual or developmental disability. These related conditions result in impairment of general intellectual functioning or adaptive behavior similar to individuals with intellectual or developmental disability, and require treatment or services similar to those required for these individuals.

b. It is manifested before the individual reaches age 22.

c. It is likely to continue indefinitely.

d. It results in substantial functional limitations in three or more of the following areas of major life activity:

Self-care, 2) Understanding and use of language, 3) Learning, 4) Mobility, 5) Self-direction or 6) Capacity for independent living. 8.401.183 Requirements for the PASRR Program A. The Level of Care determination and the Level I screening reviews shall be required by the Utilization Review Contractor prior to admission to a Medicaid certified nursing facility.

B. The Utilization Review Contractor admission start date (the first date of care covered by Medicaid) shall be assigned after the required Level II PASRR evaluation is completed and the Utilization Review Contractor certifies the member is appropriate for nursing facility care. The admission start date for individuals who do not requiring a Level II evaluation shall be the date that the Initial Screening and Intake Form and Professional Medical Information pages from the ULTC 100.2 are faxed to the Case Management Agency.

C. Individuals other than Medicaid eligible recipients, who require a Level II evaluation, shall have the Level II evaluation prior to admission. The Level II contractor shall perform the evaluation. The Level II contractor can be a qualified mental health professional, a corporation that specializes in mental health, the Comprehensive Community Behavioral Health Provider, or the Case Management Agency.

D. The Level II contractor shall conduct a review and determination for individuals or members found to be mentally ill or developmentally delayed who have had a change in mental health or developmental disability status.

E. PASRR findings, as related to care needs, shall be coordinated with the federally prescribed, routine nursing facility Resident Assessments (Minimum Data Set) requirements. These requirements are described at 42 C.F.R. part 483.20 (2024), which is hereby incorporated by reference. The incorporation of 42 C.F.R. part 483.20 excludes later amendments to, or editions of, the referenced material.

The Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 303 E. 17 th Avenue, Denver, CO 80203.

Certified copies of incorporated materials are provided at cost upon request and incorporated materials may also be obtained from the original issuer at https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart- B/section-483.20. 8.401.184 Nursing Facilities Responsibilities Under the PASRR Program A. The Utilization Review Contractor/Single Entry Point shall complete the Level I screening on the functional assessment form for Medicaid members. The nursing facility shall complete the Level I screening for non-Medicaid individuals admitted from the community or pay source change. The hospital shall complete the Level I for non-Medicaid individuals admitted to nursing facility from the hospital.

Medicaid Level I information is on the Level I screen in the ULTC-100.2 and is submitted to the Utilization Review Contractor with the rest of the Level of Care information. Private pay Level I information that indicates the resident may be mentally ill or individuals with an intellectual or developmental disability is submitted to the Utilization Review Contractor as well on the ULTC-100.2.

B. Nursing facility staff shall be trained in which diagnoses, medications, history and behaviors would result in a positive finding in a Level I screening (e.g., a Yes response to a psychiatric diagnosis or history).

C. Following review of information on the Functional Assessment form, the Utilization Review Contractor determines whether a Level II evaluation is necessary and notifies the facility.

D. If a Level II evaluation is necessary, the facility and the Level II contractor shall assure that the Level II is completed. Level II PASRR evaluations shall be done at no cost to the individual or facility by the Level II contractor for that geographic area.

E. If the individual is determined to be mentally ill or individuals with an intellectual or developmental disability as a result of the Level II, the nursing facility shall retain the results of the Level II in the resident's charts. The Level II evaluation shall be updated when the resident's condition changes. The Level II evaluations must be kept current in the resident's charts.

F. If a Level II evaluation is not required, documentation must be completed on the reasons a Level II one was not done and retained in the resident's chart.

G. The resident's chart shall contain the following information:

The psychiatric evaluation and/or Colorado Assessment Review form (COPAR);
The findings; and 3. The determination letter (from either mental health or intellectual or developmental disability authorities).

H. The nursing facility shall assure that the diagnoses are current and accurate by reconciling in the resident's record any diagnoses conflicting with the PASRR Level II diagnosis.

I. The nursing facility is responsible to arrange for services based on service recommendations from the Level II evaluation.

J. Nursing Facilities may contact the local Comprehensive Community Behavioral Health Providers or community center boards to make arrangements for the provisions of Specialized Services as indicated on the Level II reviews.

Furthermore, nursing facilities are prohibited from providing Specialized Services. .185 The State Survey and Certification Process A. The State Survey and Certification Process will be used to determine whether the resident had the following:

A comprehensive Level I and Level II assessment;
An appropriate care plan; and 3. Specialized treatment, if needed.

B. The Colorado Department of Public Health and Environment (CDPHE) shall conduct the PASRR program surveys in accordance with the Agency Agreement between CDPHE and the Department. .186 Responsibilities of the Utilization Review Contractor in Determining Level of Care A. For private pay and nursing facility residents on admission with indications of mental illness or intellectual or developmental disability, the Utilization Review Contractor shall first determine appropriate admission to a nursing facility through the following process:

A Level of Care review;
The Level I identification screen verification;
A Categorical determination, if appropriate; and 4. A Level II referral, if appropriate.

B. A nursing facility placement shall be considered appropriate when the following conditions are met:

An individual's needs are such that he or she passes the Level of Care screen for admission and the individual is seeking Medicaid reimbursement; and 2. The Level I and II screens indicate nursing facility placement is 8.401.19 LEVEL I IDENTIFICATION SCREEN .191 The Level I Screen criteria shall be as follows:

A. The Level I Screen, used by the Utilization Review Contractor to identify those who may be mentally ill shall, be applied under the following conditions:

The individual has a diagnosis of mental illness as defined above;
The individual has a recent (within the last two years) history of mental illness, as defined above; and/or 3. A major tranquilizer, anti-depressant or psychotropic medication has been prescribed regularly without a justifiable diagnosis of neurological disorder to warrant the medication; and/or 4. There is presenting evidence of mental illness (except a primary diagnosis of Alzheimer's disease or dementia) including possible disturbances in orientation, affect, or mood, as determined by the B. The Level I Screen, used by the Utilization Review Contractor to identify those who may be individuals with an intellectual or developmental disability or individuals with related conditions, shall be applied under the following conditions:
The individual has a diagnosis of intellectual or developmental disability or related conditions as defined above; and/or 2. There is a history of intellectual or developmental disability or related conditions, as defined above, in the individual's past;
There is presenting evidence (cognitive or behavior functions) of intellectual or developmental disability or related conditions;
The individual is referred by an agency that serves individuals with intellectual or developmental disability or related conditions, and the individual has been determined to be eligible for that agency's .192 When the results of the Level I Screen indicate the individual may have mental illness or intellectual or developmental disability or related conditions, the individual must undergo the additional PASRR Level II evaluation specified below, unless one or more of the following is determined by the Utilization Review Contractor:

A. There is substantial evidence that the individual is not mentally ill or individuals with an intellectual or developmental disability; or B. A categorical determination is made that:

The individual has:

a. A primary diagnosis of dementia, including Alzheimer's Disease or a related disorder;

b. The above must be substantiated based on a neurological examination.

The individual is terminally ill (i.e., the physician documents that the individual has less than six months to live).
An individual is in need of convalescent care.

a. Convalescent care is defined as:

A discharge from an acute care hospital;
An admission for a prescribed, limited nursing facility stay for rehabilitation or convalescent care; and 3) An admission for a medical or surgical condition that required hospitalization.

b. If an individual is determined to need convalescent care, the Utilization Review Contractor must follow-up to determine if the individual still needs convalescent care (and the following must occur, including):

A referral shall be made for a Level II evaluation if the individual remains in the nursing facility for longer than 60 days;
The above referral shall be made to the appropriate Comprehensive Community Behavioral Health Providers or community centered board or other designated agencies; and 3) The individual shall receive a Level II evaluation within 10 calendar days of the referral.

An individual is severely ill.

a. An individual is considered severely ill if he or she is:

comatose;
ventilator dependent;
in a vegetative state.

b. The following PASRR criteria must be met when an individual is severely ill:

A Mental Health referral shall be made and a Level II evaluation shall be completed if the individual no longer meets the above criteria as determined by the 2) An Intellectual or developmental disability Level II referral shall be made and an evaluation shall be completed within 60 days of admission, even if the individual meets the above criteria as determined for severely ill by the Utilization Review Contractor.

Emergency procedure in C.R.S. section 27-65-105, et. seq., shall supersede the PASRR process. When the State Mental Health authorities, pursuant to C.R.S. section 27-65-106, et.seq., determine that an individual requires inpatient psychiatric care and qualifies under the emergency procedures for a hold and treat order, this procedure shall supersede the PASRR determination process. .193 For individuals or residents who may have mental illness or intellectual or developmental disability as determined through the Level I screen and who are referred by the State authorities or designees for a PASRR Level II evaluation, the following applies:

A. The designated agencies completing the Level I screen shall send a written notice to the individual or resident and to his or her legal representative stating the Level I findings.

B. The Level I notice to the individual or resident shall be required if the Level I findings result in a referral for a Level II evaluation.

C. The Level I findings are not an appealable action. .194 Categorical determinations which may delay a Level II referral shall not prevent the nursing facility from meeting the psychosocial, physical and medical needs of the resident. .195 Categorical Determinations may be applied only if an individual is in no danger to him/herself or others.

8.401.20 LEVEL II PASRR EVALUATION .201 The purpose of the Level II evaluation is to determine whether:

A. Each individual with mental illness or intellectual or developmental disability requires the level of services provided by a nursing facility.

B. An individual has a serious mental illness or is individuals with an intellectual or developmental disability.

C. The individual requires a Specialized Services program for the mental illness or intellectual or developmental disability. .202 Basic Requirements for LEVEL II PASRR Evaluations and Determinations include:

A. The State Mental Health authority shall make determinations of whether individuals with mental illness require specialized services that can be provided in a nursing facility as follows:

The determination must be based on an independent physical and mental evaluation.
The evaluation must be performed by an individual or entity other than the State Mental Health authority.

B. The State Intellectual or developmental disability authority shall conduct both the evaluation and the determination functions of whether individuals with intellectual or developmental disability require specialized services that can be provided in nursing facilities.

C. The PASRR Level II contractor shall complete the evaluation within 10 working days of the referral from the URC.

D. PASRR determinations made by the State Mental Health or Intellectual or developmental disability authorities cannot be countermanded by the Department through the claims payment process or through other utilization control/review processes, or by CDPHE, survey and certification agency, or by any receiving facility or other involved entities.

E. The Final Agency action by the Department may overturn a PASRR adverse determination made by State Mental Health or Intellectual or developmental disability authorities.

F. Timely filing of PASRR billings from providers is 120 days. .203 An individual meets the requirements of a Depression Diversion Screen.

A. A Depression Diversion Screen shall be applied under the following conditions:

Depression is the only Level I positive finding (i.e. a depression diagnosis is the only Yes checked on the Level I screen); and 2. The URC or the PASRR Level II Contractor for that geographic area shall make the determination of need for a Depression Diversion B. The nursing facilities are not authorized to apply the Depression Diversion C. When a serious mental illness depression is validated as the only Level I positive finding through the Depression Diversion Screen, a complete Level II referral and evaluation is not required unless the individual's condition changes. .204 Appeals Hearing Process for the PASRR Program A. A resident has appeal rights when he or she has been adversely affected by a PASRR determination as a result of the Level II evaluation made by the State Mental Health or Intellectual or developmental disability authorities either at Pre- admission Screening or at Annual Resident Review.

B. Adverse determinations related to PASRR mean a determination made in accordance with Sections 1919(b)(3)(F) or 1919(e)(7)(B) of the Social Security Act that:

The individual does not require the level of services provided by a Nursing Facility; and/or 2. The individual does or does not require Specialized Services for mental illness or intellectual or developmental disability.
Section 1919 of the Social Security Act (1935) (42 U.S.C. section 1396r) is hereby incorporated by reference. The incorporation of 42 U.S.C. section 1396r excludes later amendments to, or editions of, the referenced material. The Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

C. Appeals of Level of Care determination are processed through the Appeals Section related to the URC's Level of Care process in Section 8.057.

D. For adverse actions related to the need for Specialized Services, the individual or resident affected by the mental illness or intellectual or developmental disability determination may appeal through procedures established for appeals in the Recipient Appeals and Hearings at Section 8.057. .205 The Level II PASRR Evaluation Process A. The URC shall refer all Medicaid clients and private pay individuals who require a Level II evaluation, to the PASRR Level II contractor.

The PASRR Level II contractor shall complete the Level II evaluation.
The State Medicaid program shall pay for the private pay evaluations.
Nursing facilities shall not complete the Level II evaluation.
The findings of these evaluations shall be returned to the URC for review and referral to the State Mental Health and/or Intellectual or developmental disability authorities for final review and determination.

B. Evaluations shall be adapted to the cultural background, language, ethnic origin and means of communication used by the individual.

C. The Level II Mental Illness Evaluation for Specialized Services shall consist of the following:

A comprehensive medical examination of the individual. The examination shall address the following areas:

a. A comprehensive medical history;

b. An examination of all body systems; and c. An examination of the neurological system which consists of an evaluation in the following areas:

Motor functioning;
Sensory functioning;
Gait and deep tendon reflexes;
Cranial nerves; and 5) Abnormal reflexes.

d. In cases of abnormal findings, additional evaluations shall be conducted by appropriate specialists; and e. If the history and physical examinations are not performed by a physician, then a physician must review and concur with the conclusions and sign the examination form.

A psychosocial evaluation of the individual, which at a minimum, includes an evaluation of the following:

a. Current living arrangements;

b. Medical and support systems; and c. The individual's total need for services are such that:

The level of support can be provided in an alternative community setting; or 2) The level of support is such that nursing facility placement is required.

A Functional Assessment shall be completed on the individual's ability to engage in activities of daily living.
A comprehensive psychiatric evaluation, at a minimum, must address the following areas:

a. A comprehensive drug history is obtained on all current or immediate past utilization of medications that could mask symptoms or use of medications that could mimic mental illness;

b. A psychiatric history is obtained;

c. An evaluation is completed of intellectual functioning, memory functioning, and orientation;

d. A description is obtained on current attitudes, overt behaviors, affect, suicidal or homicidal ideation, paranoia and degree of reality testing (presence and content of delusions, paranoia and hallucinations); and e. Certification status under provisions at C.R.S. section 27-65-107 et.seq. and need for in-patient emergency psychiatric care shall be assessed. If an individual qualifies under the emergency provisions in the statute, emergency proceedings shall be considered. This action shall supersede any PASRR activity.

If the psychiatric evaluation is performed by a professional other than a psychiatrist, then a psychiatrist's countersignature shall be required.
The Mental Health evaluation shall identify all medical and psychiatric diagnoses which require treatment and should include copies of previous discharge summaries from the hospital or nursing facility charts (during the past two years).
The Mental Health determination process shall insure that a qualified mental health professional, as designated by the State, must validate the diagnosis of mental illness and determine the appropriate level of mental health services needed.

D. The Level II Intellectual or developmental disability or related conditions evaluation for Specialized Services shall consist of the following:

A comprehensive medical examination review so that the following information can be identified:

a. A list of the individual's medical problems;

b. The level of impact on the individual's independent functioning;

c. A list of all current medications; and d. Current responses to any prescribed medications in the following drug groups:

Hypnotics, 2) Anti-psychotics (neuroleptics), 3) Mood stabilizers and anti-depressants, 4) Antianxiety-sedative agents, and 5) Anti-Parkinsonian agents.

The Intellectual or developmental disability process must assess:

a. Self-monitoring of health status;

b. Self-administering and/or scheduling of medical treatments;

c. Self-monitoring of nutrition status;

d. Self-help development such as: toileting, dressing, grooming, and eating);

e. Sensorimotor development such as: ambulation, positioning, transfer skills, gross motor dexterity, visual motor/perception, fine motor dexterity, eye-hand coordination, and extent to which prosthetic, orthotic, corrective or mechanical supportive devices improve the individual's functional capacity);

f. Speech and language (communication) development, such as: expressive language (verbal and nonverbal), receptive language (verbal and nonverbal), extent to which non-oral communication systems improve the individual's functional capacity, auditory functioning, and extent to which amplification devices (e.g., hearing aid) or a program of amplification improve the individual's functional capacity);

g. Social development, such as: interpersonal skills, recreation-leisure skills, and relationships with others;

h. Academic/educational development, including functional learning skills;

i. Independent living development such as: meal preparation, budgeting and personal finances, survival skills, mobility skills (orientation to the neighborhood, town, city), laundry, housekeeping, shopping, bed making, care of clothing, and orientation skills (for individuals with visual impairments); and j. Vocational development, including present vocational skills;

k. Affective development (such as: interests, and skills involved with expressing emotions, making judgments, and making independent decisions); and l. Presence of identifiable maladaptive or inappropriate behaviors of the individual based on systematic observation (including, but not limited to, the frequency and intensity of identified maladaptive or inappropriate behaviors).

The Level II Intellectual or developmental disability evaluation shall insure that a psychologist, who meets the qualifications of a qualified intellectual or developmental disability professional completes the following:

a. The individual's intellectual functioning measurement shall be identified; and b. The individual's intellectual or developmental disability or related condition shall be validated.

The Level II Intellectual or developmental disability evaluation shall identify to what extent the individual's status compares with each of the following characteristics, commonly associated with need for specialized services including:

a. The inability to:

Take care of most personal care needs;
Understand simple commands;
Communicate basic needs and wants;
Be employed at a productive wage level without systematic long-term supervision or support;
Learn new skills without aggressive and consistent training;
Apply skills learned to a training situation to other environments or settings without aggressive and consistent training; or 7) Demonstrate behavior appropriate to the time, situation or place, without direct supervision.

b. Demonstration of severe maladaptive behavior(s) which place the individual or others in jeopardy to health and safety;

c. Inability or extreme difficulty in making decisions requiring informed consent; and d. Presence of other skill deficits or specialized training needs which necessitate the availability of trained intellectual or developmental disability personnel, 24 hours per day, to teach the individual functional skills.

The Intellectual or developmental disability evaluation shall collect information to determine whether the individual's total needs for services are such that:

a. The level of support may be provided in an alternative community setting; or b. The level of support is such that nursing facility placement is required.

The Intellectual or developmental disability evaluation shall determine whether the individuals with an intellectual or developmental disability individual needs a continuous Specialized Services program. .206 PASRR Findings from Level II Evaluations A. PASRR Level II findings shall include the following documentation:
The individual's current functional level must be addressed;
The presence of diagnosis, numerical test scores, quotients, developmental levels, etc. shall be descriptive; and 3. The findings shall be made available to the family or designated representatives of the nursing facility resident, the parent of the minor individual or the legal guardian of the individual.

B. PASRR Findings from the Level II Evaluations shall be used by the URC in making determinations whether an individual with mental illness or intellectual or developmental disability is appropriate or inappropriate for nursing facility care, and C. The individual shall be referred back to the URC for a determination of the need for long-term care services if at any time it is found that the individual is not mentally ill or individuals with an intellectual or developmental disability, or has a primary diagnosis of dementia or Alzheimer's disease or related disorders or a non-primary diagnosis of dementia (including Alzheimer's disease or a related disorder) without a primary diagnosis of serious mental illness, or intellectual or developmental disability or a related condition.

D. The results of the PASRR evaluation shall be described in a report by the State Mental Health or Intellectual or developmental disability authorities, which includes:

The name and professional title of the person completing the evaluation, and the date on which each portion of the evaluation was administered.
A summary of the medical and social history including the individual's positive traits or developmental strengths and weaknesses or developmental needs.
The mental health services and/or intellectual or developmental disability services required to meet the individual's identified needs;
If specialized services are not recommended, any specific services identified which are of a lesser intensity than specialized services required to meet the evaluated individual's needs;
If specialized services are recommended, the specific services identified required to meet each one of the individual's needs; and 6. The basis for the report's conclusions.

E. Copies of the evaluation report will be made available to:

The individual and his or her legal representative;
The appropriate state authorities who make the determination;
The admitting or retaining nursing facility;
The individual's attending physician; and 5. The discharge hospital, if applicable. .207 PASRR Determinations from the Level II Evaluation A. Determinations which may result in admissions and/or specialized services shall include:
If an individual meets the level of care and needs the level of services provided in a nursing facility, as determined by the URC, and is determined not mentally ill or individuals with an intellectual or developmental disability, the individual may be admitted to the 2. If an individual does not meet the level of care (as determined by the URC), and is determined to not be mentally ill or individuals with an intellectual or developmental disability through the PASRR determination and is not seeking Medicaid reimbursement, the individual may be admitted to the facility.
If the determination is that a resident or applicant for admission to a nursing facility requires BOTH the nursing facility level of care and specialized mental health or intellectual or developmental disability services, as determined by the URC and the State Mental Health and Intellectual or developmental disability authorities:

a. The individual may be admitted or retained by the nursing b. The State Mental Health or Intellectual or developmental disability authorities shall provide or arrange for the provision of specialized services needed by the individual while he or she resides in the nursing facility.

Nursing facilities admitting residents requiring specialized mental health or intellectual or developmental disability services shall be responsible for assuring the provisions of services to meet all the resident needs identified in the Level II evaluations. The provisions of services shall be monitored through the State's survey and certification process.

B. Determinations which may result in denial of admission include:

If an individual does not require nursing facility services and is seeking Medicaid reimbursement, the individual cannot be admitted to the nursing facility.
If the determination is that an individual requires neither the level of services provided in a nursing facility nor specialized services, the nursing facility shall:

a. Arrange for the safe and orderly discharge of the resident from the facility; and b. Prepare and orient the resident for the discharge.

c. Provide the resident with a written notice of the action to be taken and his or her grievance and appeal rights under the procedure found at C.R.S. section 25-1-120 entitled “Nursing facilities - rights of patients”.

C. If the determination is that a resident does not require nursing facility services but requires specialized services, the following action shall be taken:

For long-term residents who have resided continuously in a nursing facility at least 30 months before the date of the first annual review determination and who require only specialized services, the nursing facility, in cooperation with the resident's family or legal representative and care givers, shall complete the following:

a. The resident shall be offered the choice of remaining in the facility or receiving services in an alternative appropriate setting; and b. The resident shall be informed of institutional and noninstitutional alternatives; and c. The effect on eligibility for Medicaid services shall be clarified if the resident chooses to leave the facility, including the effect on readmission to the facility; and d. The provision of specialized services shall be provided for or arranged regardless of the resident's choice of living arrangements.

For short term residents who require only specialized services and who have not resided in a nursing facility for 30 continuous months before the date of PASRR determination, the nursing facility, in conjunction with the State Mental Health or Intellectual or developmental disability authority, in cooperation with the resident's family or legal representative and caregivers, shall complete the following:

a. The safe and orderly discharge of the resident from the facility shall be arranged;

b. The resident shall be prepared and oriented for the discharge; and c. A written notice shall be given to the resident notifying him or her of the action to be taken and of his or her grievance and appeal rights.

d. The provision of specialized services shall be provided or arranged, regardless of the resident's choice of living arrangements.

D. Any individual with mental illness, determined through the PASRR process, to be in need of in-patient psychiatric hospitalization, shall not be admitted to the nursing facility until treatment has been received and the individual certified as no longer needing in-patient psychiatric hospitalization.

8.401.21 SPECIALIZED SERVICES FOR INDIVIDUALS WITH MENTAL ILLNESS

OR INDIVIDUALS WITH AN INTELLECTUAL OR DEVELOPMENTAL

DISABILITY .211 Specialized Services shall include the following requirements:

A. Comprehensive Community Behavioral Health Providers and Provider Agencies shall be authorized by the State to provide specialized services to individuals in Medicaid nursing facilities.

B. These services shall be reimbursed by the Medicaid program to the Comprehensive Community Behavioral Health Providers or Provider Agencies through The Department of Health Care Policy and Financing.

The cost of these services shall not be reported on the Nursing Facility cost report.

C. Specialized services may be provided by agencies other than Comprehensive Community Behavioral Health Providers or Provider Agencies or other designated agencies on a fee for service basis, but the cost of these services shall not be included in the Medicaid cost report or the Medicaid rate paid to the nursing facility. .212 Specialized Services for Individuals with Mental Illness shall be defined as services, specified by the State, which include:

A. Specified services combined with the services provided by the nursing facility, resulting in a program designed for the specific needs of eligible individuals who require the services.

B. An aggressive, consistent implementation of an individualized plan of care. .213 Specialized services shall have the following characteristics:

A. The specialized services and treatment plan must be developed and supervised by an interdisciplinary team which includes a physician, a qualified mental health professional and other professionals, as B. Specific therapies, treatments and mental health interventions and activities, health services and other related services shall be prescribed for the treatment of individuals with mental illness who are experiencing an episode of serious mental illness which necessitates supervision by trained mental health personnel. .214 The intent of these specialized services is to:

A. Reduce the applicant or resident's behavioral symptoms that would otherwise necessitate institutionalization.

B. Improve the individual's level of independent functioning.

C. Achieve a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time. .215 Levels of Mental Health services shall be provided, as defined by the State, including Enhanced and General Mental Health services. .216 Specialized Services for Individuals with Intellectual or developmental disability shall be defined as a continuous program for each individual which includes the A. An aggressive, consistent implementation of a program of specialized and generic training, specific therapies or treatments, activities, health services and related services, as identified in the plan of care.

B. The individual program plan includes the following:

The acquisition of the behaviors necessary for the individual to function with as much self determination and independence as possible; and 2. The prevention or deceleration of regression or loss of current optimal functional status. 8.401.4 GUIDELINES FOR INSTITUTIONS FOR MENTAL DISEASES (IMD's)

.41 DEFINITION

“Institution for Mental Diseases” (IMD) as defined in the Medicaid regulations at 42 C.F.R. section 435.1010 (2013), is an institution of more than sixteen (16) beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

.42 CRITERIA USED FOR DETERMINATION OF IMD STATUS

The primary criteria for the determination of the IMD status of an institution is that more than fifty percent (50%) of all patients in the facility have primary diagnoses of serious mental illness as determined by the Level II Pre-Admission Screening and Resident Review (PASRR) process which is verified by the Utilization Review Contractor.

The State has defined the following diagnostic codes contained in the DSM IV as valid for the purpose of determining whether an individual has a “mental disease”: 295.10 through 295.90 296.0 through 296.9 297.10 298.9 300.40 301.13 [Removed per S.B. 03-088, 26 CR 7]

Additional criteria applied for the purpose of IMD determination are as follows:

A. The facility is licensed as a psychiatric facility for the care and treatment of individuals with mental diseases;

B. The facility is accredited as a psychiatric facility by the Joint Commission for Accreditation for Health Care Organizations (JCAHCO);

C. The facility is under the jurisdiction of the state's mental health authority;

D. The facility specializes in providing psychiatric/psychological care and treatment as ascertained through a review of patients' records; and E. The current need for institutionalization for more than 50 percent of all patients in the facility results from major mental diseases.

Facilities that meet the primary “50%” criterion at a minimum are at serious risk of being classified as an IMD by the State and federal government. However, facilities meeting any lesser criteria may or may not be at risk of being identified as an IMD.

The assurance that a facility is not an IMD is included in all nursing facility contracts.

.43 FFP DISALLOWANCE

FFP is not available for any medical assistance under Title XIX for individuals between the ages of 21 and 65 who are patients in an IMD. The Department, in cooperation with CDPHE, will monitor long term care facilities to determine whether any facility has a census of primary psychiatric patients in excess of fifty percent (50%) of its total census.

Facilities whose psychiatric census approaches this fifty percent (50%) limit will be so notified by the Department. Should an on-site review by the Department document a psychiatric census in excess of fifty percent (50%) of total census in a facility, Medicaid reimbursement shall be denied for all residents between the ages of 21 and 65 until the Department determines that the facility is no longer an IMD.

.44 ADMINISTRATIVE PROCEDURES AND REQUIREMENTS

In order to determine whether a nursing home facility is an IMD the following administrative procedures and requirements are necessary:

A. All nursing homes shall indicate on the patient's medical record the primary, secondary and tertiary diagnoses (as applicable) of all their patients, Medicaid and private pay. All medical records shall contain this information no later than three calendar months after the effective date of this regulation.

B. All nursing homes shall report discharges to the Utilization Review Contractor.

Discharge information shall include the name of the person, state identification number if applicable, discharge destination, date, payment source Utilization Review Contractor and primary and secondary diagnoses. Discharges of all patients shall be reported within one week of discharge. Discharge is defined to mean death, transfers, discharge to home, and absent without leave.

C. CDPHE shall use the medical records diagnosis information to determine the percentage of patients with mental diseases. In cases where the percentage is higher than 40%, a notice of the potentially high percentage shall be sent to the Department and Utilization Review Contractor.

d. (1) In cases where the percentage is over 40% and less than 50% the nursing home will be instructed by the Department to provide admission data and discharge data on all private pay as well as Medicaid patients to the Utilization Review Contractor. The admission and discharge data is necessary on all patients so that the entire psychiatric census of the facility can be determined and monitored by the Utilization Review Contractor.

(2) In cases where the percentage of psychiatric patients appears to be exceeding or about to exceed 50%, the Department may instruct the Utilization Review Contractor to deny admission authorization for Medicaid patients with psychiatric diagnoses. The facility shall be notified of the Department's intent to limit admissions to only non-psychiatric patients at least five (5) days in advance of the action. The facility may appeal this action in accordance with the regulations at 10 CCR 2505-10 section 8.050 et seq..

e. (1) In cases where the percentage of psychiatric patients in the census of the facility is over fifty (50) percent, and/or the facility meets some of the other criteria, the Department shall conduct an audit of the facility to determine if it is primarily engaged in the care and treatment of persons with mental diseases (i.e. an institution for mental diseases). The basis of such a finding shall be the criteria described in the regulations. This audit shall be conducted with assistance from CDPHE and shall include medical personnel with the necessary qualifications to determine the primary characterization of a facility.

(2) Should the audit indicate a finding that the facility is an Institution for Mental Disease, then all Medicaid funding for patients between the ages of 21 and 65 shall be denied. Furthermore, should the audit indicate the facility has been an IMD for a period of time prior to the time the audit was undertaken, the facility shall refund to the Medicaid program one hundred percent (100%) of the payments for patients between the ages of 21 and 65. Under no circumstances shall the refund extend to periods of time before the effective date of the GUIDELINES FOR INSTITUTIONS FOR MENTAL DISEASES, issued April, 1987.

f. The Department shall make arrangements with the Medicaid patients of the facility determined to be an IMD to do any of the following:

(1) Relocate Medicaid patients between the ages of 21 and 65 in accordance with the regulations entitled NURSING HOME RESIDENT/CLIENT RELOCATION PLAN.

(2) Relocate a sufficient number of psychiatric patients from the facility so as to reduce the facility's psychiatric census to below 50%. Such relocation shall be completed in accordance with the NURSING HOME RESIDENT/CLIENT RELOCATION PLAN.

g. A nursing home facility determined to be an IMD may appeal such a finding in accordance with the regulations at 10 CCR 2505-10 section 8.050 et seq.. In cases where the administrative law judge issues a stay of the agency's action to terminate Medicaid payments to a provider, such an order of stay shall clearly indicate that should the State's IMD finding be correct, the facility shall repay the State one hundred percent (100%) of Medicaid payments it received during the period of the stay. In order to assure that such a payment shall be made, the administrative law judge shall require the facility to post a bond in the amount of one hundred percent (100%) of the anticipated nursing home payment for each month the stay is in effect.

8.401.50 GUIDELINES FOR CLASS V REHABILITATION FACILITIES

Section deleted eff. 3/01/02 8.402 ADMISSION PROCEDURES FOR LONG-TERM CARE 8.402.01 PRE-ADMISSION REVIEW When a physician or designee wishes to obtain skilled or maintenance services for a client, he/she shall contact the regional URC. The URC will request and record information about the client's condition and the proposed treatment plan.

In order to promote the most appropriate placement of individuals with intellectual or developmental disabilities when skilled or maintenance services are sought, the physician shall, unless an emergency admission is required, refer the client to theCommunity Centered Board (CCB) where the client resides. Class I services shall be authorized by the URC only when the following requirements have been met:

a. The CCB determines, in collaboration with the physician and the client or the client's designated representative, that Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) services or services available through Home and Community Based Services for individuals with Developmental Disabilities (HCBS-DD) are not appropriate to meet the health care needs of the client.

b. ICF/IID or HCBS-DD services are not available if such services are c. The physician and the client or the client's designated representative choose Class I services in preference to services available specifically for individuals with intellectual or developmental disabilities, and the client meets the level of care criteria for these services.

Referrals by physicians of individuals with intellectual or developmental disabilities for Class I services without review by the CCB will not be certified by the URC for Medicaid reimbursement. Clients for whom ICF/IID or HCBS-DD services are appropriate as defined in Section 8.401.18, subject to the physician's and the client's or the client's designated representative concurrence, shall be referred immediately to the URC and to the appropriate Community Centered Board under the provisions at Section 8.405. .02 After reviewing the information taken from the physician or his designee, the URC shall assign a target group designation based upon the primary reason for which long-term care services are needed. The URC shall follow the target group designations established at Section 8.402.32(A) through 8.402.32(D).

8.402.10 ADMISSION PROCEDURES FOR CLASS I NURSING FACILITIES .11 The URC/Single Entry Pointy (SEP) shall certify a client for nursing facility admission after a client is determined to meet the level of care and passes the PASRR Level 1 screen requirements for long-term care. However, the URC/SEP shall not certify a client for nursing facility admission unless the client has been advised of long-term care options including Home and Community Based Services as an alternative to nursing facility care. .12 The medically licensed provider must complete the necessary documentation prior to the client's admission. .13 The Level of Care Eligibility Determination Screen and other transfer documents concerning medical information as applicable, must accompany the client to the .14 The nursing facility or hospital shall notify the URC/SEP agency of the pending admission by faxing or emailing the appropriate form. The date the form is received by the URC/SEP agency shall be the effective start date if the client meets all eligibility requirements for Medicaid long-term care services. .15 The URC/SEP case manager shall determine the client's length of stay using the appropriate form developed by the Department. The length of stay shall be less than a year, one year or indefinite. All indefinite lengths of stay shall be approved by the case manager's supervisor. .16 The URC/SEP agency shall notify in writing all appropriate parties of the initial length of stay assigned. Appropriate parties shall include, but are not limited to, the client or the client's designated representative, the attending physician, the nursing facility, the Fiscal Agent, the appropriate County Department of Social/Human Services, the appropriate community agency, and for clients within the developmentally disabled or mentally ill target groups, the Department of Human Services or its designee. .17 The nursing facility shall be responsible for tracking the length of stay end date so that a timely Reassessment is completed by the URC/SEP. .18 The URC will determine the start date for nursing facility services. The start date of eligibility for nursing facility services shall not precede the date that all the requirements (functional level of care, financial eligibility, disability determination) have been met.

8.402.30 ADMISSION PROCEDURES FOR HOME AND COMMUNITY BASED

SERVICES .31 When the client meets the level of care requirements for long-term care, is currently living in the community, and could possibly be maintained in the community, the URC/SEP agency shall immediately communicate with the appropriate community agency, according to the URC/SEP agency-determined target group, for an evaluation for alternative services. The URC/SEP agency shall forward a copy of the worksheet plus a State prescribed disposition form to the agency either immediately after the telephone referral, or in place of the telephone referral. .32 Based upon information obtained in the pre-admission review, the URC/SEP case manager shall make the referral to the appropriate community agency based on the member's target group designation, as defined below:

A. Individuals determined by the URC/SEP agency to be in the Mentally Ill target group, regardless of source, shall be referred to an appropriate Comprehensive Community Behavioral Health Providers or other Medicaid enrolled behavioral health provider. .

B. Individuals determined by the URC to be in the Functionally Impaired Elderly target group, or the Physically Disabled or Blind target group shall be referred to the appropriate Single Entry Point Agency for evaluation for Home and Community Based Services for the Elderly, Blind and Disabled (HCBS-EBD).

C. Individuals identified by the URC to be in the Developmentally Disabled target group shall be referred to the appropriate Community Centered Board.

D. Individuals determined by the URC to be in the Persons Living with AIDS target group shall be referred to the appropriate Single Entry Point Agency for evaluation for HCBS-EBD.

E. The URC shall notify any members referred to case management agencies of the referral, the provisions of the program, and shall inform them of the complaint procedures. .33 The case management agency or Comprehensive Community Behavioral Health Providers, or clinic shall complete an evaluation for alternative services within five (5) working days of the referral by the URC. .34 Single Entry Point Agencies shall conduct the evaluation in accordance with the procedures at Sections 8.486 and 8.390. .35 Community Centered Boards shall conduct the evaluation in accordance with procedures at Section 8.500. .36 Comprehensive Community Behavioral Health Providers, and clinics shall conduct the evaluation in accordance with Standards for Conducting Evaluations and Establishing a Report, 2 CCR 505-1 Section 21.940 and Care and Treatment of Persons With A Mental Health Disorder In A Designated Facility, 2 CCR 502-1

Section 21.280. 2 CCR 505-1 Section 21.940 and 2 CCR 502-1 Section 21.280 are incorporated herein by reference. The incorporation of these Sections excludes later amendments to, or editions of, the referenced material. Pursuant to C.R.S. § 24-4-103(12.5), the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at:

Colorado Department of Health Care Policy and Financing, 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at chromeextension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.sos.state.co.us/CCR/ GenerateRulePdf.do?ruleVersionId=10931&fileName=2%20CCR%20505-1, and at chromeextension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.sos.state.co.us/CCR/ GenerateRulePdf.do?ruleVersionId=12100&fileName=2%20CCR%20502-1. .37 If the community agency develops an approved plan for long-term care services, the URC will approve one (1) certification for long-term care services and the member shall be placed in alternative services. Following receipt of the fully completed LOC Screen the URC will review the information submitted and make a certification decision. If certification is approved, the URC shall assign an initial length of stay for alternative services. If certification is denied, the decision of the URC may be appealed in accordance with Sections 8.057 through 8.057.8. .38 If the appropriate community agency cannot develop an approved plan for longterm care services, the URC will approve certification for long-term care services and utilize the procedure for nursing home admissions described previously in this section.

8.402.40 ADMISSION TO NURSING FACILITY WITH REFERRAL FOR

COMMUNITY SERVICES .41 When a client who meets the level of care requirements for long-term care is currently hospitalized but could possibly be maintained in the community, certification shall be issued. The client may be placed in the nursing facility, given a short length of stay and immediately referred to the appropriate community agency for evaluation for alternative services in accordance with the procedure described in the preceding section.

8.402.50 DENIALS (ALL TARGET GROUPS) .51 When, based on the pre-admission review, the client does not meet the level of care requirements for skilled and maintenance services, certification shall not be issued. The client shall be notified in writing of the denial. .52 If the URC denied long-term care certification based upon the information on the LOC Screen written notification of the denial shall be sent to the client, the attending physician, and the referral source (hospital, nursing facility, etc.).

If the information provided on the LOC Screen indicates the client does meet the level of care requirements, the URC shall proceed with the admission and/or referral procedures described above. .53 Denials of certification for long-term care may be appealed in accordance with the procedures described at 10 CCR 2505-10 Section 8.057 through 8.057.8. .54 Denial of designation into a specifically requested target group may also be appealed in accordance with 10 CCR 2505-10 Section 8.057 through 8.057.8.

8.402.60 CONTINUED STAY REVIEWS: SKILLED AND MAINTENANCE

SERVICES .61 The URC shall authorize all skilled nursing facility and intermediate care facility services, Home and Community Based Services for the Elderly, Blind and Disabled, and mental health clinic services when such services are appropriate and necessary for eligible clients. The URC may also limit the period for which covered long-term care services are authorized by specifying finite lengths of stay, and may perform periodic continued stay reviews, when appropriate, given the eligibility, functional and diagnostic status of any eligible Client. .62 Continued Stay Reviews shall, at a minimum, be conducted as frequently as necessary for the purpose of reviewing and re-establishing eligibility for all Home and Community Based Services waiver programs, in accordance with all applicable statutes, regulations and federal waiver provisions. .63 The frequency of the continued stay reviews and the determination of length of stay for nursing facilities may be conducted for the purpose of program eligibility.

The process for these decisions will be prescribed in criteria developed by the .64 Continued Stay Reviews for long-term care clients receiving HCBS-EBD or mental health clinic services may be conducted more frequently at the request of the case manager, client, authorized representative, or the behavioral health .65 The Continued Stay Review will follow the same procedures found at Section 8.401.11-.17(H) and if applicable, Section 8.485.61(B)(3). .66 As a result of the Continued Stay Review, the URC shall renew or deny 8.403 LONG TERM CARE SERVICES FOR INDIVIDUALS WITH INTELLECTUAL OR DEVELOPMENTAL DISABILITIES Long-term care services for individuals with intellectual or developmental disabilities include institutional services available through ICF/IID and Home and Community Based Services for individuals with Developmental Disabilities (HCBS-DD). These specialized services are available to Medicaid eligible clients who meet the target group designation for individuals with developmental disabilities and meet the level of care guidelines described below.

8.403.1 LEVEL OF CARE GUIDELINES FOR LONG-TERM CARE SERVICES

FOR TINDIVIDUALS WITH INTELLECTUAL OR DEVELOPMENTAL DISABILITIES

Level of care guidelines for programs for individuals with intellectual or developmental disabilities are used to determine if the profile of a client's programmatic and/or medical needs are appropriate to a specific ICF/IID nursing home class or equivalent set of HCBS-DD services. .11 Clients shall be certified for admission to a specific class of ICF/IID based on the following criteria:

A. Minimum/Moderate - individuals with intellectual or developmental disabilities who exhibit the following characteristics:

Have deficiencies in adaptive behavior that preclude independent living and require a supervised living environment;
Need supervision and training in self-help skills and activities of daily living, but do not display excessive behavior problems which are disruptive to other residents or which prevent participation in group or community activities;
Are capable of attending appropriate day services or engaging in supported or competitive employment; and, 4. Are capable of being maintained in a community-based setting.

Clients certified at this level of care may be provided Class II ICF/IID services if HCBS-DD services (as set forth in the regulations at Section 8.500) are not available, after a reasonable search has been conducted by the CCB, due to lack of availability of appropriate providers.

B. Specialized Intensive - individuals with intellectual or developmental disabilities whose psychological, behavioral, and/or developmental needs require 24-hour supervision, and who have potential for movement to a less restrictive living arrangement.. These individuals must conform to one of the profiles described below:

Behavior development profile:

Function at a severe to moderate overall level of intellectual or developmental disability;
May present a danger to self or others in the absence of supervision and habilitative services;
Display severe maladaptive and/or anti-social behaviors, and may have exhibited delinquent behaviors;
May display destructive or physically aggressive behaviors;
Need specialized behavior management, counseling, and supervision;

Social emotional development profile:

Function at a moderate to mild overall level of intellectual or developmental disability.
Exhibit severe social and emotional problems attributable to a mental disorder.
May be verbally abusive and/or physically aggressive toward self, others, or property.
May display run-away, withdrawal, and/or bizarre behavior attributable to a mental disorder;
Need social, adaptive, and intensive mental health services.

Intensive developmental profile:

Function at a profound to severe level of intellectual or developmental disability;
Exhibit severe deficiencies in behaviors such as eating, dressing, hygiene, toileting, and communication;
May display inappropriate social and/or interpersonal behaviors;
Need intensive self-management and adaptive behavior training.

Additionally, these individuals are capable of functioning in a communitybased setting.

Clients certified at this level of care may be provided Class II or Class IV ICF/IID services if HCBS-DD services (as provided in the regulations at

Section 8.500) are not available, after a reasonable search has been conducted by the CCB, due to lack of availability of appropriate providers.

C. Intensive Medical/Psychosocial - individuals with intellectual or developmental disabilities who have intensive medical and psychosocial needs that require highly structured, in house, comprehensive, medical, nursing and psychological treatment. These individuals must meet at least one of the following requirements:

Exhibits extreme deficiencies in adaptive behaviors in association with profound or severe intellectual or developmental disabilities or in association with medical problems requiring availability of medical life support services on a continuous basis; and/or Exhibits maladaptive behavior(s) potentially injurious to self or others to the degree that intensive programming in an institutional or closed setting is required; and Inappropriate for placement in less restrictive settings, such as minimum/moderate or specialized intensive community-based services, due to the nature and/or severity of their disabilities.
Appropriate for service in less restrictive community residential programs, but all local and statewide avenues for alternative placement have been investigated and exhausted prior to referral to a Class IV facility. Plans for eventual community placement have been established;
Committed by court action to a Regional Center under the Division Regional Center Operations, Department of Human Services.

Clients certified at this level of care may be provided Class IV ICF-IID services if HCBS-DD services (as provided in the regulations at Section 8.500) are not available after a reasonable search has been conducted by the CCB, due to lack of availability of appropriate providers.

8.404 ADMISSION CRITERIA: PROGRAMS FOR THE DEVELOPMENTALLY

DISABLED 8.404.1 Clients needing ICF/IID level of care are those who:

A. Require aggressive and consistent training to develop, enhance or maintain skills for independence (e.g., on-going reliance on supervision, guidance, support and reassurance); or B. Are generally unable to apply skills learned in training situations to other settings and environments; or C. Generally cannot take care of most personal care needs, cannot make basic needs known to others, and cannot understand simple commands, (e.g., requires assistance or prompts in bathing and/or dressing, neglects to wear protective clothing, does not interact appropriately with others, speaks in muffled/unclear manner, fails to take medications correctly, confuses values of coins, spends money inappropriately); or D. Are unable to work at a competitive wage level without support, (e.g., specially trained managers, job coach, or wage supplements) and are unable to engage appropriately in social interactions (e.g., alienates peers by teasing, arguing or being cruel, does not make decisions); or E. Are unable to conduct themselves appropriately when allowed to have time away from the facility's premises (e.g., loses self-control when s/he cannot get what s/he wants, performs destructive acts, unsafe crossing streets or following safety signs) or F. Have behaviors that would put self or others at risk for psychological or physical injury. .11 Clients needing placement in an ICF/IID are those who require an active treatment program. An active treatment program is defined as the aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services that is directed toward:

A. The acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible; and B. The prevention or deceleration of regression or loss of current optimal functional status.

8.404.2 CONTINUED STAY REVIEW CRITERIA: PROGRAMS FOR

INDIVIDUALS WITH INTELLECTUAL OR DEVELOPMENTAL DISABILITIES

Same as admission criteria unless the individual needs the help of an ICF/IID to continue to function independently because s/he has learned to depend upon the programmatic structure it provides. The fact that s/he is not yet independent, even though s/he can be, makes it appropriate for s/he to receive active treatment services directed at achieving needed and possible independence. 8.404.3 Adherence to the following sections of CDPHE and/or Department of Health Care Policy and Financing rules and regulations are critical to the provision of active treatment and active habilitation:

A. Assessments B. Individual habilitation plans C. Individual program plans D. Community integration E. Independence training F. Behavior management G. Psychotropic medication use For individuals needing placement in the ICF/IID facility, a list of specific services or interventions needed in order to make progress must be provided.

8.405 ADMISSION PROCEDURES: PROGRAMS FOR THE DEVELOPMENTALLY

DISABLED

.10 PREADMISSION REVIEW

For admission to ICF/IID facilities clients must be evaluated by the Case Management Agency in the area where the client resides. If services will be provided through an agency in another area, the client shall be evaluated by that area's Case Management Agency.

The client shall be referred by the Case Management Agency to the URC for admission review and to the appropriate County Department of Social/Human Services for determination of Medicaid eligibility. The URC shall not determine admission certification under Medicaid for any intellectually or developmentally disabled client in the absence of a referral from the Case Management Agency except for emergency admissions to the Class I facilities. .11 The Case Management Agency evaluation must contain background information as well as currently valid assessments of functional, developmental, behavioral, social, health, and nutritional status to determine if the facility can provide for the client's needs and if the client is likely to benefit from placement in the facility. .12 Case Management Agency Adverse Recommendation In cases where the Case Management Agency declines to recommend placement of a client into an ICF/IID facility, the Case Management Agency shall inform the client of the recommendation using the HCBS-DD-21 form. The Case Management Agency shall also notify the client or the client's designated representative of the client's right to request a formal URC level of care review.

The client shall have thirty (30) days from the postmark date of the notice to request a formal URC review. If the client requests a formal URC level of care review, the Case Management Agency shall submit the required documentation plus any new documentation submitted by the client to the URC. The URC shall review and make a level of care determination in accordance with the admission procedures below.

8.405.2 ADMISSION PROCEDURES FOR ICF/IID FACILITIES .21 When, based on Case Management Agency review, the Member cannot reasonably be expected to make use of ICF/IID or HCBS-DD, the Case Management Agency shall notify the physician and the URC. The physician and the URC/ Case Management Agency shall then proceed with the SNF or ICF placement under the provisions set forth at Section 8.402.10. 22 When the Case Management Agency determines that a client is not appropriately served through HCBS-DD services or, in accordance with provisions permitting the client or the client's designated representative to choose institutional services as an alternative to HCBS-DD services, the Case Management Agency shall recommend placement to an ICF/IID facility. The Case Management Agency shall seek the approval of the client's physician. The physician shall notify the URC/ Case Management Agency agency of the proposed placement. Based on information provided by the Case Management Agency and the client's physician, the URC Case Management Agency may certify the client for long-term care prior to ICF/IID admission. .23 The URC/ Case Management Agency shall advise the County Department of Social/Human Services of the certification to enable the County Department staff to assist with the placement arrangements.

The LOC Screen and other transfer documents concerning medical information as applicable must accompany the client to the facility. .25 Following receipt of the fully completed LOC Screen, the URC/ Case Management Agency shall review the information and make a final certification decision. If certification is approved, the URC/ Case Management Agency shall assign an initial length of stay according to Section 8.404.1. If certification is denied, the decision of the URC/CCB may be appealed in accordance with the appeals process at Section 8.057.

8.405.30 ADMISSION PROCEDURES FOR HCBS-DD .31 Case Management Agencies shall use evaluation and admission criteria at Sections 8.7100-8.7200 et seq.for HCBS-DD admissions Case Management Agencies may evaluate clients for HCBS-DD services if such services represent a viable alternative to SNF, ICF, or ICF/IID services. The evaluation shall be carried out in accordance with the procedures set forth in 2 C.C.R. Section 503- 1. .32 If the Case Management Agency recommends HCBS-DD placement, then the URC shall approve certification for services for the developmentally disabled at the level of care recommended by the Case Management Agency. The Member shall be placed in alternative service.

Following receipt of the completed LOC Screen and any other supporting information, the URC Case Management Agency shall review the information and make a final certification determination.

If certification is approved, the URC Case Management Agency shall assign an initial length of stay for HCBS-DD services.

If certification is denied, the decision of the URC/Case Management Agency may be appealed in accordance with Section 8.057.

8.405.4 CONTINUED STAY REVIEW PROCEDURES; SERVICES FOR

INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES .41 Continued Stay Reviews shall be conducted by the URC for all intellectually and clients in ICF/IID services, in accordance with 42 CFR Part 456 Subpart F. .42 As a result of the Continued Stay Review, the URC shall renew or deny 8.405.50 GENERAL PROVISIONS A. These rules shall not be construed nor interpreted to expand, diminish, or change any statutory provisions or duties of registered professional nurses, licensed practical nurses, or any other person subject to, or under the supervision of registered professional nurses or licensed practical nurses pursuant to the Professional Nurses Act, but are intended to explain the method by which the department shall reimburse the providers of nursing care services available under the Colorado Medical Assistance Program.

B. The Department of Health Care Policy and Financing (“Department”) is the single state agency responsible for administration of the Medical Assistance Program (“ Medicaid”) pursuant to Title XIX of the Social Security Act. The Department is responsible for determining eligibility for program benefits; providers of medical care; level of reimbursement for the provision of medical care; and terms and conditions that shall govern the payment of such providers for the medical care services provided.

C. The Department receives partial reimbursement from federal funds pursuant to Titles I, X, XIV, XVI, and XIX of the Social Security Act.

D. All participating skilled nursing care facilities and intermediate health care facilities must be administered by a nursing facility administrator licensed pursuant to C.R.S. section 12-39-101 et seq. For inclusion in the audited cost rate (see 10 CCR 2505-10 section 8.440 et seq.) the administrator must be employed full-time by the applicant facility, and may not have other conflicting employment obligations. The administrator must be responsible on a 24-hour-aday basis, with primary duties being performed during the day shift.

8.406 NURSING FACILITY CARE - LEVELS OF CARE

The Department provides payment for nursing facility care in three (3) categories or levels of care: (1) “skilled nursing care”, (2) “intermediate nursing care”, and (3)

“residential care.”

8.406.1 SKILLED NURSING CARE

Skilled nursing care is available for eligible clients when a physician licensed to practice in the State of Colorado certifies care to be medically necessary. Such care must be provided in a facility that holds a valid and current license from CDPHE as a Nursing Care Facility pursuant to the Standards for Hospitals and Health Facilities, CDPHE, Health Facilities Division. The facility must also meet the standards defined in the U.S.

Code of Federal Regulations, Title 42 C.F.R., as rules of the Department. Title 42 of the Code of the Federal Regulations is hereby incorporated by reference. The Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated

Section 1902(a)(26) of the Social Security Act (42 U.S.C. section 1396a) and 42 C.F.R.

section 400 et seq. require the Department to:

A. Pursue a regular program of medical review and evaluation of each eligible client's medical need for skilled nursing care; and B. Conduct periodic inspections of all skilled nursing care facilities which participate in the Medicaid Program (see 10 CCR 2505-10 section 8.420) to ascertain:

The actual care being provided;
The adequacy of the services available to meet the current health needs and to promote the maximum physical well-being of the eligible client;
The necessity and desirability of the continued placement of eligible clients in skilled nursing care facilities; and 4. The feasibility of meeting the client's health care needs through alternative C. Section 1902 of the Social Security Act (1935) (42 U.S.C. section 1396r) is hereby incorporated by reference. The incorporation of 42 U.S.C. section 1396r excludes later amendments to, or editions of, the referenced material. The Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203.

Certified copies of incorporated materials are provided at cost upon request.

8.406.2 INTERMEDIATE NURSING CARE

The Department shall:

A. Pursue a regular program of medical review and evaluation of each eligible client's medical need for intermediate nursing care; and B. Conduct periodic inspections of all intermediate health care facilities which participate in the Medicaid Program (see 10 CCR 2505-10 section 8.420) to ascertain:

The actual care that is being provided;
The adequacy of the services available to meet the current health needs and to promote the maximum physical well-being of the eligible client;
The necessity and desirability of the continued placement of eligible clients in intermediate health care facilities; and 4. The feasibility of meeting the client's health care needs through alternative 8.406.3 INTERMEDIATE NURSING CARE - INTELLECTUAL OR DEVELOPMENTAL DISABILITY 15 BEDS OR LESS A. Intermediate nursing care is available in facilities of 15 beds or less for eligible clients who are individuals with an intellectual or developmental disability or have related conditions provided:
The facility holds a valid and current license from CDPHE as a residential care facility or higher classification.
Clients who are individuals with an intellectual or developmental disability or have related conditions are certified by a physician licensed to practice in the State of Colorado to be (a) ambulatory, (b) receiving active treatment, (c) capable of following directions and taking appropriate action for self-preservation under emergency conditions, and (d) not in need of professional nursing services.

B. All other provisions of these rules shall apply to care and services provided in such facilities in accordance with the provisions of 42 C.F.R Part 442.

8.407 SPECIAL PROVISION CONCERNING CLIENTS ELIGIBLE FOR SOCIAL

SECURITY AGE-72 BENEFITS (PROUTY)

8.407.1 SPECIAL AGE-72 BENEFITS (PROUTY)

Federal regulations require that welfare clients cannot receive both the Special Age-72 Benefit and a public assistance payment. Rule A-4232 requires that all available income to a client (or applicant) must be sought by the client or applicant.

SSA must receive assurance from the County Departments of Social/Human Services that as of a certain date no further assistance payments (including $50 personal needs allowance) will be paid to the client.

8.407.2 REQUEST FOR ADDITIONAL INFORMATION ON FORM SSA-1610

When a county has authorized a nursing facility placement for a person over 72 years of age, who is eligible for a Prouty Benefit, Social Security must be notified.

8.408 LEVELS OF CARE DEFINED - SKILLED NURSING CARE

A. Skilled nursing services in a licensed nursing care facility are those services performed by licensed nursing personnel, or personnel under their supervision.

These services must be performed according to a plan of treatment written by a physician licensed to practice medicine in the State of Colorado. These services apply to clients whose condition(s) require medical services to maintain a degree of stability, which has been achieved. Components of these services include:

The medical need for the attending physician to visit the client on a professional basis at least once every thirty (30) days.
Observation and assessment of the total needs of the client, utilizing skilled nursing judgment.
Planning, organizing, and managing the client care plan which requires specialized training to accomplish delivery of health care, or to attain the desired results or to render direct services to “the patient”.

B. These health care services require regular medical care and 24-hour licensed nursing services for illnesses, injury, or disability. Nursing service shall be organized and maintained to provide 24-hour licensed nursing services under the direction of a registered professional nurse employed full time and at least two (2) hours total nursing staff time for each patient per 24-hour day.

C. Covered skilled nursing services must adhere to one or more of the following principles:

A service which requires a substantial specialized judgment and skill based on knowledge and application of the principles of biological, physical, and social sciences, necessary to perform or supervise effectively the services rendered, or 2. A service that is unskilled but which requires skilled performance, supervision, or observation because of special medical complications.

Medical complications and special services must be documented by the physician's order and the nursing notes.

D. In addition to meeting the definition of skilled nursing services, coverage of such services is warranted only if skilled nursing personnel must be available on a continuous 24-hour basis. In determining whether the continuous availability of such personnel is warranted, the following principles apply:

Frequency of Services - The frequency of skilled nursing services required, rather than their regularity, is the controlling factor in determining whether the continuous availability of skilled nursing personnel is warranted.
Observation - Where observation is the principle continuous service provided, because symptoms exist that indicate the need for immediate modification of treatment of institution of medical procedures.

E. The purpose of the above-stated components and principles, and of 10 CCR 2505-10 section 8.408.1 et seq., is to provide general direction and guidelines for admission, utilization review, and medical review; with the intent that the individual's overall medical situation (including mental condition) shall be taken into account in evaluation and determination of the level of care to be provided.

8.408.1 SPECIFIC SERVICES WHICH ARE SKILLED

Based upon the principles set forth, skilled nursing services include but are not limited to the following:

A. Subcutaneous or intramuscular injections and intravenous medications and/or feedings.

B. Levine tube and gastrostomy feedings.

C. Naso-pharyngeal aspiration.

D. Insertion and replacement of catheters.

E. Aseptic application of dressings involving prescription medications.

8.408.2 SPECIFIC SERVICES WHICH ARE SUPPORTIVE

Supportive services which can be learned and performed by the average non-medical person who has been trained in these procedures, provided to either skilled or intermediate care patients include but are not limited to the following:

A. Provision of routine maintenance medications.

B. Prevent decubiti, keep clean, and comfortable.

C. Safety measures against accident and injury.

D. General maintenance are of colostomy or ileostomy.

E. Routine services in connection with in-dwelling bladder catheters.

F. Changes in dressings in noninfected postoperative or chronic conditions.

G. Prophylactic and palliative skin care, including bathing and application of creams, and care of minor skin problems.

H. General methods of caring for incontinent patients, including use of diapers.

I. General care of patients with a plaster cast.

J. Routine care in connection with braces and similar devices.

K. Use of heat for palliative and comfort purposes.

L. Administration of medical gases after initial phases of institution of therapy.

M. Assistance in dressing, eating, and going to the toilet.

N. General supervision of exercises which have been taught to the patient.

O. Diet supervision and administration for those persons requiring specialized diet.

P. Skilled paramedical services involving specialized training outside the licensed nursing curriculum.

8.408.3 ORGANIZATION OF SKILLED NURSING SERVICE

The following nursing care services and organization must be established as a minimum in order for a skilled nursing care facility to receive reimbursement.

A. Administrative and supervisory responsibilities must be in writing.

B. Duties must be clearly defined in writing and assigned for staff members.

C. Written policies and procedures for client care must be available to all personnel.

D. All professional services rendered by the nursing facility staff, physician, or other professional personnel, must be entered in the client's individual record and signed.

8.408.4 PROFESSIONAL PERSONNEL

8.408.41 DIRECTOR OF NURSING

The nursing services must be under the direction of a director of nursing service who:

Is a registered professional nurse.
Is qualified by education, training, or experience for supervisory duties.
Is responsible to the administrator for development of standards, policies, and procedures governing skilled nursing care, and for assuring that such standards, policies, and procedures are observed.
Is responsible to the administrator for the selection assignment, and direction of the activities of nursing services personnel.
Is employed full time in the facility.
Devotes their full time to direction and supervision of the nursing services; and, 7. Is on duty during the day shift.

8.408.42 CHARGE NURSE (RN OR LPN)

At all times, there must be on duty and in charge of the facility's nursing activities either:

A registered professional nurse; or, 2. A practical (or vocational) nurse who:

a. Is licensed by the State as a practical (or vocational) nurse; and b. Has graduated from a State-approved school of practical nursing; or, c. Has other education and formal training that is found by the State authority responsible for licensing of practical nurses to provide a background considered to be equivalent to graduation from a State-approved school of practical nursing.

8.408.43 NURSING PERSONNEL

Nursing personnel means registered nurse (RN), licensed practical nurse (LPN), and those auxiliary workers, other than RN or LPN, in the nursing service.

To assure the provision of adequate nursing services, each nursing care facility must provide sufficient:

Numbers and categories of personnel as determined by the number of patients in the facility and their particular nursing care needs. This determination is made in accordance with accepted policies of effective nursing care and with these guidelines will provide at least two (2) hours total nursing staff time for each patient per 24-hour day.
Nursing and auxiliary personnel employed and assigned to duties on the basis of their qualifications or experience to perform designated duties.
Amounts of nursing time to assure that each patient:

a. Receives treatments, medications, and diet as prescribed;

b. Is kept comfortable, clean, and well-groomed;

c. Receives proper care to prevent decubitus ulcers;

d. Is protected from accident and injury by appropriate safety measures;

e. Is encouraged to perform out-of-bed activities as permitted; and, f. Receives assistance to maintain optimal physical and mental function.

8.408.44 ANCILLARY PERSONNEL

Authorized subsidiary personnel performing duties in support of professional health care services may or may not be included in arriving at the computation of cost allowances set forth in 10 CCR 2505-10 section 8.400 et seq.

A. Dietary - Professional planning and supervision of meal services.

Special and restricted diet files shall be maintained for thirty (30) days, and any substitutions or variations noted. The patient's reaction and acceptance of food must be observed and recorded.

Menus must be planned and supervised by professional personnel meeting the following qualifications:

A dietician who meets the American Dietetic Association's standards for qualification as a dietician; or, 2. A graduate holding at least a bachelor's degree from the university program, with major study in food or nutrition; or, 3. A trained food service supervisor, an associate degree dietary technician, or a professional registered nurse, with frequent and regularly scheduled consultation from a dietician or a nutritionist meeting the above-stated qualifications.

Inclusion of dietary consultation costs are an allowable item in computing the rate of payment above-referenced.

B. Pharmacy Consultant - A person licensed to practice pharmacy in the State of Colorado, and whose duties are related to the nursing facility administration of drugs to patients. Such duties relate to:

Drug interactions;
Proper medication usage pertinent to the diagnosis and length of medication; specific to proper usage in records, stop orders, etc.;
Appropriate storage and safeguards of medications;
Study of possible brand interchanges;
Check on authenticity of medication pursuant to labeling;
Contraindications and other professional activities related to drug administration, receipting, storage, etc.

Costs related to pharmacal consultation are allowable in determining the rate to be paid, under the same conditions as for dietary in item 1 above.

C. Housekeeping and Maintenance - Allowed pursuant to above-cited rules on cost computation.

8.408.5 CLINICAL RECORDS

8.408.51 MAINTENANCE

The following records, as a minimum, must be kept current, dated and signed, and must be made available for review if applicable:

Identification and summary sheets.
Hospital discharge summary sheet.
Medical evaluation and treatment plan.
Physician's orders.
Physician's progress notes.
Nurse's progress notes.
Medication and treatment record.
Laboratory and X-ray reports.
Consultation reports.
Dental reports.
Social Service notes.
Pharmacal Consultant records.
PASRR documentation to include the Level I and Level II Reviews and the determination letters.

8.408.52 RETENTION OF RECORDS

Files shall be retained for at least six years.
In the event that a client is transferred to another health facility, certain transfer information should be incorporated in a record to accompany the client. Such transfer information shall include:

a. Transfer form with diagnosis;

b. Aid to daily living information;

c. Transfer orders;

d. Nursing care plan;

e. Physician's orders for care.

8.408.53 CONFIDENTIALITY OF RECORDS

Disclosed only to authorized persons.
Form APA-4, “Authorization for Release of Medical Information” shall be executed in duplicate (original to the nursing facility medical record with a copy to the County Department of Social/Human Services) at the time of admission. This form must be signed by the client, the client's designated representative, the client's parent (if a minor), guardian, or other legally responsible person.

8.408.54 RECORDS ADMINISTRATOR

The nursing care facility must have available, and a staff person designated:

a. A consultant or full-time employee who is a registered records administrator (Medical Records Librarian), or an accredited records technician, or;

b. A registered records administrator or other employee who is trained in medical records, and who receives supervision from a registered records administrator; or, c. If the facility does not have such employee with such training, an employee of the facility is assigned the responsibility for assuring that records are maintained, completed, and preserved. Such person, however, must be trained by, and receive regular consultation from a registered records administrator or accredited records technician.

8.408.6 MEDICAL BASIS FOR CARE - SKILLED NURSING FACILITY CARE

Eligible clients may be admitted to approved facilities only upon the certification of a physician licensed to practice in Colorado that there is a medical need for such admission (Form ULTC-100). The clients' freedom of choice of physician shall be respected. Health care of the client must continue under the supervision of a physician.

The facility must have a physician available for necessary medical care in case of emergency.

8.408.61 PHYSICIANS' INVOLVEMENT

8.408.62 DETERMINATION FOR SKILLED NURSING CARE

The medical need of a client for skilled nursing care shall be delineated in the plan of treatment and substantiating orders written by the physician and by the performance of the necessary skilled nursing services implementing such plans and orders. Upon admission to a skilled nursing care facility, the facility must obtain for the medical record of each such client:

A summary of the course of treatment by the attending physician or which was followed in the hospital, the diagnosis(es) and current medical findings, and the rehabilitation potential.
An evaluation by the physician. Physical examination must be accomplished within 48 hours of admission and recorded; unless such an examination has been accomplished within five days prior to admission to the skilled nursing care 3. Physician's orders. Orders must be written for the immediate care of the client.

These may be written by the attending physician or by the physician who has the responsibility for emergency care in this facility. The current hospital summary of the course of treatment, with orders used, is acceptable as emergency orders.

The physician's treatment plan. The plan must be written and must be directed towards maintaining the health status of the client, preventing further deterioration of the physical well-being of the client, and preparing the client for normal non-institutional life. The plan must be reviewed and revised as necessary, and must include medication and treatment orders which will be in effect for the specified number of days indicated by the physician. This period shall be monthly unless reordered in writing by the physician. Telephone orders may be accepted by licensed nurses only and must be written into the clinical record by the receiving nurse. These orders must be countersigned by the ordering physician within 48 hours.

The medical necessity for a physician's visit, at least once every thirty (30) days, must be evidenced in the clinical record by a valid signed entry.

Plan for Emergency Care - Each skilled nursing care facility must provide for one, or more, physicians to be available to furnish emergency medical care if the attending physician is not immediately available. A schedule listing the name, telephone number and days on call for a given physician will be posted at each nursing station. The skilled nursing care facility must also establish procedures which will be followed in the emergency care of the client, the persons to be notified, and the reports to be prepared.

8.408.63 PHYSICIANS' INVOLVEMENT - REDETERMINATION FOR SKILLED

NURSING CARE

The medical need of the client for skilled nursing care shall be redetermined monthly at the time of the physician's required monthly visit.

The term “substantial change” does not encompass short-term treatment regimens for temporary illness, adjustments to prescribed medications, or changes to be in effect for less than a thirty (30) day period.

8.408.7 MEDICAL REVIEW AND MEDICAL INSPECTION - SKILLED NURSING

CLIENTS

Medical review of the treatment of all clients in skilled nursing care facilities who are entitled to medical assistance will be accomplished prior to May 2, 1972 (to meet requirements of 42 C.F.R. section 456.2), and annually thereafter. Medical review procedures herein are in addition to those set forth in 10 CCR 2505-10 section 8.449 concerning Utilization Review.

8.408.71 MEDICAL REVIEW TEAM

8.408.72 COMPOSITION AND MEMBERSHIP REQUIREMENTS

The medical review team for skilled nursing care clients will be led by a Colorado Registered Nurse or a Colorado Licensed Physician. The teams will include other appropriate health and social service personnel. Nurse-led teams will report to a physician.

No member of the team may be employed by or have financial interest in any nursing facility. No physician member of a team may inspect the care of clients for whom he is the attending physician.

8.408.73 FUNCTION - MEDICAL REVIEW AND EVALUATION

The medical treatment of skilled nursing clients entitled to medical assistance shall be reviewed at least annually.
Annual review shall consist of an evaluation of the treatment, utilizing the medical record and personal contact with, and observation of, each client in the nursing facility surroundings. This review, at a minimum, will elicit:

a. Medical necessity for visit by attending physician at least once every thirty (30) days.

b. Adequacy in quality and quantity as well as the timeliness of treatment to meet health needs.

c. Adherence to the written physician's treatment plan.

d. Tests, or observations of clients, indicated by their medication regimen have been made at appropriate times and properly recorded.

e. Physician, nurse, and other professional staff progress notes are made as required, and appear to be consistent with observed condition of the client.

f. Adequate services are being rendered to each client as shown by such observations as cleanliness, absence of decubiti, absence of signs of malnutrition or dehydration, and apparent maintenance of optimal physical, mental, and psychosocial function.

g. Client's need for any service not available in, or actually being furnished by the particular facility, or through arrangements with others.

h. Each client actually needs continued placement in the facility, or there is an appropriate plan to transfer the client to an alternate method of care.

8.408.74 REPORTS

Review reports of care in each facility are submitted to the Department.

a. After review copies are forwarded to:

Nursing care facility 2) Nursing care facility Utilization Review Committee 3) CDPHE 2. Reports will cover observations, conclusions and recommendations with respect to adequacy and quality of client services in the facility, and of physician services to clients in the facility. They will also cover specific findings with respect to individual clients and any recommendations resulting therefrom.

8.408.75 STATE DEPARTMENT ACTION

Reports submitted as a result of Medical Review may result in decisions to reclassify clients into a different level of care, or recommendations for modification of treatment.

Such decisions or recommendations will be transmitted as appropriate, to the:

a. Attending physician.

b. Administration of the nursing facility.

c. County Department of Social/Human Services responsible for the client.

Changes in classification recommended will be affected prior to the next billing period.

8.408.76 REVIEW OF STATE DEPARTMENT ACTION

Disagreements with the decisions and recommendations of the Review Team may be adjudicated through the Administrative Review mechanism of the Department; however, the Department will retain the right to final decision.

8.409 LEVELS OF CARE DEFINED - INTERMEDIATE NURSING CARE

Intermediate nursing services in a licensed intermediate health care facility are defined as those services furnished in an institution or distinct part thereof to those clients who do not have an illness, disease, injury, or other condition that requires the degree of care and treatment which a hospital, Extended Care Facility, or Skilled Nursing Care Facility is designed to provide. Such services are provided under the supervision of a registered professional nurse or licensed practical nurse during the day shift, seven (7) days per calendar week. Covered intermediate services will be at a level less than those described as skilled nursing services and will include guidance and assistance for each client in carrying out their personal health program to assure that preventive measures, treatment, and medications prescribed by the physician are properly carried out and recorded.

These services are provided for according to a plan of treatment written by a physician licensed to practice medicine in the State of Colorado, and apply to clients whose conditions require medical services to maintain a degree of stability which has been achieved.

There must exist a medical need for the attending physician to visit the client on a professional basis at least once in every calendar quarter.

8.409.1 SEPARATION OF SKILLED NURSING FACILITY PATIENTS FROM

THOSE REQUIRING INTERMEDIATE CARE: DISTINCT PART REQUIREMENT

All nursing facilities which provide both skilled nursing facility care and care and services to clients classified as requiring intermediate nursing care, shall set aside a distinct part, or identifiable unit in such facility for the provision of such intermediate care to such clients.

A “distinct part” is one that meets the following conditions:

Identifiable unit - The distinct part of the nursing facility is an entire unit such as an entire ward or contiguous wards, wing, floor, or rooms. With respect to facilities having 2 or more rooms, such must be contiguous. The identifiable unit must consist of all beds and related facilities in the unit and house all patientclients classified as intermediate care clients for whom payment is being made, except as provided in paragraph (d) below. It is clearly identified and is approved, in writing (licensed), by CDPHE.

Staff - Appropriate personnel shall be assigned to the identifiable unit and must work regularly therein. Immediate supervision of staff shall be provided at all times by qualified personnel as required for licensure.

Shared Facilities and Services - The identifiable unit may share such control services and facilities as management services, dietary, building maintenance and laundry, with other units.

Transfers Between Distinct Parts - Nothing herein shall be construed to require transfer of a client within the nursing facility, when, in the opinion of the client's physician, such transfer might be harmful to the physical or mental health of the client. Such opinion of the physician must be recorded on the patient's nursing facility medical chart and stand as a continuing order unless the circumstances requiring such exception change.

8.409.2 ORGANIZATION OF INTERMEDIATE NURSING SERVICE

The following nursing care services and organization must be established as a minimum in order for an intermediate nursing care facility to receive reimbursement:

Administrative and supervisory responsibilities must be in writing.
Duties must be clearly defined in writing and assigned for the staff members.
Written policies and procedures for client care must be available to all personnel.

8.409.21 PROFESSIONAL PERSONNEL - “DIRECTOR OF NURSING”

There must be on duty and in charge of the facility's nursing activities either a registered professional nurse or a licensed practical nurse who:

Is qualified by education, training, or experience for supervisory duties;
Is responsible to the administrator for development of standards, policies, and procedures governing intermediate nursing care, and for assuring that such standards, policies and procedures are observed;
Is responsible to the administrator for the selection, assignment, and direction of the activities of nursing service personnel;
Is employed full time (40 hours per week) in the facility;
Is devoted, full-time to direction and supervision of the nursing services; and 6. Is on duty during the day shift.

8.409.22 NURSING PERSONNEL

For the two day shifts (16 hours per calendar week) not covered by the Director of Nursing, there shall be a Registered Professional Nurse or a licensed Practical Nurse, and:

There shall be, at all times, a responsible staff member actively on duty in the facility, and immediately accessible to all residents, to whom residents can report injuries, symptoms of illness, or emergencies, and who is immediately responsible for assuring that appropriate action is promptly taken.
Assistance as needed to clients with routine activities of daily living including such services as help in bathing, dressing, grooming, and management of personal affairs.
Continuous supervision for residents whose mental condition is such that their personal safety requires such supervision.

8.409.23 PROFESSIONAL PLANNING AND SUPERVISION OF MEAL SERVICE

At least three meals a day, constituting a nutritionally adequate diet must be served in one or more dining areas separate from the sleeping quarters. Tray service must be provided for clients temporarily unable to leave their rooms.

If the facility accepts or retains clients in need of medically prescribed special diets, the menus for such diets shall be planned by a professionally qualified dietitian, or must be reviewed and approved by the attending physician. The facility must provide supervision of the preparation and serving of the meals and their acceptance by clients.

8.409.24 ANCILLARY PERSONNEL

Authorized subsidiary personnel performing duties in support of professional health care services include:

Nurse aides 2. Dietary 3. Housekeeping and maintenance To assure the provision of adequate nursing services, each intermediate nursing care facility must provide sufficient:
Numbers and categories of personnel, as determined by the number of clients in the facility and their particular nursing care needs. This determination is made in accordance with accepted policies of effective nursing care and with these regulations.
Nursing and auxiliary personnel are employed and assigned to duties on the

basis of their qualifications or experience to perform designated duties.

Bedside care under direction of the client's physician in the presence of minor illness and for temporary periods to include nursing service provided by, or supervised by, a professional nurse or licensed practical nurse.

An intermediate care facility may, at its option, secure the services of a pharmacy consultant. If such facility takes this option, the provisions of rule item 2 are applicable.

8.409.3 CLINICAL RECORDS

8.409.31 MAINTENANCE

The following records, as a minimum, must be kept current, dated and signed, and must be made available for review if applicable:

Identification and summary sheets.
Hospital discharge summary sheet.
Medical evaluation and treatment plan.
Physician's orders.
Physician's progress notes.
Nurse's progress notes.
Medication and treatment record.
Laboratory and X-ray reports.
Consultation reports.
Dental reports.
Social Service notes.
Pharmacy Consultant's notes.

8.409.32 RETENTION OF RECORDS

Files retained at least six (6) years. (Before destruction of records, however, the nursing home's legal counsel should be consulted.)
In the event that a patient is transferred to another health facility, certain transfer information should be incorporated in a record to accompany the patient. This information should include:

a. A transfer form of diagnosis;

b. Aid to daily living information;

c. Transfer orders;

d. Nursing care plan;

e. Physician's orders for care.

8.409.33 CONFIDENTIALITY OF RECORDS

Disclosed only to authorized persons.
Form APA 4, “Authorization for Release of Medical Information” shall be executed in duplicate (original to the nursing home medical record with a copy to the county department) at the time of admission. This form must be signed by the client, or the client's designated representative, parent (if a minor), guardian, or other legally responsible person.

8.409.34 RECORDS ADMINISTRATOR

It is recommended that the Intermediate Health Care Facility have available:

A consultant who is a registered records administrator, or a person who is accredited as a records technician.
An employee who is trained or is receiving training in medical records management for accreditation as a records technician or a registered records administrator.

8.409.4 MEDICAL BASIS FOR CARE - INTERMEDIATE NURSING CARE

Eligible clients may be admitted to approved facilities only upon the certification of a physician licensed to practice in Colorado that there is a functional need for such admission. The client's freedom of choice of physician shall be respected. Health care of the client must continue under the supervision of a physician. The facility must have a physician available for necessary medical care in case of emergency.

8.409.41 PHYSICIANS' INVOLVEMENT

8.409.42 DETERMINATION FOR INTERMEDIATE NURSING CARE

The medical need of a client for Intermediate Nursing Care shall be delineated in the plan of treatment and substantiating orders written by the physician and by the performance of the necessary Intermediate nursing services implementing such plans and orders.

Upon admission to an Intermediate Nursing Care Facility, the facility must obtain for the medical record of each such client:

A summary of the course of treatment by the attending physician or which was followed in the hospital, the diagnosis(es) and current medical findings, and the rehabilitation potential.
An evaluation by the physician. Physical examination must be accomplished within 48 hours of admission and recorded, unless such an examination has been accomplished within five days prior to admission to the Intermediate Nursing Care Facility.
Physician's Orders. Orders must be written for the immediate care of the client.

The physician's treatment plan. The plan must be written and must be directed towards maintaining the health status of the client, preventing further deterioration of the physical well-being of the client, and preparing the client for normal noninstitutional life. The plan must be reviewed consistent with the continuing professional care by the physician, and revised as necessary, and must include medication and treatment orders which will be in effect for the specified number of days indicated by the physician. This period shall not exceed ninety (90) days unless reordered in writing by the physician. Telephone orders may be accepted by licensed nurses, but must be written into the clinical record by the receiving nurse. These orders must be countersigned by the ordering physician within 48 hours. The medical necessity for a physician's visit, at least once every quarter, must be evidenced in the clinical record by a valid signed entry.
Plan for Emergency Care. Each Intermediate Nursing Care Facility must provide for one, or more, physicians to be available to furnish emergency medical care, or surgical procedures, if the attending physician is not immediately available. A schedule listing the name, telephone number, and days on call for a given physician will be posted at each nursing station. An RPN or LPN must be on call (for availability to handle emergencies; to contact the physician, receive orders or medications) for all shifts other than the day shift. The Intermediate Nursing Care Facility must also establish procedures which will be followed in the emergency care of the client, the persons to be notified, and the reports to be prepared.

8.409.43 PHYSICIANS' INVOLVEMENT REDETERMINATION FOR

INTERMEDIATE NURSING CARE

The medical need of the client for Intermediate Nursing Care shall be redetermined every six months or at the time of the physician's required quarterly visit if the client's condition has changed.

The term “substantial change” does not encompass short-term treatment regimens for temporary illness, adjustments to prescribed medications when the frequency and dosage is not affected, or changes to be in effect for less than a thirty (30) day period.

8.409.5 MEDICAL REVIEW AND MEDICAL INSPECTION - INTERMEDIATE

CARE NURSING CLIENTS

Medical review of the treatment of all clients in intermediate nursing care facilities who are entitled to medical assistance will be accomplished annually.

8.409.51 MEDICAL REVIEW TEAM

8.409.52 COMPOSITION AND MEMBERSHIP REQUIREMENTS

The medical review team for intermediate nursing clients shall be composed of one or more nurses and other appropriate health and social service personnel as indicated and will function under the supervision of a physician.

No member of the team may be employed by or have financial interest in any nursing home. No physician member of a team may inspect the care of patients for whom he is the attending physician.

8.409.53 FUNCTION - MEDICAL REVIEW AND EVALUATION

The medical treatment of intermediate nursing facility clients entitled to medical assistance shall be reviewed at least annually.
Annual review consists of an evaluation of the treatment, utilizing the medical record and physical contact with, and observation of, each client in the nursing facility surroundings. This review, at a minimum, will elicit:

a. Medical necessity for visit by attending physician at least once every calendar quarter.

b. Adequacy in quality and quantity as well as the timeliness of treatment to meet health needs.

c. Adherence to the written physician's treatment plan.

d. Review of prescribed medications by the attending physician at least every ninety (90) days during the necessary client visit.

e. Tests, or observations of clients, indicated by their medication regimen have been made at appropriate times and properly recorded.

f. Physician, nurse, and other professional staff progress notes are made as required, and appear to be consistent with observed condition of the client.

g. Adequate services are being rendered to each client as shown by such observations as cleanliness, absence of decubiti, absence of signs of malnutrition or dehydration, and apparent maintenance of optimal physical, mental, and psychosocial function.

h. Client's need for any service not available in, or actually being furnished by the particular facility, or through arrangements with others.

i. Each client actually needs continued placement in the facility, or there is an appropriate plan to transfer the client to an alternate method of care.

8.409.54 REPORTS

Review reports of care in each facility are submitted to the Department.

a. After review copies are forwarded to:

The intermediate care facility.
The intermediate care facility Utilization Review Committee.
CDPHE.

Reports will cover observations, conclusions, and recommendations with respect to adequacy and quality of client services in the facility, and of physician services to clients in the facility. They will also cover specific findings with respect to individual clients and any recommendations resulting therefrom.

8.409.55 STATE DEPARTMENT ACTION

Reports submitted as a result of Medical Review may result in decisions to reclassify clients into a different level of care, or recommendations for modification of treatment.

Such decisions or recommendations will be transmitted as appropriate to the:

a. Attending physician.

b. Administration of the Intermediate Nursing Care Facility.

c. County department responsible for the client.

Changes in classification recommended will be made prior to the next billing period.

8.409.56 REVIEW OF STATE DEPARTMENT ACTION

8.415 ROLE OF COUNTIES AND NURSING FACILITIES

.10 ROLE OF THE COUNTY DEPARTMENT OF SOCIAL/HUMAN SERVICE STAFF

IN NURSING FACILITY PLACEMENTS

The County Department of Social/Human Services shall be responsible for the following in all nursing facility placements involving either clients of medical assistance or applicants for assistance:

A. The determination of existing or potential eligibility for medical assistance.

B. The referral, whenever possible, of all Medicaid eligible clients/applicants who are eligible for Medicare benefits to facilities certified for participation in the Medicare Program.

C. In those instances in which an individual residing in a nursing facility under some method of reimbursement other than Medicaid makes application for medical assistance, the county must provide notice of the application referral date to both the nursing facility and the Utilization Review Contractor.

Such notice must be provided verbally to both the facility and the Utilization Review Contractor within two (2) working days of the application referral date.
Written notice must be mailed to the facility within five (5) working days.
Such notice is critical to the timely conduct of admission review by the D. In those instances where eligibility is determined to be effective three months prior to the date of application pursuant to Department rules and regulations, the County Department of Social/Human Services shall notify the nursing facility of this circumstance in writing.

This should be written in the area reserved for comments in Section VI(5) of the Form AP-5615. Similar verbal or written notice must be given or mailed to the Utilization Review Contractor, utilizing a format as determined by the .11 The Form AP-5615 is intended as a method for communicating the status of a resident or applicant, or actions which change that status, between nursing facility, the County Department of Social/Human Services, and the Department.

Examples of such actions are admission, discharge, readmission, death or changes in resident income. Failure to complete the AP-5615, or to properly verify information reported thereon in a timely fashion, results in inappropriate reimbursement to nursing facilities, inequitable assistance payments, and the loss of documentation necessary for Department field audit staff. Upon receipt of Form AP-5615, the County Department of Social/Human Services shall be responsible for the following.

A. Verify, correct, and complete, when necessary, the client/applicant's name, State ID number, and all other identifying data:

B. Verify client/applicant income. Such verification must occur on a regular

basis. All income of the client which is in excess of the amount reserved for personal needs allowance, less earned income (if appropriate), less spousal and dependent care allowance, and less home maintenance allowance, and any other applicable changes to patient payment per Sections 8.100.5.E. through 8.100.7.V., must be applied by the client/applicant toward their care or retained within an income trust as required under applicable regulations. Changes in income must be reflected in submission of a new eligibility reporting form and a new AP- 5615.

C. Calculation of Patient Payment. Other medical and remedial expenses covered under the nursing facility PETI must be preapproved by the Department. Nursing facility PETI-approved expenses are allowed only for residents with a patient payment but do not change the patient payment amount. For nursing facility PETI, see Sections 8.482.33 and 8.100.7.V.3.)

The Department may make an exception for:

Hospice related PETI-IME adjustments.
Resolution of appeals related to patient liability or PETI-IME adjustments.

D. Verify client payment. This amount must be calculated by per diem appropriately in all months for which Medicaid reimbursement covers less than a full month's care.

Client payment may be waived and zero (-0-) client payment applied only under the conditions as defined in Section 8.482.34.D.1.
Client payment may not be waived (other than for the exceptions provided for in Section 8.415.11.C.1), in the instances defined in

Section 8.482.34.D.2.

When client payment is calculated by per diem, the amount shown on the AP-5615 will be that amount to be paid by the resident, rather than the amount to be calculated by per diem calculation.
Corrections to income or client payment shall be initialed and dated by the income maintenance technician from the County Department of Social/Human Services.

E. Review the date of action, such as admission, readmission, discharge, death, or change in client payment being reported and verify as necessary;

F. Indicate approval or denial of action being reported and effective date of that approval or denial; and G. Sign and date all copies. Provide a copy to the facility and the Department at HCPF_LTC_FinCompliance@state.co.us.

8.415.20 RESPONSIBILITY OF THE NURSING FACILITY IN NURSING FACILITY

PLACEMENTS

These rules set forth the administrative procedures that must be followed by nursing facilities. Failure of the facility to meet the requirements set forth herein will result in denial of reimbursement.

A. Admission When an admission to the nursing facility is proposed, it is the responsibility of the nursing facility to:

Determine, prior to an applicant's admission, whether or not the individual is a member or has applied for medical assistance;
Complete the ULTC 100.2 prior to or on the day of admission. Based on this information, the Utilization Review Contractor will determine the level of care and assign an initial length-of-stay.
For purposes of this regulation, admission is defined as a. any new admission; or b. any change from other sources of reimbursement to the Medical Assistance program.

B. Changes in Resident Status Form AP-5615 shall be used by the nursing facility to notify the County Department of the current or changed status of all members and applicants residing within the nursing facility.

The nursing facility shall initiate Form AP-5615 for all admissions, readmissions, transfers from private pay or Medicare, discharges, deaths, changes in resident income, and leaves of absence; and shall submit copies to the responsible county and the Department at 2. The nursing facility is solely responsible for collecting the correct amount of client payment due from the resident, the family, or representatives.

Failure to collect client pay, in whole or in part, shall not allow the nursing facility to bill the Medical Assistance Program for the uncollected client 3. The county department may initiate the AP-5615 when appropriate, which may include, but is not limited to, changes in resident income of which the county becomes aware.

C. Transfer and Discharge The nursing facility must determine that all requirements for an orderly transfer or discharge are met before relinquishing their responsibility to the resident. This is necessary in order to assure continuity of total care. Therefore, the nursing facility is responsible for following the procedures as outlined at section C.R.S. section 25-1-120 et. seq, entitled “Nursing and intermediate care facilities - rights of patients”, including the section on grievance procedures.

8.420 REQUIREMENTS AND PROVISIONS FOR PARTICIPATION BY COLORADO

NURSING FACILITIES

Prior to receiving reimbursement from the Department, nursing facility must be enrolled as a Medicaid provider. . For the purposes of this section, the term “nursing facility” includes an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

Nursing facilities are required to maintain proper accountings of resident personal needs accounts as provided in Section 8.482.5.

8.421 RESPONSIBILITY OF COUNTY DEPARTMENT CONCERNING

PARTICIPATION

It shall be the responsibility of each county department to inform the State Department whenever it is aware that:

A licensed nursing home has permanently discontinued or decreased the qualified nursing service under which it was licensed.

Any person is operating an unlicensed nursing home or violating terms of license for a nursing home in which there are three or more recipients not related to the owner, and is providing any nursing service in an unlicensed home or one with a limited license to such recipients in addition to board and room services.

Any other condition exists which operates to the detriment of the patients in the home.

This would include observation by the county department of such things as uncleanliness, poor or inadequate food, safety hazards, overcrowding, poor or inhumane treatment of patients, etc.

8.422 VISITS TO RECIPIENTS BY SOCIAL SERVICES PERSONNEL, PRIVACY FOR

CONFERENCES WITH RECIPIENTS

In order to maintain continuing eligibility to recipients, to provide necessary services to recipients, and to conduct other official business pertaining to nursing home payment, the nursing home is required to admit duly authorized representatives of the Colorado Department of Human Services or County Department of Social/Human Services at any reasonable time. Social Services personnel shall be afforded privacy for conferences with nursing home recipient/patients. All such information is considered in terms of the rules contained in the Income Maintenance Manual.

8.423 VISITS TO RECIPIENTS BY THE COLORADO LONG-TERM CARE

OMBUDSMAN AND DESIGNATED REPRESENTATIVES

A. Definitions:

Designated Representatives - are persons who have been specifically appointed by the Colorado Ombudsman to be an official part of the statewide ombudsman program.

Such designated representatives shall receive a minimum of twenty (20) hours of training using the manual provided by the Colorado Long-term Care Ombudsman Program as well as other materials. Included in this training shall be material regarding the rights of patients and specifically procedures which protect the confidentiality of information regarding Medicaid patients.

Official Colorado Ombudsman Program - the agency which has received the Ombudsman grant from the Older Americans Act through the Colorado Department of Human Services is for purposes of this regulation considered to be the official State Ombudsman Program.

B. The Colorado Ombudsman and designated representatives shall have access to the physical premises of nursing home facilities and the Medicaid residents of these facilities. Visits to the nursing home should be during reasonable hours except in instances where the nature of a complaint investigation requires visitation during off hours.

All designated representatives (after they have completed the necessary training) will be provided with identification showing them to be a part of the State Ombudsman Program. Under normal circumstances such identifications will be presented to the nursing home administrator or person in charge during the administrator's absence.

C. The Colorado Ombudsman or designees shall only disclose information received from a Medicaid patient's records and/or files when:

The Ombudsman authorizes the disclosure and 2. In cases of identifying a patient, the patient or the legal representative of the patient must consent in writing to the disclosure and specify to whom the identity may be disclosed or 3. A court orders the disclosure.

D. Non-compliance with the provisions of this Section of the regulation will not be considered sufficient good cause as defined in Section 8.130.4.

8.424 PERIODIC VISITS OR REQUESTS FOR DOCUMENTATION - NURSING

HOME RECORDS TO BE MADE AVAILABLE

Staff of the county Department of Health and Human Services, the staff of the State Department of Human Services, the staff of the Colorado Department of Public Health and Environment or contractors of said Department or members of the Medicaid Fraud Control Unit, may make periodic visits and request documentation to nursing facilities for purposes of determining compliance with applicable regulations and to determine the appropriate rate to be paid to the facility , and for other purposes as may be authorized for the administration of the Colorado Medical Assistance Program.

All medical and financial records and documents related to the above purposes shall promptly be made available to the Department.

“Closing” The Department will conduct an audit when there is a pending change of ownership in order to determine whether payment adjustments or recoveries are necessary pursuant to Section 8.443.15 Change of Ownership, Change in Tax ID or Withdrawal from Medicaid.

8.430 MEDICAID CERTIFICATION OF NEW NURSING FACILITIES OR ADDITIONAL

BEDS

8.430.A DEFINITIONS

Action” means denial or approval of the application or request for additional information regarding an application.
Case-mix group” means the system determined by the Department for grouping a nursing facility’s residents according to their clinical and functional status as identified from data supplied by the facility’s minimum data set as published by the United States Department of Health and Human Services.
Existing Colorado nursing facility” means a facility licensed by the Colorado Department of Public Health and Environment (CDPHE) and Medicaid certified by the Colorado Department of Health Care Policy and Financing (“Department”) as of June 30, 2021.
Financially solvent” means the ability of a company, that owns one or more nursing facilities, to meet its long-term financial obligations, as verified by independent audited financial statements.
Green House or green house like” is a model of skilled nursing facility care that prioritizes a home-like environment and promotes resident autonomy and person-centered care. These homes typically house 10-16 residents.

Staff are trained to provide comprehensive care including cooking, cleaning and assisting with daily activities.

Licensed bed capacity” means the licensed bed capacity of a nursing facility on file with Colorado Department of Public Health and Environment (CDPHE).
Measurable innovative practices” mean observable and/or verifiable design and/or programmatic features that demonstrate a person-centered approach, industry-recognized best practices, and incorporate achievable measurable goals. Examples of measurable innovative practices may include but are not limited to:

a. Improvements in technology b. Access to private rooms.

c. Access to outdoor common areas.

d. Improvements to noise control features.

e. Lighting modifications that support safety and independence.

f. General features that promote safety and independence.

g. Air quality/airflow measures that serve to prevent infections.

New nursing facility” means a facility not licensed and Medicaid certified as a Colorado nursing facility as of June 30, 2021.
Per diem rate” means the daily dollar amount of reimbursement that the Department pays a nursing facility provider per patient.
Special focus facility” means a nursing facility that has a history of serious quality issues or is included in the Centers for Medicare & Medicaid Services (CMS) program to stimulate improvements in the nursing facility’s quality of care.

8.430.2 APPLICABILITY 8.430.2.A. Section 8.430 applies to all nursing facilities except:

A nursing facility that is currently Colorado Medicaid certified and experiences a change of ownership or a facility that is placed into receivership under the United States Bankruptcy Code and/or pursuant to C.R.S. § 25-3-108.
A nursing facility exclusively serving the developmentally disabled (intermediate care facility for individuals with intellectual disabilities (ICF/IID) and home and community- based services for the developmentally disabled group homes).
A replacement facility for existing residents in a facility owned/operated by the applicant. Approval for the replacement facility shall only be granted if the conditions in subparagraphs a. through e., are met.

a. The applicant clearly documents that the old structure was substantially inadequate to efficiently and effectively provide quality of care for the residents.

b. The replacement facility is located no more than five miles from the original facility, or 15 miles if the original facility is in a rural community.

c. If the facility is the only Medicaid certified facility in the county, the replacement facility shall have no distance limitation, but must be in the same county d. Residents living in the original facility at the time it is closed are given the right of first refusal for beds in the replacement facility.

e. The replacement facility has measurable innovative practices and design features exceeding that of the current facility.

8.430.3 NEW NURSING FACILITY CERTIFICATION 8.430.3.A. Procedures and Criteria for Medicaid Certification of a new nursing facility 1. The burden of demonstrating the need for a new Medicaid facility shall be on the applicant.

The applicant for Medicaid certification of a new nursing facility shall:

a. File a letter of intent to apply for certification with the Department in January or July of the year in which the application will be filed.

The letter of intent shall specify:

i. The person or corporation that will submit the application.

ii. The proposed geographic service area.

iii. The number of beds in the new facility for which Medicaid approval will be requested.

b. No later than five months from the date of filing the letter of intent, the applicant shall submit a complete application. The application shall include:

i. The name, address and telephone number of the person or corporation requesting approval for the new nursing facility.

ii. The total number of proposed beds and the number of beds requested for Medicaid certification.

iii. A description of the geographic service area and justification that the service area can be reasonably served by the new nursing facility.

iv. If construction of the additional beds or the new nursing facility has not been completed by the date the application is filed, the following documentation shall also be provided:

Official written documentation showing ownership of the proposed new nursing facility.
Location of the proposed new nursing facility including documentation of ownership, lease, or option to buy the land on which the facility is being built.
Documentation from a financial institution regarding financing support for the new nursing facility.
Complete, written documentation that preliminary architectural plans for the proposed new nursing facility have been submitted to CDPHE.
Expected completion date of the new nursing facility.

v. A statement regarding any previous contracts with or enrollment in any and all state Medicaid programs. The statement shall assure that the applicant has never been found guilty of fraud or been decertified or terminated from participation in the Medicaid program in Colorado or any other state.

A completed application will be made available on the Department's website for public review and comment. In addition, the applicant must submit a local public newspaper notice published for 30 days within the service area defined in the application at the applicant's expense. The applicant must provide a copy of the newspaper notice after the application has been posted for public review. A public hearing on the application may be conducted by the Department.
Facilities facing enhanced oversight or designated as a special focus facility or special focus facility candidate are not eligible for Medicaid 5. Approval or denial of an application for Medicaid certification of a new nursing facility is based on all the following information from the applicant:

a. Planned resident capacity and payer mix.

b. Planned measurable innovative practices of the proposed new facility from existing nursing facilities in the same geographic service area.

c. Demographic analysis of the applicant's designated service area, including review of State demography data and a market analysis of other available long-term care services, e.g., assisted living, home health, home and community-based services, etc., and the extent to which such alternative services are utilized.

d. Projections of net patient revenue and operating costs.

e. The Department may request additional financial documentation as necessary, including but not limited to:

i. A statement from an actuary, certified public accountant, or financial firm indicating that applicant will be able to remain financially solvent for a time period of no less than 36 months post certification.

ii. Financial declaration used to obtain loans associated with the facility.

iii. Audited financial statements for the most recently closed fiscal year for the individual or corporation seeking Medicaid f. Historical information concerning the quality of care and survey compliance in other nursing facilities owned or managed by the applicant or a related entity or individual.

g. Facilities facing enhanced oversight or designated as a special focus facility or special focus facility candidate are not eligible for Medicaid certification.

h. A statement assuring cooperation with de-institutionalization and community placement efforts.

i. Documentation of whether the proposed new facility provides needed beds to an underserved geographic area, as described in

Section 8.430.3.A.5.j.i., or to an underserved special population, as described in Section 8.430.3.A.5.j.ii.

i. To qualify as an underserved geographic area of the state, the application must demonstrate, with appropriate documentation, that:

The new nursing facility is located in the service area defined by the application. The service area must be no smaller than one full county. The service area shall be no more than two contiguous counties in the state.
The service area shall have a nursing facility bed to population ratio of less than 40 beds per 1,000 persons over the age of 75 years.

a) The population projections shall be based upon statistics issued by the State Department of Local Affairs.

b) The applicable statistics for applications involving beds for which construction is complete at the time of application shall be the population statistics for the period including the date on which the application is filed.

c) The applicable statistics for applications involving beds for which construction is not complete at the time of application shall be the population projections for the expected date of completion of the beds set forth in the application.

d) The service area ratio will exempt Colorado Veterans Community Living Centers and include only beds generally available to the public.

j. An application for a new nursing facility to serve an underserved special population shall contain the following information and documentation:

A description of the special populations to be served and why they cannot be served in the community.
Justification for the service area to be served.
A determination of whether there are existing excess beds in the proposed service area and, if so, why the existing excess beds cannot be used by or converted for use by the special populations.

a) The determination of existing excess beds shall include a population ratio analysis and occupancy analysis as set forth in Section 8.430.3.A.5.j.i., and shall be calculated by utilizing the formulas, methods and statistics set forth therein.

b) The justification of why existing excess beds cannot be used for or converted for use by the special populations(s) must be clearly demonstrated and supported by relevant and competent evidence.

Applications based on an underserved special population must document the special population of clients who have been certified for a hospital level of care in accordance with

Section 8.470 is underserved in the proposed service area.

The Department will verify the need using utilization records, hospital backlogs, and historical admission denials.

The following requirements may also apply to approval of new nursing facilities for special populations:

a) The Statewide Utilization Review Contractor (URC) shall certify long-term care prior authorization requests for Medicaid clients who are verified as meeting the special populations definitions provided in

Section 8.430.3.A.5.j.ii.4.

b) In the case of applications for approval of new nursing facilities for individuals with intellectual or developmental disabilities, all restrictions concerning Medicaid reimbursement described at Section 8.401.41 et seq., uidelines for Institutions for Mental Disease (IMDs), shall apply.

A bed approved for a specific underserved special population shall not be used for any other population, even if a Medicaid client occupying this type of bed is discharged or experiences a change in physical condition which requires transfer to a general skilled nursing unit bed.

a) The Department may authorize an additional number of beds for individuals transitioning in/out of the specific special need or to support solvency of the special population program.

b) The Department’s approval or denial determination will be communicated through Operational Memos.

8.430.4 COMPLETION OF APPROVED NURSING FACILITY 8.430.4.A. Construction of approved nursing facilities shall adhere strictly to the specifications provided in the application. A new application shall be submitted and shall be subject to the criteria for approval in effect at the time of the new application when any of the following changes apply to the new facility with approved Medicaid beds:

Persons or corporations which have ownership.
The site upon which the new facility will be constructed.
Proposed geographic service area.
Condition under which approval of facility is requested with reference to underserved geographical or underserved population criteria in accordance with Section 8.430.3.A.5.j. 8.430.4.B. The applicant shall complete the project within 60 months of the date of the Department's approval of the application. The Department may authorize one extension of up to 30 months if the applicant can show a good faith effort towards completion of the project. 8.430.4.C. No extension beyond the 90-month period shall be considered unless completion of the project is delayed for reasons beyond the applicant's control.
The following shall be considered reasons beyond the applicant's control:

a. Natural disasters.

b. Hazardous soil or water conditions documented by local authorities and unknown to applicant at time of acquisition of the property.

c. Fires or explosions at the construction site serious enough to substantially delay the project.

d. Public health emergency.

The following shall not be considered beyond the applicant's control:

a. Lack of financing or changes in need for financing.

b. Delays due to litigation.

c. Construction delays (examples of construction delays which would not be granted an extension: weather, management-labor problems, subcontractor missed deadlines, permit or zoning variance problems). 8.430.4.D. Applicants who complete the project within the 60-month period or any extension period are eligible for a Medicaid provider agreement so long as the facility is inspected on-site and found by CDPHE to be in compliance with standards for licensure as a nursing facility and certification for Medicaid participation and so long as the applicant meets all other conditions of participation. 8.430.4.E. When two or more applications for the same service area or special population are received in the same application period, the Department will select the applicant that demonstrates the more measurable innovative practices.

8.430.6 LIMITED MEDICAID CERTIFICATION 8.430.6.A. Non-Medicaid certified facilities may designate up to five beds for Medicaid members for the purpose of minimizing transfer trauma, coordinating transfers, and accommodating long term residents of the facility that have outlived their third-party coverage or ability to privately pay for room and board.

Facilities will not be considered Medicaid certified and not subject to the criteria in 8.430.3 New Medicaid Certification.
Facilities seeking to add up to the allowable five beds shall submit a Provider Enrollment letter requesting the beds to the Department.
Facilities seeking more than the allowable five beds must comply with the application process in Section 8.430.

8.435 ENFORCEMENT REMEDIES RELATED TO SURVEY DEFICIENCIES

8.435.1 DEFINITIONS

Civil Money Penalty (CMP) means any penalty, fine or other sanction for a specific monetary amount that is assessed or enforced by the Department for a Class I non- State-operated Medicaid-only Nursing Facility or by the Centers for Medicare and Medicaid Services (CMS) for all other Class I nursing facilities.

Enforcement Action means the process of the Department imposing against a Class I non-State operated Medicaid-only nursing facility one (or more) of the remedies for violation of federal requirements for participation as a nursing facility enumerated in the Federal Omnibus Reconciliation Act of 1987, 1989, and 1990, 42 U.S.C. 1396r(h), which is hereby incorporated by reference. The incorporation of 42 U.S.C. 1396r(h) excludes later amendments to, or editions of, the referenced material. The Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated Nursing Home Innovations Grant Board means a board authorized by C.R.S. section 25-1-107.5 (2013) to distribute funds from the nursing home penalty cash fund for measures that will benefit residents of nursing facilities by improving their quality of life at the facilities.

Grantee means a recipient of funds from the Nursing Home Penalty Cash Fund for measures that will benefit residents of nursing facilities by improving their quality of life as specified in 10 CCR 2505-10 section 8.435.2.E.4.b.

Immediate Jeopardy means a situation in which the nursing facility’s non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident.

Medicaid-Only Nursing Facility means a nursing facility that is reimbursed by Medicaid, but not Medicare.

Nursing Home Penalty Cash Fund means the account that contains the money collected from CMPs imposed by the Department and also the amount transmitted by CMS from CMPs imposed by CMS. CMS computes the amount to be transmitted, the Medicaid portion, by applying the percentage of Medicaid clients in the nursing facility to the total CMP amount.

8.435.2 GENERAL PROVISIONS 8.435.2.A. The Department enforces remedies for Class I Non-State-Operated Medicaid-Only Nursing Facilities. Remedies for all other Class I nursing facilities are enforced pursuant to 42 C.F.R. section 488.330. Class I nursing facilities are subject to one or more of the following remedies when found to be in substantial non-compliance with program requirements:

Termination of the Medicaid provider agreement.
Civil Money Penalty (CMP).
Denial of payment for new admissions of Medicaid clients.
Temporary management.
Transfer of residents.
Transfer of residents in conjunction with facility closure.
The following three remedies with imposition delegated to CDPHE:

a. State monitoring.

b. Directed plan of correction.

c. Directed in-service training. 8.435.2.C. The Class I non-State-operated Medicaid-only nursing facility will receive a Notice of Adverse Action from the Department. The appeal procedures set forth at Section 8.050 apply. 8.435.2.D. Enforcement Actions for Class I nursing facilities 1. Termination of the Medicaid provider agreement:

a. Shall be effective within 23 days after the last day of the survey if the nursing facility has not removed the Immediate Jeopardy as determined by the Colorado Department of Public Health and Environment (CDPHE).

b. May be rescinded by the Department when CDPHE notifies the Department that an Immediate Jeopardy is removed.

Denial of payment for new Medicaid admissions will end on the date CDPHE finds the nursing facility to be in substantial compliance with all participation requirements.

a. If substantial compliance is achieved before the denial of payment effective date, the denial of payment will be rescinded.

b. If substantial compliance is not achieved before the denial of payment effective date, the denial of payment will stop as of midnight on the date determined by CDPHE.

(1) Medicaid monies paid to the nursing facility for any resident admitted during the denial of payment effective period is subject to recoupment by the Department.

Civil Money Penalty (CMP)

a. CMPs are effective on the date the non-compliance began.

b. If the nursing facility waives its right to an appeal in writing within 60 calendar days from the date the CMP is imposed, the CMP shall be reduced by 35%, notwithstanding the provisions of Section 8.050.

c. The CMP shall be submitted to the Department or the federal Centers for Medicare and Medicaid Services (CMS) as defined by the adverse action notification.

d. Payment of CMP shall not be an allowable cost on the nursing facility’s annual Med-13 cost reports as described in Section 8.441.

8.440 NURSING FACILITY BENEFITS

A. Special definitions relating to nursing facility reimbursement:

“Acquisition Cost” means the actual allowable cost to the owners of a capital-related asset or any improvement thereto as determined in accordance with generally accepted accounting principles.
“Actual cost” or “cost” means the audited cost of providing services.
“Administration and General Services Costs” means costs as defined at

Section 8.443.8.

“Appraised value” means the determination by a qualified appraiser who is a member of an institute of real estate appraisers, or its equivalent, of the depreciated cost of replacement of a capital-related asset to its current owner. The depreciated replacement appraisal shall be based on the valuation system as determined by the Department.

a. The depreciated cost of replacement appraisal shall be redetermined every four years by new appraisals of the nursing facilities. The new appraisals shall be based upon rules promulgated by the state board.

“Array of facility providers” means a listing in order from lowest per diem cost facility to highest for that category of costs or rates, as may be applicable, of all Medicaid-participating nursing facility providers in the state.
“Base value” means:

a. The appraised value of a capital-related asset for the fiscal year 1986-87 and every fourth year thereafter.

b. The most recent appraisal together with fifty percent of any increase or decrease each year since the last appraisal, as reflected in the index, for each year in which an appraisal is not done pursuant to subparagraph (a) of this paragraph (1).c. For the fiscal year 1985-86, the base value shall not exceed twentyfive thousand dollars per licensed bed at any participating facility, and, for each succeeding fiscal year, the base value shall not exceed the previous year’s limitation adjusted by any increase or decrease in the index.

d. An improvement to a capital-related asset, which is an addition to that asset, as defined by rules adopted by the state board, shall increase the base value by the acquisition cost of the improvement.

“Capital-related asset” means the land, buildings, and fixed equipment of a participating facility.
“Case-mix” means a relative score or weight assigned for a given group of residents based upon their levels of resources, consumption, and needs.
“Case-mix adjusted direct health care services costs” means those costs comprising the compensation, salaries, bonuses, workers’ compensation, employer-contributed taxes, and other employment benefits attributable to a nursing facility provider’s direct care nursing staff whether employed directly or as contract employees, including but not limited to DONs, registered nurses, licensed practical nurses, certified nurse aides and restorative nurses.
“Casemix index” means a numeric score assigned to each nursing facility resident based upon a resident’s physical and mental condition that reflects the amount of relative resources required to provide care to that 11. “Casemix neutral” means the direct health care costs of all facilities adjusted to a common case-mix.
“Casemix reimbursement” means a payment system that reimburses each facility according to the resource consumption in treating its case-mix of Medicaid residents, which case-mix may include such factors as the age, health status, resource utilization, and diagnoses of the facility’s Medicaid residents as further specified in this section.
“Class I nursing facility provider” means a private for-profit or not-for-profit nursing facility provider or a facility provider operated by the state of Colorado, a county, a city and county, or special district that provides general skilled nursing facility care to residents who require twenty-fourhour nursing care and services due to their ages, infirmity, or health care conditions, including residents who are behaviorally challenged by virtue of serious mental illness or dementia. Swing bed facilities are not included as Class I nursing facility providers.
“Core Component per diem rate” means the per diem rate for direct and indirect health care services costs, administrative and general services costs, and fair rental allowance for capital-related assets for Class 1 nursing facility providers.
“Direct health care services costs” means those costs subject to case-mix adjusted direct health care services costs.
“Direct or indirect health care services costs” means the costs incurred for patient support services as defined at Section 8.443.7.
“Facility population distribution” means the number of Colorado nursing facility residents who are classified into each Case-Mix group as of a specific point in time.
“Fair rental allowance” means the product obtained by multiplying the base value of a capital-related asset by the rental rate.
“Improvement” means the addition to a capital-related asset of land, buildings, or fixed equipment.
“Index” means the RSMeans construction systems cost index or an equivalent index that is based upon a survey of prices of common building materials and wage rates for nursing home construction.
“Index maximization” means classifying a resident who could be assigned to more than one category to the category with the highest case-mix index.
“Median per diem cost” means the daily cost of care and services per patient for the nursing facility provider that represents the middle of all of the arrayed facilities participating as providers or as the number of arrayed facilities may dictate, the mean of the two middle providers.
“Medicare patient day” means all days paid for by Medicare. For instance, a Medicare patient day includes those days where Medicare pays a Managed Care Organization for the resident’s care.
“Minimum data set” means a set of screening, clinical, and functional status elements that are used in the assessment of a nursing facility provider’s residents under the Medicare and Medicaid programs.
“MMIS per diem reimbursement rate” means the per diem rate used for Medicaid Management Information Systems (MMIS) claims-based reimbursement.
“Normalization ratio” means the statewide average case-mix index divided by the facility’s cost report period case-mix index.
“Normalized” means multiplying the nursing facility provider’s per diem case-mix adjusted direct health care services cost by its case-mix index normalization ratio for the purpose of making the per diem cost comparable among facilities based upon a common case-mix in order to determine the maximum allowable reimbursement limitation.
“Nursing facility provider” means a facility provider that meets the state nursing facility licensing standards established pursuant to C.R.S. §25- 1.5-103 and is maintained primarily for the care and treatment of inpatients under the direction of a physician.
“Nursing salary ratios” means the relative difference in hourly wages of registered nurses, licensed practical nurses, and nurse’s aides.
“Nursing weights” means numeric scores assigned to each category of the Case-Mix groups that measure the relative amount of resources required to provide nursing care to a nursing facility provider’s residents.
“Occupancy-imputed days” means the use of a predetermined number for patient days rather than actual patient days in computing per diem cost.
“Per diem cost” means the daily cost of care and services per patient for a nursing facility provider.
“Per diem fee” means the dollar amount of provider fee that the Department shall charge a nursing facility provider per non-Medicare day.
“Provider fee” means a state imposed fee on nursing facilities used to fund Medicaid.
“Raw food” means the food products and substances, including but not limited to nutritional supplements, that are consumed by residents.
“Rental rate” means the average annualized composite rate for United States treasury bonds issued for periods of ten years and longer plus two percent. The rental rate shall not exceed ten and three-quarters percent nor fall below eight and one-quarter percent.
“Statewide average per diem rate” means the average per diem rate for all Medicaid-participating nursing facility providers in the state.
“Substandard Quality of Care” means one or more deficiencies related to participation requirements under 42 C.F.R § 483.12 Freedom from abuse, neglect, and exploitation, 42 C.F.R. § 483.24 Quality of life, or 42 C.F.R. § 483.25, Quality of care that constitute either immediate jeopardy to resident health or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm. 42 C.F.R § 483.12, 42 C.F.R. § 438.24, and 42 C.F.R. § 483.25 are hereby incorporated by reference. This regulation is available from the federal Government Printing Office at www.gpo.gov. The incorporation of 42 C.F.R § 483.12, 42 C.F.R. § 438.24, and 42 C.F.R. § 483.25 excludes later amendments to, or editions of, the referenced material. The Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 303 East 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.
“Supplemental Payment” means a lump sum payment that is made in addition to a nursing facility provider’s MMIS per diem reimbursement rate.

A supplemental Medicaid payment is calculated on an annual basis using historical data and paid as a fixed monthly amount with no retroactive adjustment.

8.440.1 SERVICES AND ITEMS INCLUDED IN THE PER DIEM PAYMENT 8.440.1.A. Payment to nursing facilities, swing-bed facilities and intermediate care Facilities for Individuals with Intellectual Disabilities shall be an all-inclusive per diem rate, except as provided for within this rule. This rate covers the necessary services to the resident, including room and board, as well as nursing and ordinary supplies and equipment related to the day-to-day care of the resident and the operation of the facility. 8.440.1.B. The following general service areas shall be provided within the per diem rate:

Nursing services, therapies, aide services and medically related social services;
Dietary services;
Activities program;
Room/bed maintenance services;
Routine personal hygiene items and services; and 6. Laboratory services performed by a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certified laboratory 8.440.1.C. Each nursing facility shall furnish, within the per diem rate, equipment necessary to the operation of the facility and provide for necessary medical, nursing, respiratory and rehabilitation care. Such equipment includes, but is not limited to, the following:
Adaptive equipment for activities of daily living;
Air mattresses, other special mattresses, sheepskins and other devices for preventing/treating decubitus ulcers;
Apnea monitors and necessary supplies and equipment;
Atomizers;
Autoclaves and sterilizers;
Bath equipment, i.e., raised and/or padded toilet seats, trapeze benches, tub/shower stools or benches;
Bedrails, footboards, trapeze bars, traction and fracture frames, bedside stands;
Bed linens;
Beds, including hospital beds;
Blood glucose monitors;
Commode chairs;
Deodorizers;
Emesis basins;
Flameproof curtains;
Flashlights;
Foot pumps;
Gerry chairs, cushioned chairs;
Ice bags or equivalent;
Intermittent positive pressure breathing equipment, including Sodium Chloride or sterile water required for operation;
Irrigating solutions, i.e., Acetic Acid, Potassium Permanganate, Sodium Chloride, and sterile water;
Lifts, i.e., hydraulic, tub, slings;
Lymphedema pumps and compressors;
Medically necessary manual or power wheelchairs for intermittent and fulltime use, including cushions and pads as required for the prevention or treatment of skin breakdown, if purchased by the nursing facilities.

a. Wheelchairs, if required, shall meet the specific needs of the resident and shall be ordered by a physician. The primary care physician shall concur that the wheelchair being prescribed for the resident is medically necessary.

b. All costs associated with the purchase of the wheelchair shall be charged to the health care line of the nursing facility. Wheelchair expenses shall be reported in the appropriate health care line of the MED-13.

c. The wheelchair shall be sent with the resident in the event the resident is transferred to another facility or returns home. The transferring facility shall expense the remainder of the chair in the fiscal year during which the transfer occurs.

Medicine cups;
Oxygen masks, regulators, humidifiers, hoses, nasal catheters, as needed, for the administration of oxygen;
Percussors and respirators;
Positioning pillows;
Reading lights;
Scissors, forceps, and nail files;
Sitz baths;
Sphygmomanometers, stethoscopes, and other examination equipment;
Splints;
Stryker pads;
Suction apparatus and gavage tubing;
Supplies and equipment necessary for delivery of special dietary needs;
Surgical stockings for routine use;
Ventilators and related equipment and supplies;
Walkers, crutches, canes and medically necessary accessories for ambulatory devices;
Weighing scales. 8.440.1.D. All supplies, including disposables, necessary for effective resident care shall be provided by the nursing facility within the per diem rate. Such supplies include, but are not limited to, the following:
Band-Aids, gauze pads, dressings and bandages;
Bedside utensils, bedpans, basins;
Catheters and related supplies, irrigating trays and accessories;
Charting supplies;
Colostomy and ileostomy bags, supplies, and dressings, ostomy supplies;
Disposable sterile nursing supplies including, but not limited to, cotton, face masks, gloves, tape, finger cots;
Drinking tubes/straws, water pitchers/glasses;
Fleece pads;
Foot soaks;
Hypodermic syringes and needles, including syringes and needles for insulin administration, intravenous supplies and equipment and related equipment;
Minor medical surgical supplies;
Miscellaneous applicators;
Nebulizers, recreational/therapeutic equipment and supplies to conduct on-going activities programs;
Safety pins;
Thermometers;
Tongue depressors;
Tracheostomy care kits, cleaning supplies;
Urinals, urinary bags, and tubes and supplies. 8.440.1.E. Routine personal hygiene items/services shall be provided by the nursing facility within the per diem rate. These items include, but are not limited to, hair hygiene services (i.e., simple trims, such as trimming bangs or cutting of some hair that may need minor cutting in the back) hair hygiene supplies (i.e., shampoo, hair conditioner, comb, brush); bath soap, disinfecting soaps or specialized cleaning agents when indicated to treat skin problems or to fight infection; razors, shaving cream; toothbrush, toothpaste, mouthwash, denture adhesive, denture cleanser, dental floss; moisturizing lotion; tissues, cotton balls, cotton swabs; deodorant) incontinence care and supplies (i.e., pads, cloth and disposable diapers, pants, liners, sanitary napkins and related supplies); towels, washcloths, and hospital gowns; bathing; shaving; nail hygiene services (i.e., routine trimming, cleaning and filing, not polishing). 8.440.1.F. Various over-the-counter (OTC) drugs and supplies as required to meet the residents' assessed needs shall be furnished by the facility, within the per diem rate, at no charge to the resident. OTC drugs/supplies including but not limited to:
Artificial tears;
Aspirin, acetaminophen, ibuprofen, and other non-prescription analgesics available now or in the future;
Cough and cold supplies, i.e., cold tablets, decongestants, cough syrup/tablets;
Douches;
Evacuant suppositories, laxatives, stool softeners, enemas;
First aid supplies, i.e., alcohol, hydrogen peroxide, Merthiolate and other antiseptics/germicides, Betadine, Phisohex, chlorhexidine gluconate, povidone/iodine solution and wash, Epsom salt;
Lubricants, rubbing compounds and ointments, i.e., petroleum jelly, bag balm, other body lotions for treatment of dry skin or skin breakdowns, bacitracin ointment and other ointments used in treatment of wounds;
Vitamins (multi and single) and mineral supplements. 8.440.1.G. The following services and provisions shall be provided by the facility within the per diem rate:
Food and dietary services, including special diets, supplements and nutrients ordered by the physician, in accordance with the needs of the residents and appropriate licensing requirements;
Room for accommodation of the resident in accordance with licensing requirements, including storage for personal belongings, bedside equipment, suitable bed, clean and comfortable mattress, pillows and an adequate supply of clean linen;
Maintenance of clean, comfortable and sanitary environment through provision of heat, light, ventilation and sanitation to meet health and aesthetic needs of the resident, in accordance with the physicians' orders and licensing regulations;
Basic personal laundry, excluding dry-cleaning, mending, hand washing, or other specialties.
Consultant services when the facility employs or contracts with consultants in an effort to meet regulations.
Specialized rehabilitative services, including, but not limited to, physical therapy, speech-language pathology, occupational therapy and mental health rehabilitative services for mental illness and intellectual or developmental disability, when required in the resident's comprehensive plan of care. Specialized rehabilitative services shall be provided under the written order of a physician by qualified personnel. The facility shall provide the required services or obtain the required services from a provider of specialized rehabilitative services.
Ongoing activities program directed by a qualified professional, to meet the interests and the physical, mental and psychosocial well-being of each resident. The nursing facility can charge for entertainment and social events that are outside the scope of the required activities program.

8.440.2 SERVICES AND ITEMS NOT INCLUDED IN THE PER DIEM PAYMENT 8.440.2.A. The following general categories and examples of items and services are not included in the facility’s per diem rate. Items 1 – 11 may be charged to the resident's personal needs account if requested in writing by a resident and/or the responsible party. (Refer to Section 8.482 for policy guidance on resident personal needs accounts):

Cosmetic and grooming items and services in excess of those for which payment is allowed under the per diem rate, i.e., beauty permanents, hair relaxing, hair coloring, hair styling, hair curling, shaving lotion and cosmetics such as lipstick, perfume, eye shadow, rouge/blush, haircuts beyond simple trimming normally performed by licensed barbers or beauticians;
Purchases on behalf of a resident if:

a. The resident’s basic financial needs must be covered before the purchase.

b. The resident is able to approve the purchase or in the event the responsible party is making the purchase, the purchase is in line with what the resident wants or needs.

c. The balance in the resident’s personal needs account is sufficient to cover the purchase and the resident’s personal needs account is not depleted below one month’s personal needs allowance amount.

d. Outstanding debt due the facility related to uncollectible patient payment for room and board is an allowable purchase.

e. Reasonable funeral or burial expenses 3. Non-covered special care services, i.e., a private duty nurse not employed by the nursing facility or non-medical leave expenses incurred in supporting or benefitting the resident.

Items or services requested by the resident, including but not limited to, over the counter drugs/related items not prescribed by a physician, not included in the nursing care plan and not ordinarily furnished for effective patient care. In these instances, it is required that:

a. The resident has made an informed decision supported by a statement in the resident personal needs account file that the resident/responsible party is willing to use personal needs funds.

b. The balance in the resident’s personal needs account is sufficient to cover the charge and does not deplete the account.

Personal clothing and dry cleaning;
Personal comfort items, including smoking materials, notions, novelties and confections/candies;
Personal reading material, subscriptions;
Upgrades to private rooms in facilities that typically offer semi-private room setting;
Social events and entertainment offered off premises and outside the scope of the regular facility activities program;
The facility shall provide each resident with a nourishing, palatable, wellbalanced diet that meets the daily nutritional and special dietary needs of each resident. If the resident refuses the prepared food the facility shall offer substitutes. Residents may be charged for specially prepared food only if they are informed that there will be a charge, and the charge may be only the difference in price between the requested item and the covered item pursuant.
Telephone, television/radio for personal use, if not equally available to all residents.
Provider fee.
Prescription drugs.
Ambulance and medical transport, including emergent and non-emergent.
Oxygen 16. Physician fees 17. Non-nursing costs, including but not limited to direct and indirect outpatient therapy, assisted living, independent living, adult day care and meals-on-wheels.
Non-Medicaid ancillary services such as laboratory, radiology, physical therapy, occupational therapy, speech therapy and respiratory therapy.
DME and supplies for imminent discharges (including wheelchairs) covered under 8.590.2.B.1.
DME repairs for member-owned DME purchased prior to admission covered under 8.590.2.B.2. 8.440.2.C The following items are allowable costs for class II and class IV facilities only:
Eye/Hearing examinations 2. Eyeglasses and repairs 3. Hearing aids and batteries 4. Provider fees 8.441 NURSING FACILITY COST REPORTING 8.441.1 SUBMISSION OF THE MED-13 AND MINIMUM DATA SET (MDS) 8.441.1.A. For purposes of completing MED-13, each nursing facility shall:
Establish a 12-month period that is designated to the Department as the facility's fiscal year. The fiscal year shall remain the same as designated to the Department with two exceptions:

a. Providers seeking to coordinate their fiscal year with the fiscal year they have established with the Internal Revenue Service.

b. Subchapter “S” corporations required by law to have a fiscal year end of December 31.

Provide adequate cost data that:

a. Is based on their financial and statistical records. All financial and statistical records of the facility shall be maintained in accordance with generally accepted accounting principles as approved by the American Institute of Certified Public Accountants.

b. Is verifiable through adequate supporting documentation provided to auditors during the normal course of their audit;

c. Is based on the accrual basis of accounting. i Under the accrual basis of accounting, revenue is reported in the period when it is earned, regardless of when it is collected and expenses are reported in the period in which they are incurred, regardless of when they are paid. ii Where a governmental institution operates on a cash basis of accounting, cost data based on such accounting shall be acceptable, subject to appropriate treatment of capital expenditures.

d. Includes the Medicare cost report that was most recently filed with the Medicare fiscal intermediary. If the facility cannot file a current Medicare cost report for reasons beyond its control, the facility shall submit other reliable Medicare cost information that the Department has approved.

Maintain financial and statistical records in a manner consistent from one reporting period to another in order to provide the required cost data and not impair comparability.
Retain all records required to support information supplied on the MED-13 for a period of at least five (5) years from the date of submission. 8.441.1.B. Nursing facilities shall submit all Minimum Data Set (MDS) resident assessments and tracking documents to the Centers for Medicare and Medicaid Services (CMS) MDS database for Colorado maintained at CDPHE. All assessment data submitted shall conform to federal and state specifications and meet minimum editing and validation requirements. 8.441.1.C. Failure to maintain adequate accounting and/or statistical records shall be cause for termination or suspension of the facility’s provider agreement.

8.441.2 COMPLETION OF THE MED-13 – GENERAL INSTRUCTIONS 8.441.2.A. The MED-13 consists of the certification page and all schedules. All information called for in the schedules must be furnished unless:

It is not applicable to the nursing facility operation; or 2. The books and records do not provide the information, and it is not available by other reasonable means. 8.441.2.B. The financial information included shall be based on that appearing in the facility’s audited financial statements. Adjustments to convert to the accrual basis of accounting shall be required if the records are maintained on other accounting bases. 8.441.2.C. Nursing facilities that are a part of a larger health facility extending short term, intensive or other health care not generally considered nursing facility care may submit a cost apportionment schedule prepared in accordance with recognized methods and procedures. In certain instances, such cost apportionment schedules may be required by the Department if deemed necessary for a fair presentation of expenses attributable to nursing facility patients. 8.441.2.D. The instructions regarding the MED-13 are designed to cover those items that may require additional explanation or to provide an example.

8.441.3 COMPLETION OF THE MED-13 CERTIFICATION PAGE 8.441.3.A. Type of control indicates ownership or auspices under which the nursing facility is conducted. 8.441.3.B. Accounting basis:

Accrual Recording revenue when earned and expenses when incurred.
Modified Cash Recording revenue when received and expenses when incurred.
Cash Recording revenue when received and expenses when paid after giving effect to adjustments for prepayments, etc. and depreciation.
Nursing facilities not using the accrual basis of accounting shall adjust recorded amounts to the accrual basis. 8.441.3.C. Statistical Data 1. The statistical data shall be accurate. A resident day is that period of service rendered to resident between the census taking hours on two (2) successive days, the day of discharge being counted only when the resident was admitted that same day.
The total resident days for the period shall be accurate and not an estimate of days of care provided. Resident days shall include days for residents having special duty nurses.
Each nursing facility shall maintain and submit an annual census summary record for all residents, including both Medicaid and non- Medicaid residents, in a format prescribed by the Department. Sample copies of the required format may be obtained from the Department. 8.441.3.D. The certification statement on the MED-13 shall be read and signed by the licensed owner or corporate officer and the preparer of the MED-13. 8.441.3.E. The Department may require a nursing facility to provide the opinion of a certified public accountant if, in the Department’s opinion, adjustments made to prior reports indicate disregard of the certification and reporting instructions. The accountant shall certify that the report is in compliance with the Department’s regulations and shall give an opinion of fairness of presentation of operating results or revenues and expenses.

8.441.4 COMPLETION OF REVENUES SCHEDULE 8.441.4.A. Revenues shall be listed as recorded in the general books and records and are affected by the accounting basis and procedures used. Expense recoveries credited to expense accounts shall not be reclassified in order to be reflected as revenues for purposes of completing the revenue schedule. 8.441.4.B. Revenue from patients shall be classified sufficiently in the accounting records to allow preparation of this schedule.

“Routine services” or “daily services” are those services that include room, board, nursing services and such services as supervision, feeding, and incontinency for which the associated costs are in nursing service.
“Routine services” or “daily services” shall represent only the established charge for daily care, excluding additional charged, if any, for other 8.441.4.C. Revenue from ancillary services provided to residents, such as pharmacy, medical supplies and occupational therapy supplies shall be applied in reduction of the related expense. The resulting expense, after adjustment, shall not be a negative figure. A revenue classification “Miscellaneous” or “Sundry” requires an analysis and determination of the amounts included therein, which represent expense recoveries or income to be applied in reduction of a related expense. 8.441.4.D. Medical supplies, with certain specific exceptions, shall be provided to Medicaid residents without separate additional charges to the resident or relatives. The costs of these supplies or services shall be included in audited costs. 8.441.4.E. Account for specific medical supplies or services for which a separate additional charge is allowed as “Items Purchased for Resale.” Show the cost on the appropriate line for elimination. 8.441.4.F. Revenues related to services rendered which are not an obligation of the state shall be offset against allowable costs if the associated expense cannot be determined. If the associated expense can be determined, related expense should be removed as non-allowable (i.e., if barber and beauty shop revenue is $1,000 and the related expense is $900, enter $900; however, if expenses cannot be determined, enter $1,000). 8.441.4G. Revenues not related to patient care (“Other Revenue Centers”) shall be applied in reduction of the related expense. Remove the cost, if known, (such as employee meals or telephone expense) or the gross revenue if cost cannot be determined. 8.441.4.H Revenue from residents, or others, resultant from charges made for room reservations, shall be classified sufficiently in the accounting records, and such amount shall be entered on the Revenue Schedule and identified as room reservation charges. This revenue shall also be offset against allowable expenses. 8.441.4.I. An investment or interest income adjustment shall be necessary only if interest expense is incurred, and only to the extent of such interest expense. 8.441.4.J. Laundry revenue shall be applied to laundry expense. 8.441.4.K. Open lines are provided for entry of sundry sources of revenue not directly related to patients, such as pay telephone commissions, contributions and grants received. These items need not be applied as a reduction of expense. 8.441.4.L. Accounts receivable charged off or provision for uncollectible accounts shall be reported on the Revenue Schedule as a deduction from gross revenue.

However, if a nursing home accounts for such revenue deductions as an administrative expense, the amounts shall be entered as “Other expenses not related to patient care.”

8.441.5 COMPLETION OF NON-REIMBURSABLE EXPENSES AND EXPENSE

LIMITATIONS AND ADDITIONS SCHEDULE 8.441.5.A. The following expenses shall be excluded or limited from operating expenses because they are not normally incurred in providing patient care:

Fees paid to directors and non-working officers’ salaries shall not be allowed as reimbursable costs.
Loan acquisition fees and lender or underwriter standby fees shall not be considered part of the current expense of patient care but shall be amortized over the life of the related loan.

8.441.5.B. COMPENSATION OF OWNERS AND OWNER-RELATED EMPLOYEES

For purposes of 10 CCR 2505-10 section 8.441.5.B, the following definitions apply:

a. Compensation” means the total benefit received by the owner for services rendered to the facility. Such compensation shall only include: i Salary amounts paid for managerial, administration, professional and other services; ii Amounts paid by the facility for the personal benefits of the owner; iii The costs of assets and services which the owner receives from the facility; and iv Deferred compensation.

b. Necessary services” means those services needed for the efficient operation and sound management of the facility such that, had the owners or owner-related individuals not rendered the services, the facility would have had to employ another individual to perform the c. Owner” means an individual with a five percent (5%) or more ownership interest in the facility.

d. Owner-related individual” means an individual who is a member of an owner’s immediate family which includes a spouse, natural or adoptive parent, natural or adopted child, step-parent, step-child, sibling or step-sibling, in-laws, grandparents and grandchildren.

e. Ownership interest” means the entitlement to a legal or equitable interest in any property of the facility whether such interest is in the form of capital, stock or profits of the facility.

Compensation for services of owners and owner related employees shall be adequately documented to be necessary and qualified to provide these services. Adequate documentation shall include but not be limited to:

a. Date and time of services;

b. Position description;

c. Individual's educational qualifications, professional title and work experience;

d. Type and extent of ownership interest;

e. Relationship to and name of owner (if an owner related individual).

The methods set forth below shall determine the allowable costs of salaries paid to owner and owner related employees. For each method, if an owner or owner-related employee is compensated for services to the facility, any compensation paid to another individual in the same position shall be excluded from the allowable costs for that cost reporting period.

a. Owner and Owner-Related Administrators: The maximum allowable cost of salaries paid to owner and owner-related administrators shall be equal to the median of salaries paid to all non-owner and non-owner related administrators in facilities of comparable size.

The median shall be computed by the Department from a survey of all Colorado Medicaid participating facilities conducted each January, and shall be applied to salaries for that calendar year.

Categories of facilities, based on licensed bed capacity, for purposes of determining comparability shall be as follows: 1 to 74; 75 to 99; 100 to 149; 150 to 200 and more than 200.

b. Owner and Owner-Related Assistant Administrator: The maximum allowable cost for such services shall be 75% of the maximum allowable salary of an owner or owner related assistant administrator of a comparable facility. No costs shall be allowable for owner or owner related assistant administrators in facilities with licensed bed capacities less than 150.

c. Owner and Owner-Related Physicians Performing Administrative Services: Salaries shall be an allowable cost up to the maximum established for owner and owner-related administrators in a comparable facility.

d. Owner and Owner-Related Nursing Directors: Salaries shall be an allowable cost up to a maximum of 65% of the maximum allowable salary of an owner or owner-related administrator of a comparable facility.

Fringe benefits for owner and owner-related employees shall be allowable costs up to a maximum established by the Department each March for that calendar year. This maximum shall be equal to the fringe benefit percentage of private employees in Colorado as determined by the survey conducted by the State Department of Personnel, minus that portion of the computation that includes holidays, vacation and sick leave days.
Exceptions to the application of the median as the maximum allowable salary for owner and owner-related employees shall be approved by the Department only where the nursing home can demonstrate that it has unique characteristics or the employee in question has special qualifications and experience which would make application of the median for that size facility unreasonable. Requests for exceptions shall be submitted to the Department in writing no later than 90 days prior to the end of the facility's fiscal year.

8.441.5.C. LEGAL FEES, EXPENSES AND COSTS

Legal fees, expenses and costs incurred by nursing facilities shall be allowable, in the period incurred, if said costs are reasonable, necessary and patient-related. These legal fees, expenses and costs shall be documented in the provider's files, and shall be clearly identifiable, including identification by case number and title, if possible. Failure to clearly identify these costs shall result in disallowance.
The following categories are not deemed reasonable, necessary and patient-related:

a. Legal fees, expenses and costs incurred in connection with the appeal of a Medicaid classification or reimbursement rate, rate adjustment, resident personal needs account audit, or payment for any financial claim by or against the State of Colorado, or its agencies by a provider, in the event the State of Colorado or any of its agencies prevails in such a proceeding. In the event that each party prevails on one or more issues in litigation, allowable legal fees, expenses and costs in such cases shall be apportioned by percentage, for reimbursement purposes, by the administrative law judge rendering the final agency decision. In the event of the stipulated settlement of any such appeal, the parties shall, by agreement, determine the allowability for the provider's legal fees, expenses and costs. If a settlement agreement is silent concerning legal fees, expenses or costs, they shall not be allowable.

b. Legal fees, expenses and costs incurred in connection with a proceeding by the Department or CDPHE to deny, suspend, revoke or fail to renew or terminate the license or provider contract of a long term care facility, or to refuse to certify, decertify or refuse to recertify a long term care facility as a provider under Medicaid and the Departments prevail in such a proceeding. Legal fees, expenses and costs incurred in connection with a proceeding by the United States Department of Health and Human Services to refuse to certify, decertify, or refuse to recertify a long term care facility and the Department prevails in such a proceeding. For the purposes of this paragraph, the word “prevail” shall mean a result, whether by settlement, administrative final agency action or judicial judgment, which results in a change of the terms of a previously granted provider license, certification, or contract, including involuntary change of ownership or probation.

c. Legal fees, expenses and costs incurred in connection with a civil or criminal judicial proceeding against the provider by the State of Colorado and any of its agencies as the result of the provider's participation in the Medicaid program, resulting from fraud or other misconduct by the provider, and the State or its agencies prevail in such proceeding. For the purposes of this paragraph, the word “prevail” shall mean any result but dismissal or acquittal of a criminal action or dismissal, directed judgment, or judgment for the provider in a civil action.

d. Legal fees, expenses and costs incurred in connection with an investigation by federal, state, or local governments and their agencies that might lead to a civil or criminal proceeding against the provider as a result of alleged fraud or other misconduct by the provider in the course of the provider's participation in the Medicaid program shall not be allowable where the provider makes any payment of funds to any federal, state, or local governments and their agencies as a result of the alleged fraud or misconduct which was the subject of the investigation.

e. Legal fees, expenses and costs incurred for lobbying Congress, the Legislature of Colorado, or the Medical Services Board, Health or Human Services.

f. Legal fees, expenses and costs incurred by the seller in the normal course of the sale of a nursing home.

g. Nonrefundable retainers paid to counsel.

h. Legal fees, expenses and costs associated with a change of ownership incurred for any reason after a change of ownership has occurred.

i. Legal fees, expenses, or costs as a result of an attorney entering an appearance in person or in writing by counsel for the provider during any Informal Reconsideration conducted pursuant to

Section 8.050.4. Legal fees, expenses and costs that are advisory in nature before and during the Informal Reconsideration process will be allowable.

8.441.5.D. DEPRECIATION

For purposes of this section concerning depreciation, the following definitions shall apply:

a. “MAI appraiser” means the designation “Member, Appraisal Institute” awarded by the American Institute of Real Estate Appraisers.

b. “Straight line method of depreciation” means the method of depreciation where the amount to be depreciated is first determined by subtracting the estimated salvage value of the asset from its cost or fair market value in the case of donated assets. The amount to be depreciated is then distributed equally over the estimated useful life of the asset.

Allowable depreciation shall be determined in accordance with The Provider Reimbursement Manual CMS Pub. 15-1. . The Provider Reimbursement Manual, CMS Pub. 15-1, July 1, 2025, is hereby incorporated by reference. No later amendments or editions are incorporated. Certified copies of the incorporated material are available from the Centers for Medicare & Medicaid Service at https://www.cms.gov.

Depreciation on assets used to provide covered services to Medicaid recipients may be included as an allowable patient cost. Only the straightline method of computing depreciation may be utilized for purposes of Medicaid reimbursement. Depreciation costs shall be identifiable as such, and shall be recorded in the provider's accounting records in accordance with “generally accepted accounting principles.”
Depreciable items must be capitalized and written off over the estimated useful life of the item using the straight-line method of depreciation. With respect to expenditures during every facility fiscal year which begins on or after July 1, 1998, the following items must be depreciated:

a. Assets that, at the time of acquisition, had an estimated useful life of (2) two years or more; and a historical cost of $5,000 or more.

b. Betterments or improvements that extend the original estimated useful life of an asset by (2) two years or more, or increase the productivity of an asset significantly; and cost $5,000 or more.

c. For the purpose of applying the $5,000 threshold in paragraphs A and B above, the costs of assets, betterments, and/or improvements shall be combined if the costs:

i. Are incurred within the same fiscal year of the nursing ii. Are of the same type or relate to the same project. For example, costs related to renovations or improvements to a facility's kitchen must be combined.

d. Major repairs are repairs which:

i. Occur infrequently, involve significant amounts of money, and increase the economic usefulness of the asset in the future, because of either increased efficiency, greater productivity, or longer life; or ii. Restore the original estimated useful life of an asset where without such repairs, the useful life of the asset would be reduced or immediately ended; these repairs occur infrequently and have a significant cost in relation to the asset being repaired.

e. If the composite method of depreciation is used, the time period over which the major repair must be depreciated is not necessarily the remaining life of the composite asset. For example, a major repair to a roof of a facility that has a remaining useful life of thirty (30) years would not have to be depreciated over thirty (30) years if the normal life of the roof is only fifteen (15) to twenty (20) years; the shorter period could be used.

f. The following are examples of major repairs and are not intended as a complete list: replacement or partial replacement of a roof, flooring, boiler, or electrical wiring.

8.441.5.E. EXPENSED ITEMS

Items which are to be entirely expensed in the year of purchase, rather than depreciated, are as follows:

a. All repair and maintenance costs, except major repairs.

b. Assets that, at the time of acquisition, had an estimated useful life of less than two (2) years; or cost less than $5,000.

c. Betterments or improvements that do not extend the useful life of an asset by two (2) years or more, or do not increase the productivity of an asset significantly; or cost less than $5,000.

d. For the purpose of applying the $5,000 threshold in paragraphs “b” and “c” above, assets, betterments, and/or improvements that are purchased separately shall be combined if they meet the criteria described in 10 CCR 2505-10 section 8.441.5.D.

8.441.5.F. HISTORICAL COSTS

Historical costs shall be established in accordance with The Provider Reimbursement Manual, CMS Pub. 15-1, 2. When the Internal Revenue Service requires a facility to change its allocation of costs of land, buildings or equipment for purposes of tax reporting, a copy of the IRS notice shall be submitted to the Department in order for the changes to be reflected in the cost report.
In regard to a determination of a bona fide sale, an initial presumption that the sale was not bona fide may be offset by a valuation report of an MAI appraiser of the reproduction cost depreciated to date on a straight-line

basis. Cost determined in this manner shall be accepted for future depreciation purposes.

An initial presumption that a sale was not bona fide shall be made when any of the following factors exist:

a. The seller and purchaser are persons for whom a loss from the sale or exchange of property is not allowed under the Internal Revenue Code between:

i. Members of a family;

ii. An individual and a corporation if the individual owns (directly or indirectly) more than 50% in value of the outstanding stock;

iii. Two corporations if more than 50% in value of the outstanding stock in both is owned, directly or indirectly, by the same individual, but only if either one of the corporations was a personal holding company or a foreign personal holding company for the taxable year preceding the date of the sale or exchange;

iv. A grantor and a fiduciary of any trust;

v. A fiduciary of one trust and a fiduciary of another trust, if the same person is grantor of both trusts;

vi. A fiduciary of a trust and any beneficiary of such trust;

vii. A fiduciary of a trust and a beneficiary of another trust, if the same person is a grantor of both trusts;

viii. A fiduciary of a trust and a corporation more than 50% in value of the outstanding stock of which is directly or indirectly owned by or for the trust or a grantor of the trust.

This would, for example, have the effect of denying a loss in a transaction between a corporation, more than 50% of the stock of which was owned by a parent, and a trust established for the children. Under the constructive ownership rules (below), the children are treated as owning the stock owned by the parent; and ix. A person and an exempt charitable or education organization controlled by the person or, if the person is an individual, by the individual or the family.

b. The term “family” means a brother or sister (whole or half-blood relationship), spouse, ancestor, or lineal descendant, including inlaws and in-laws of ancestors of lineal descendants.

c. In determining stock ownership:

i. The transaction was affected without significant investment on the part of the purchaser; i.e., cash or property was not transferred from the purchaser to the seller and the sales price was met by assumption of existing debt and promises to pay additional amounts or issuance of life annuities to the seller.

ii. The sales price could be considered excessive when compared with other sales or costs of constructing, furnishing, and equipping other facilities of comparable size and quality during the preceding twelve months.

8.441.5.G. INTEREST

For purposes of this section concerning interest, the following definitions shall apply:

a. Interest” means the cost incurred for the use of borrowed funds.

b. Interest on current indebtedness” means the cost incurred for funds borrowed for a relatively short term. This is usually for such purposes as working capital for normal operating expense.

c. Interest on capital indebtedness” means the cost incurred for funds borrowed for capital purposes such as acquisition of facilities and equipment, and capital improvements. Generally, loans for capital purposes are long term loans.

d. Necessary” means that the interest:

i. Is incurred on a loan made to satisfy a financial need of the provider. Loans which result in excess funds or investments shall not be considered necessary;

ii. Is incurred on a loan made for a purpose reasonably related to patient care; and iii. Is reduced by investment income except where such income is from gifts and grants whether restricted or unrestricted, and which are held separate and not commingled with other funds. Income from funded depreciation or provider’s qualified pension fund shall not be used to reduce interest expense.

e. Proper” means that interest:

i. Is incurred at a rate not in excess of what a prudent borrower would have had to pay in the money market existing at the time the loan was made; and ii. Is paid to a lender not related through control or ownership or personal relationship to the borrowing organization.

However, interest shall be allowable if paid on loans from the provider’s donor restricted funds, the funded depreciation account or provider’s qualified pension funds.

To be allowable, the interest expense shall be incurred on indebtedness established with lenders or lending organizations not related through control, ownership, or personal relationship to the borrower. Presence of any of these factors affects the bargaining process that usually accompanies the making of a loan and could be suggestive of an agreement on higher rates of interest or of unnecessary loans. Loans shall be made under terms and conditions that a prudent borrower would make in arms-length transactions with lending institutions. The intent of this provision is to assure that loans are legitimate and needed and that the interest rate is reasonable.
Interest on loans to providers by partners, stockholders or related organizations are allowable as costs at a rate not in excess of the prime rate.
Where the general fund of a provider “borrows” from a donor-restricted fund and pays interest to the restricted fund, the interest shall be an allowable cost. The same treatment shall be accorded interest paid by the general fund on money “borrowed” from the funded depreciation account of the provider or from the provider's qualified pension fund. In addition, if a provider operated by members of a religious order borrows from the order, interest paid to the order shall be an allowable cost.
Where funded depreciation is used for purposes other than improvement, replacement, or expansion of facilities or equipment related to patient care, allowable interest expense is reduced to adjust for offsets not made in prior years for earnings on funded depreciation. A similar treatment will be accorded deposits in the provider's qualified pension fund where such deposits are used for other than the purpose for which the fund was established.
Allowable interest expense on current indebtedness of a provider shall be adjusted to reflect the extent to which working capital needs which are attributable to covered services for beneficiaries have been met by payment to the provider designed to reimburse currently as services are furnished to beneficiaries.

8.441.5.H. MANAGEMENT SERVICES

The following requirements apply to all management companies:

a. Management company costs shall be considered administrative costs except as described at Section 8.443.7.A.12.

b. Management company costs allocated to facilities shall be based on actual services provided to the facility. The allocation shall be documented.

c. If the compensation to on-site management staff is separately reported on the cost report, that compensation shall not also be included in the allowable management costs for the facility. This

rule shall apply regardless of whether owners or owner-related organizations are involved in the administration or management 2. In addition to the requirements of Section 8.441.5.H.1, the following requirements shall apply to owner-related management companies:

a. “Owner-related management company” means an individual or organization that is related to, owned or controlled by the owner(s) of the nursing facility, as described in Section 8.441.5.B.

b. Management services provided to the nursing facility by an ownerrelated management company are subject to the related party rules at Section 8.441.5.B.

c. When management services are provided to a nursing facility by an owner-related management company, the nursing facility shall compile and present for inspection supporting documentation of actual costs incurred in providing the management company services. This shall include, at a minimum, the following:

i. Documentation supporting the reasonableness of salaries paid to owners and owner-related employees of the management company, as specified in Section 8.441.5.B;

ii. Allocation schedules;

iii. Home Office Cost Statement, Form CMS-287-22;

iv. All tax records and filings of the management company;

v. All management company records to support financial statements.

d. Documentation supporting the reasonableness of salaries and other compensation paid to owners and employees of an ownerrelated management company shall be available for inspection and shall include, but not be limited to, the following:

i. Salary survey(s) for the geographic location demonstrating that the salaries and other compensation are comparable to market for their respective position and size of entity;

If the provider does not provide a salary survey, the auditor shall use the latest survey of the Healthcare Financial Management Association (HFMA).2) Salary surveys are to be of a sufficiently large sample, including non-related nursing facility management companies, to lend support to the salaries. Surveys including a small number of facilities (less than ten), facilities related through common ownership or control or facilities of incomparable size shall be considered unacceptable.

ii. A position description for the person listing the duties performed;

iii. Date and time of services provided by each owner-related individual;

iv. Job applications, resumes, professional title, educational qualifications, and other documentation of work experience and qualifications; and v. The type and extent of ownership interest for each owner or owner-related individual employed by or performing services for the management company.

e. Limitations shall be based on the median salaries included in the survey(s) referenced in Section 8.441.5.H.2.d. If the owner or owner-related party receives compensation from two or more entities, the total compensation received from those entities shall be evaluated for reasonableness. In the absence of reasonable documentation that the owners and/or owner-related parties are working employees, the compensation claimed for these persons shall be disallowed as a cost not related to patient care.

f. Compensation to owners of related party companies, regardless of organizational structure, must be paid within 75 days of the end of the fiscal year. Payment of the compensation shall be evidenced by documentation submitted to the IRS. Failure to provide adequate documentation during the field audit process shall result in disallowance of unsupported or unpaid amounts. Disallowed compensation shall not be allowed in any future period.

8.441.5.I. ITEMS FURNISHED BY RELATED ORGANIZATIONS OR COMMON

OWNERSHIP

Costs applicable to services, facilities and supplies furnished by organizations related to the nursing facility by common ownership or control are allowable costs of the nursing facility at the cost to the related organization or the open market price, whichever is less.
The following definitions are applicable for the purposes of this regulation:

a. Common ownership” means that an individual or individuals directly or indirectly possess a significant (5% or more) ownership interest, as defined in Section 8.441.5.B, in the nursing facility and the institution or organization serving the nursing facility.

b. Control” means that an individual or an organization has common ownership with or is related to another organization or institution, or has the power, directly or indirectly, to influence significantly or to direct the actions or policies of another organization or an institution.

c. Related to the nursing facility” means:

i. The nursing facility, to a significant extent, is associated or affiliated with, or has control of, or is controlled by the organization furnishing the services, facilities or supplies; or ii. An owner-related individual, as defined in Section 8.441.5.B, is employed by the nursing facility at the time that the nursing facility is obtaining services, facilities or supplies from an organization whose owner is related to the nursing facility employee; or iii. An owner-related individual, as defined in Section 8.441.5.B, is employed by an organization which is providing services, facilities or supplies to a nursing facility whose owner is related to the supplier's employee.

Related providers or organizations shall be identified by the nursing facility on Schedule F of the MED-13.
The charge by the related provider or organizations for the services, facilities or supplies shall be considered an allowable cost when the nursing facility demonstrates all the following by clear and convincing evidence:

a. The supplying organization is a bona fide separate organization;

b. A substantial part of the supplier's business activity of the type carried on with a nursing facility is transacted with others than the nursing facility and organizations related to the supplier by common ownership or control; and there is an open, competitive market for the type of services, facilities, or supplies furnished by the organization; and c. The services, facilities or supplies are those which commonly are obtained by institutions, such as the nursing facility, from other organizations and are not basic elements of patient care ordinarily furnished directly to the patients by such institutions; and d. The charge to the nursing facility is in line with the charge for such services, facilities, or supplies in the open market and no more than the charge made under comparable circumstances to others by the organization for such services, facilities or supplies.

8.441.5.J. NON-SALARIED STAFF

Members of religious orders serving under an agreement with their administrative offices shall be allowed comparable salaries paid persons performing comparable services.
If maintenance is provided such persons by the nursing facility, i.e., room and board and/or clothing, the amount of these benefits shall be deducted from the amount otherwise allowed for a person not receiving maintenance.

8.441.5.K. OXYGEN

Only purchased oxygen concentrator costs, whether expensed or capitalized, shall be allowable costs on the MED-13. Such costs include, but are not limited to, all supplies, equipment and servicing expenses related to the maintenance of the purchased concentrators.
Oxygen concentrators of any size leased by medical supply companies to Medicaid nursing facility residents shall not be allowable costs and shall not be included in the MED-13.

8.441.5.L. LIMITATION ON MEDICARE PART A AND PART B COSTS

Effective July 1, 2024, Medicare and other third party (non-Medicaid) ancillary costs shall be excluded from the allowable Medicaid reimbursement for Class I nursing facilities.

8.441.6 COMPLETION OF OPERATING EXPENSES SCHEDULE 8.441.6.A. All expenses should be reported on the operating expenses schedule. All adjustments to eliminate expenses or to apply expense recoveries shall be made on the operating expenses schedule. 8.441.6.B. Expense centers in operating expenses shall be used for distribution of expenses by object or natural classifications within the department or function.

The expenses shall be classified sufficiently within the accounting records to allow preparation of operating expenses schedule. 8.441.6.C. Total expenses reported on the operating expenses schedule shall agree with the total expenses in the general ledger.

8.442 SUBMISSION OF COST REPORTING INFORMATION 8.442.1.A. Each nursing facility shall complete a Financial and Statistical Report for Nursing Facilities (MED-13) and submit it to the Department’s designee at 12month intervals within ninety (90) days of the close of the facility’s fiscal year. 8.442.1.B. A nursing facility may request an extension of time to submit the MED-13.

The request for extension shall:

Be in writing and shall be submitted to the Department.
Properly document the reasons for the failure to comply.
Be submitted no less than 10 working days prior to the due date for submission of the MED-13. 8.442.1.. Failure of a nursing facility to submit its MED-13 within the required 90 day period shall result in the Department withholding all payments not yet released to the provider as described below:
When a nursing facility fails to submit a complete and auditable MED-13 (i.e., the information represented on the MED-13 cannot be verified by reference to adequate documentation as required by generally accepted auditing standards) on time, the MED-13 shall be returned to the facility with written notification that it is unacceptable.

a. The facility shall have either 30 days from the postmark date of the notice or until the end of the original 90-day submission period, whichever is later, to submit a corrected MED-13.

b. If the corrected MED-13 is still determined to be incomplete or unauditable, the nursing facility shall be given written notification that it shall, at its own expense, submit a MED-13 that has been prepared by a certified public accountant (CPA). The CPA shall certify that the report is in compliance with all Department regulations and shall give an opinion of fairness of presentation of operating results or revenues and expenses.

c. The Department shall withhold all payments not yet released to the provider once the original 90-day filing period and 30-day extension have expired and no acceptable MED-13 has been submitted.

If the audit of the MED-13 is delayed by the nursing facility’s lack of cooperation, the effective date for the new rate shall be delayed until the first day of the month in which the audit is completed. Lack of cooperation means failure of the nursing facility to meet its responsibility to submit a timely MED-13 or failure to provide documents, personnel or other resources within its control and necessary for completion of the audit, within a reasonable time.
When the rate for the facility during a period of delay is found to have been higher than the new rate, the new rate shall be applied retroactively to this period and the Department shall make any adjustments and/or recoveries of overpayments.

8.442.2 DELAYS OR CORRECTIONS IN MINIMUM DATA SET (MDS)

SUBMITTAL 8.442.2.A. A nursing facility shall be notified each quarter of its residents’ case mix index values, and shall be granted not less than 14 calendar days in which to make any corrections to the resident MDS assessments. After the period of time for correcting resident assessments has passed each quarter, the final nursing facility resident assessment data shall be used by the Department, or its designee, to calculate that quarter’s resident case mix acuity adjustment for each 8.442.2.B. A nursing facility may request to amend or correct the MED-13 after it has been submitted to the Department’s designee as follows:

Requests shall be in writing and shall include an explanation of the need for the revision.
If the revision will not be submitted to the Department’s designee within the original 90-day filing period, the date of submission of the MED-13 shall be the date of receipt of the submission. The Department may grant a 30-day extension of the filing period.
Once the original 90-day filing period and 30-day extension have expired, the Department shall withhold all warrants not yet released to the provider if the revision still has not been submitted to the Department. 8.442.2.C. Where the Department withholds warrants not yet released to the provider, the following shall apply:
The Department shall withhold all warrants not yet released to the provider for services rendered in the prior three calendar months (four months if an extension was granted) and thereafter until an acceptable MED-13 is received.
Once the Department determines that the MED-13 submitted is complete and auditable, the provider's withheld payments shall be released.
If an acceptable MED-13 has not been submitted within 90 days after the Department began withholding payments, the provider's participation in the Medicaid program shall be terminated and the payments withheld shall be released to the provider.
Interest paid by the provider on loans for working capital while payments are being withheld shall not be allowable costs for purposes of reimbursement under Medicaid.
When the delayed submission of the MED-13 causes the effective date of a new lower rate to be delayed, the new rate shall be applied retroactively to this period and the Department shall make recoveries of overpayments.

8.442.3 PROPOSED ADJUSTMENTS 8.442.3.A. Following completion of a field audit, desk review or rate calculation, the Department or its contract auditor shall notify the affected provider in writing of any proposed adjustment(s) to the costs reported on the facility's MED-13 form and the basis of the proposed adjustment(s). 8.442.3.B. The provider may submit additional documentation in response to proposed adjustments. The department or its contract auditor must receive the additional documentation or other supporting information from the provider within 60 calendar days of the date of the proposed adjustments letter or the documentation will not be considered. 8.442.3.C. The Department may grant an additional period, not to exceed 30 calendar days, for the facility to submit such documents and information, when necessary and appropriate, given the facility's particular circumstances. 8.442.3.D. The Department’s contract auditor shall complete the field audit, desk review or rate calculation within 30 days of the expiration of the 60-day provider response period. The contract auditor shall also complete and deliver the resulting rate letter to the Department by the 30th day following the expiration of the 60-day provider response period.

8.443 NURSING FACILITY PROVIDER REIMBURSEMENT 8.443.1.A. Where no specific Medicaid authority exists, the sources listed below shall be considered in reaching a rate determination:

Medicare statutes.
Medicare regulations.
Medicaid and Medicare guidelines.
Generally accepted accounting principles.

8.443.1.B. CLASS 1 NURSING FACILITY PROVIDER REIMBURSEMENT

The MMIS per diem reimbursement rate shall equal the July 1 Core Component per diem rate multiplied by a percent factor. The percent factor shall be a percentage such that the statewide average MMIS per diem reimbursement rate net of patient payment equals the previous year statewide average MMIS per diem reimbursement rate net of patient payment increased or decreased.
The Core Component per diem rate shall be determined using information on the MED-13, the Minimum Data Set (MDS) resident assessment information and information obtained by the Department or its designee retained for cost auditing purposes.

a. The Core Component per diem rate shall be the sum of the following per diem rates:

i. Health care per diem rate described in Section 8.443.7.D, ii. Administrative and general per diem rate described in

Section 8.443.8.E, and iii. Fair rental allowance per diem rate described in Section 8.443.9.B.

In addition to the MMIS claims reimbursement, a Class 1 nursing facility provider may be reimbursed supplemental payments. Supplemental payments are funded using available provider fee dollars collected as described in Section 8.443.17. Supplemental payments shall be funded in the subsequent order based upon the hierarchy below.

a. Medicaid utilization supplemental payment described in Section 8.443.10.C, b. Acuity Adjusted Core Component supplemental payment described in Section 8.443.11.B, c. Pay-For-Performance supplemental payment described in Section 8.443.12, d. Cognitive Performance Scale supplemental payment described in

Section 8.443.10.A, e. Preadmission Screening and Resident Review II Resident supplemental payment described in Section 8.443.10.B, f. Preadmission Screening and Resident Review II Facility supplemental payment described in Section 8.443.10.B, and g. Core Component supplemental payment described in Section 8.443.11.A. 8.443.1.C For class II and privately-owned class IV intermediate care Facilities for Individuals with Intellectual Disabilities, a payment rate for each participating facility shall be determined on the basis of the MED-13 and information obtained by the Department or its designee retained for the purpose of cost auditing.

The facility’s prospective per diem rate includes the following components:

a. Health Care.

b. Administrative and General.

c. Fair Rental Allowance for Capital-Related Assets. 8.443.1.D For state-operated class IV intermediate care Facilities for Individuals with Intellectual Disabilities, a payment rate for each participating facility shall be determined on the basis of the MED-13 and information obtained by the Department or its designee retained for the purpose of cost auditing.

The facility’s retrospective per diem rate includes the following components:

a. Health Care.

b. Administrative and General, which includes capital. 8.443.1.E. For swing-bed facilities, the annual payment rate shall be determined as the state-wide average class I nursing facilities payment rate at January 1 of each year. 8.443.1.F. No nursing facility care shall receive reimbursement unless and until the nursing facility:

Has a license from CDPHE, and 2. Is a Medicaid participating provider of nursing care services, and 3. Meets the requirements of the Department’s regulations.

8.443.2 NURSING FACILITY CLASSIFICATIONS

Class I facilities are those facilities licensed and certified to provide general skilled nursing facility care.
Class II (ICF/IID) facilities are those facilities whose program of care is designed to provide services for individuals with intellectual or developmental disabilities who have intensive medical and psychosocial needs which require a highly structured in-house comprehensive medical, nursing, developmental and psychological treatment program.

a. Class II (ICF/IID) facilities shall provide care and services designed to maximize each resident’s capacity for independent living and shall seek out and utilize other community programs and resources to the maximum extent possible according to the needs and abilities of each individual b. Class II (ICF/IID) facilities serve persons whose medical and psychosocial needs require services in an institutional setting and are expected to provide such services in an environment which approximates a home-like living arrangement to the maximum extent possible within the constraints and limitations inherent in an institutional setting.

c. Class II (ICF/IID) facilities shall be licensed by CDPHE 3. Class IV (ICF/IID) facilities are those facilities whose program of care is designed to treat developmentally disabled individuals who have intensive medical and psychosocial needs which require a highly structured in-house comprehensive medical, nursing, developmental and psychological treatment program.

a. Class IV (ICF/IID) facilities shall offer full-time, 24-hour interdisciplinary and professional treatment by staff employed at such facility. Staff must be sufficient to implement and carry out a comprehensive program to include, but not necessarily be limited to, care, treatment, training and education for each individual.

b. Class IV (ICF/IID) facilities shall be licensed by CDPHE.

c. State-administered, tax-supported facilities are not subject to the maximum reimbursement provisions and do not earn an incentive allowance.

d. Private, non-profit or proprietary facilities that are not tax-supported or state-administered are subject to the maximum reimbursement provisions and may earn an incentive allowance.

8.443.3 IMPUTED OCCUPANCY FOR CLASS II FACILITIES 8.443.3.A. The Department or its designee shall determine the audited allowable costs per patientday.

The Department shall utilize the total audited patient days on the MED-13 unless the audited patient days on the MED-13 constitute an occupancy rate of less than 85 percent of licensed bed day capacity when computing the audited allowable cost per patient day for all rates.
In such cases, the patient days shall be imputed to an 85 percent rate of licensed bed day capacity for the nursing facility and the per diem cost along with the resulting per diem rate shall be adjusted accordingly except that imputed occupancy shall not be applied in calculating the facility’s health care services and food costs.
The licensed bed capacity shall remain in effect until the Department is advised that the licensed bed capacity has changed through the filing of a subsequent cost report.
The imputed patient day calculation shall remain in effect until a new rate from a subsequent cost report is calculated. Should the subsequent cost report indicate an occupancy rate of less than 85 percent of licensed bed day capacity, the resulting rate shall be imputed in accordance with the provisions of this section. 8.443.3.B. Nursing facilities located in rural communities with a census of less than 85 percent shall not be subject to imputed occupancy. A nursing facility in a rural community shall be defined as a nursing facility in:
A county with a population of less than fifteen thousand; or 2. A municipality with a population of less than fifteen thousand which is located ten miles or more from a municipality with a population of over fifteen thousand; or 3. The unincorporated part of a county ten miles or more from a municipality with a population of fifteen thousand or more. 8.443.3.C. Any nursing facility that has a reduction in census, causing it to be less than 85 percent, resulting from the relocation of mentally ill or developmentally disabled residents to alternative facilities pursuant to the provisions of the Omnibus Budget Reconciliation Act of 1987 shall:
Be entitled to the higher of the imputed occupancy rate or the median rate computed by the Department for two cost reporting periods.
The imputed occupancy calculation shall be applied when required at the end of this period. 8.443.3.D. Imputed occupancy shall be applied to a new nursing facility as follows:
A new nursing facility means a facility not in the Colorado Medicaid program within thirty days prior to the start date of the Medicaid provider agreement.
For the first cost report submitted by a new facility, the facility shall be entitled to the higher of the imputed rate or the median rate computed by 3. For the second cost report submitted by a new facility, imputed occupancy shall be applied but the rate for the new facility shall not be lower than the 25th percentile nursing facility rate as computed by the Department in the median computation.
For the third cost report and cost reports thereafter, imputed occupancy shall be applied without exception. 8.443.3.E. Nursing facilities undergoing a state-ordered change in case mix or patient census that significantly reduces the level of occupancy in the facility shall:
Be entitled to the higher of the imputed occupancy rate or the monthly weighted average rate computed by the Department for two cost reporting periods.
At the end of this period, the imputed occupancy calculation shall be applied when required.

8.443.4 INFLATION ADJUSTMENT 8.443.4.A For class I nursing facilities, the per diem amount paid for direct and indirect health care services and administrative and general services costs shall include an allowance for inflation in the costs for each category using a nationally recognized service that includes the federal government's forecasts for the prospective Medicare reimbursement rates recommended to the United States Congress. Amounts contained in cost reports used to determine the per diem amount paid for each category shall be adjusted by the percentage change in this allowance measured from the midpoint of the reporting period of each cost report to the midpoint of the payment-setting period.

The percentage change shall be rounded at least to the fifth decimal point.
The index used for this allowance will be the Skilled Nursing Facility Market Basket (without capital) published by Global Insight, Inc. The latest available publication prior to July 1 rate setting shall be used to determine inflation indexes. The inflation indexes shall be revised and published every July 1 to be used for rate effective dates between July 1, and June 30. 8.443.4.B For class II facilities, at the beginning of each facility’s new rate period, the inflation adjustment shall be applied to all costs except provider fees, interest, and costs covered by fair rental allowance.
The inflation adjustment shall equal the annual percentage change in the National Bureau of Labor Statistics Consumer Price Index (U.S. city average, all urban consumers), from the preceding year, times actual costs (less interest expense and costs covered by the fair rental allowance) or times reasonable cost for that class facility, whichever is less.
The annual percentage change in the National Bureau of Labor Statistics Consumer Price Index shall be rounded at least to the fifth decimal point.
The price indexes listing in the latest available publication prior to the July 1 limitation setting shall be used to determine inflation indexes. The inflation indexes shall be revised and published every July 1 to be used for rate effective dates between July 1 and June 30.
The provider’s allowable cost shall be multiplied by the change in the consumer price index measured from the midpoint of the provider’s cost report period to the midpoint of the provider’s rate period.

8.443.5 ADMINISTRATIVE COST INCENTIVE ALLOWANCE FOR CLASS II

AND CLASS IV FACILITIES 8.443.5.A. If the nursing facility's combined audited administration, property, and room and board (excluding raw food, land, buildings, leasehold and fixed equipment) cost per patient day is less than the maximum reasonable cost for administration, property and room and board (excluding raw food, land, buildings, leasehold and fixed equipment) costs for the class, the provider will earn an incentive allowance. 8.443.5.B. The incentive allowance for class II facilities shall be calculated at 25 percent of the difference between the facility's audited inflation adjusted cost and the maximum reasonable cost for that class. The incentive allowance will not exceed 12 percent of the reasonable cost. 8.443.5.C. No incentive allowance shall be paid on health care services, raw food, fair rental value allowance and leasehold costs.

8.443.6 CASE MIX ADJUSTMENTS 8.443.6.A A resident’s case mix index shall be determined using a case mix classification system. The case mix classification system shall be maintained through public postings on the Department’s website. The case mix classification system may be updated to reflect advances in resident assessment or classification subject to federal requirements. 8.443.6.B A resident’s case mix index shall be determined on a Quarterly basis.

The Department shall distribute facility listings identifying current assessments for residents in the nursing facility on the 1st day of the first month of each quarter as reflected in the Department’s MDS assessment database.

a. The listings shall identify resident social security numbers, names, assessment reference date, the calculated case mix index, and the payor source as reflected on the prior full assessment and/or current claims data.

Resident listings shall be reviewed by the nursing facility for completeness and accuracy.
If data reported on the resident listings is in error or if there is missing data, facilities shall have until the last day of the second month of each quarter to correct data submissions, or until a later date if approved by the Department pursuant to Section 8.442.2.

a. Errors or missing data on the resident listings due to untimely submissions to the CMS database maintained by CDPHE shall be corrected by the nursing facility transmitting the appropriate assessments or tracking documents to CDPHE.

b. Errors in key field items shall be corrected by following the CMS key field specifications through CDPHE c. Errors on the current payor source shall be noted on the resident listings prior to signing and returning to the Department.

Each nursing facility shall sign and return its resident listing to the Department no later than 15 calendar days after it was mailed by the 5. Residents shall be assigned a case mix index based on their most current non-delinquent assessment available on the 1st day of the first month of each quarter as amended during the correction period.

a. The case mix group shall be translated to the appropriate case mix index or weight.

b. Two average case mix indices for each Medicaid nursing facility shall be determined from the individual case mix weights for the applicable quarter:

i. The facility average case mix index shall be a simple average, carried to four decimal places, of all resident case mix indices.

ii. The Medicaid average case mix index shall be a simple average, carried to four decimal places, of all residents where Medicaid is the per diem payor source anytime during the 30 days prior to their current assessment.

c. Any incomplete assessments and current assessment in the database older than 122 days shall be included in the calculation of the averages using the case mix index established in these rules.

8.443.7 HEALTH CARE REIMBURSEMENT RATE CALCULATION 8.443.7.A Health Care Services Defined: “Health care services” means the categories of reasonable, necessary and patient-related support services listed below. No service shall be considered a health care service unless it is listed below:

Direct Health Care: The salaries, payroll taxes, worker compensation payments, training and other employee benefits, including contracted or temporary staff in the categories listed below. All personnel shall be appropriately licensed and/or certified:

a. Director of nursing;

b. Assistant director of nursing;

c. Registered nurses, excluding registered nurses performing quality control or infection prevention;

i. Excluding infection preventionists who are classified as indirect health care;

d. Licensed practical nurses;

e. Restorative aides;

f. Certified nursed aides, including nurse aides in training up to four months before becoming certified;

i. Universal Care Workers or Shahbazim are a certified nursing aid who additionally performs non-medical care services such as dietary or housekeeping functions in a green house or green house like setting. Expenses for these staff (salaries, payroll taxes, worker compensation payments, training and other employee benefits) shall be split 70% direct health care and 30% administration.

g. Certified medication aides;

h. Feeding assistants i. Nursing administration (not clerical) case manager;

j. Patient care coordinator;

k. Quality improvement;

l. Clinical director;

Indirect Health Care Services: The salaries, payroll taxes, workers compensation payments, training and other employee benefits of:

a. Licensed therapists;

b. Physical therapy or occupational therapy assistants and aides;

c. Registered nurses conducting quality improvement;

d. Dieticians;

e. MDS coordinators;

f. Nursing staff development personnel;

g. Health Information Managers (Medical Records Librarians), must work directly with the maintenance and organization of medical records; h Social Workers including life enhancement specialists and admissions coordinators:

i. Community/clinical liaisons visit specific potential residents to assess the nursing facility’s ability to care for that resident.

ii. This does not include admissions staff whose duties are primarily clerical or other marketing professionals.

i. Central or Medical Supply personnel including duties associated with stocking and ordering medical and/or central supplies;

j. Activity personnel including personnel classified as “activities” must have a direct relationship (i.e., providing entertainment, games, and social opportunities) to residents.

i. For instance, security guards and hall monitors do not qualify as activities personnel.

ii. Costs associated with security guards and hall monitors are classified as administrative and general.

iii. Expenses for van drivers as described in Section 8.443.7.A.9.

k. Nursing scheduler is an individual who solely coordinates nursing scheduling;

l. Companion Aide is an individual who provides personalized, nonmedical care and companionship to residents. Their primary role is to ensure the safety, comfort, and emotional well-being of residents who require constant supervision or support due to medical conditions, cognitive impairments, or social isolation.

m. Clinical Liaison is a person who acts as a bridge between healthcare providers, patients, and families, assessing patient needs, coordinating care transitions (like moving to rehab/home), advocating for patients, managing referrals, and promoting facility services, requiring strong clinical knowledge, excellent communication, and sales/marketing skills to ensure smooth patient flow and appropriate care.

If a facility employee or a management company/home office employee or owner has dual health care (direct or indirect) and/or administrative duties, the provider must keep contemporaneous time records or perform time studies to verify hours worked performing health care related duties. If no contemporaneous time records are kept or time studies performed, total salaries, payroll taxes and benefits of personnel performing health care and administrative functions will be classified as administrative and general. Licenses are not required unless otherwise specified. Periodic time studies in lieu of contemporaneous time records may be used for the allocation. Time studies used must meet the following criteria:

a. A minimally acceptable time study must encompass at least one full week per month of the cost reporting period.

b. Each week selected must be a full work week (Monday to Friday, Monday to Saturday, or Sunday to Saturday).

c. The weeks selected must be equally distributed among the months in the cost reporting period, e.g., for a 12 month period, 3 of the 12 weeks in the study must be the first week beginning in the month, 3 weeks the 2nd week beginning in the month, 3 weeks the 3rd, and 3 weeks the fourth.

d. No two consecutive months may use the same week for the study, e.g., if the second week beginning in April is the study week for April, the weeks selected for March and May may not be the second week beginning in those months.

e. The time study must be contemporaneous with the costs to be allocated. Thus, a time study conducted in the current cost reporting year may not be used to allocate the costs of prior or subsequent cost reporting years.

f. The time study must be provider specific. Thus, chain organizations may not use a time study from one provider to allocate the costs of another provider or a time study of a sample group of providers to allocate the costs of all providers within the chain.

g. Punch cards/timesheets or any method of tracking hours is acceptable and preferred. 4.

a. If the provider’s chart of accounts directly identifies payroll taxes and benefits associated with health care versus administrative and general cost centers, the amounts directly identified will be appropriately allowed as either health care or administrative and general.

b. If these costs are comingled in the chart of accounts, payroll taxes and benefits shall be allocated to the cost centers (health care and administrative and general) based on total employee wages reported in those cost centers. The reporting method for payroll taxes and benefits by cost center is required to be consistent from year to year.

c. When a provider wishes to change its reporting method because it believes the change will result in more appropriate and a more accurate allocation, the provider must make a written request to the Department for approval of the change ninety (90) days prior to the end of that cost reporting period. The Department has sixty (60) days from receipt of the request to make a decision, or the change is automatically accepted. The provider must include with the request all supporting documentation to establish that the new method is more accurate. If the Department approves the provider's request, the change must be applied to the cost reporting period for which the request was made and to all subsequent cost reporting periods. The approval will be for a minimum three-year period. The provider cannot change methods until the three-year period has expired.

Personnel licensed to perform patient care duties shall be reported in the administrative and general cost center if the duties performed by these personnel are administrative in nature.
Expenses for non-prescription drugs ordered by a physician that are included in the per diem rate, including costs associated with vaccinations are indirect health care costs.
Consultant fees for nursing, medical records, registered dieticians, patient activities, social workers, pharmacies, physicians and therapies.

Consultants shall be appropriately licensed and/or certified, as applicable and professionally qualified in the field for which they are consulting. The requirements set forth in Sections 8.443.7.A. 1 and 2 above for employees also applies to consultants.

Purchases, rental, depreciation, interest and repair expenses of health care equipment and medical supplies used for health care services such as nursing care, medical records, social services, therapies and activities.

Purchases, lease expenses or fees associated with computers and software (including the associated training and upgrades) used solely in departments that provide direct or indirect health care services to residents, including but not limited to scheduling software. Dual purpose software that includes both a health care and administrative and general component will be considered an indirect health care service.

Purchase or rental of motor vehicles and related expenses, including salary and benefits associated with the van driver(s), for operating or maintaining the vehicles to the extent that they are used to transport residents to activities or medical appointments. Such use shall be documented by contemporaneous logs if there is dual purpose. An example of the dual-purpose vehicle is one used for both resident transport and maintenance activities.

a. Expenses related to resident medical transport or activities are indirect health care.

b. Expenses related to other uses are administrative and general.

Copier lease expense is indirect health care.
Salaries, fees, or other expenses related to health care duties performed by a facility owner or manager who has a medical or nursing credential shall be apportioned according to Sections 8.443.7.A. 1 and 2 above. Note that costs associated with the Nursing Home Administrator are an administrative and general cost.
Related Party Management Fees and Home Office Costs a. Related party management fees and home office costs shall be classified as administrative and general. However, costs incurred by the facility as a direct charge from the related party which are listed in this Section 8.443.7.A, may be included in the health care cost center equal to the actual costs incurred by the related party.

Documentation supporting the cost and health care licenses must be maintained. Only salaries, payroll taxes and employee benefits associated with health care personnel will be considered as allowable in the health care cost center. No overhead expenses will be included. The amount allowable in the health care cost category will be calculated in one of two ways:

i. Keeping contemporaneous time logs in 15-minute increments supporting the number of hours worked at each ii. Distributing the cost evenly across all facilities as follows: the amount allowable in each health care facility’s health care costs shall be equal to the total salary, payroll taxes and benefits of the health care personnel divided by the number of facilities where the health care personnel worked during the year. For example, if a nurse’s total salary, payroll taxes, and benefits total $80,000, and the nurse worked on five facilities during the year, $16,000 is allowable in each of the facility’s health care costs.

b. Auditable documentation supporting the number of facilities worked on during the year must be maintained. Even if a related party exception is granted in accordance with Section 8.441.5.I.4, no mark-up or profit will be allowed in the health care cost center, only supported actual costs.

Non-Related Party Management Fees a. Non-related party management fees shall be classified as administrative and general. However, costs incurred by the facility as a direct charge from the management company which are listed in this Section 8.443.7.A, may be included in the health care cost center. Management contracts which specify percentages related to health care services will not be considered a direct charge from the management company.
Professional liability insurance premiums and brokerage surplus and stamping fees, whether self-insurance or purchased, a. Professional liability loss settlements, deductibles and claims paid and associated legal fees will be included in administrative and general.
Medical director fees are indirect health care.
Therapies and services provided by an individual qualified to provide these services listed below are classified as indirect health carepursuant to Federal Medicare/Medicaid regulations:

a. Utilization review b. Dental care, when required by federal law c. Psychology and mental health services d. Physical therapy e. Recreational therapy f. Occupational therapy g. Speech therapy h. Respiratory therapy 17. Nursing licenses and permits, disposal costs associated with infectious material (medical or hazardous waste), background checks and flu or hepatitis shots and uniforms for personnel listed in Section 8.443.7.A. 1 above, shall be classified as indirect health care.

Food Costs means the cost of raw food, and shall not include the costs of property, staff, preparation or other items related to the food program, shall be classified as indirect health care.
Any health care expense (direct or indirect) made by a management company/home office must be directly attributed to an individual facility with the exception of:

a. Shared software services; or b. Expenses with alternate allocations identified elsewhere in this

Rule.

8.443.7.B CLASS I HEALTH CARE STATE-WIDE MAXIMUM ALLOWABLE PER

DIEM REIMBURSEMENT RATES (LIMIT)

For the purpose of reimbursing Medicaid-certified nursing facility providers a per diem rate for direct and indirect health care services and raw food, the state department shall establish an annual maximum allowable rate (limit). In computing the health care per diem limit, each nursing facility provider shall annually submit cost reports, and actual days of care shall be counted, not occupancy-imputed days of care. The health care limit will be calculated as follows:

a. Determination of the health care limit beginning on July 1 each year shall utilize the most current MED-13 cost report filed, in accordance with these regulations, by each facility on or before December 31 of the preceding year.

b. The MED-13 cost report shall be deemed filed if actually received by the Department’s designee or postmarked by the U.S. Postal Service on or before December 31.

c. If, in the judgment of the Department, the MED-13 contains errors, whether willful or accidental, that would impair the accurate calculation of the limit, the Department may:

i. Exclude part, or all, of a provider’s MED-13.

ii. Replace part, or all, of a provider’s MED-13 with the MED-13 the provider submitted in its most recent audited cost report adjusted by the percentage change in the Skilled Nursing Facility Market Basket (without capital) published by Global Insight, Inc. measured from the midpoint of the reporting period to the midpoint of the payment-setting period.

d. The health care limit and the data used in that computation shall be subject to administrative appeal only on or before the expiration of the thirty (30) day period following the date the information is made available.

e. The health care limit shall not exceed one hundred twenty-five percent (125%) of the median costs of direct and indirect health care services and raw food as determined by an array of all class I facility providers; except that, for state veteran nursing homes, the health care limit will be one hundred thirty percent (130%) of the median cost.

i. In determining the median cost, the cost of direct health care shall be case-mix neutral.

ii. Actual days of care shall be counted, not occupancy-imputed days of care, for purposes of calculating the health care limit.

iii. Amounts contained in cost reports used to determine the health care limit shall be adjusted by the percentage change in the Skilled Nursing Facility Market Basket (without capital) inflation indexes published by Global Insight, Inc. measured from the midpoint of the reporting period of each cost report to the midpoint of the payment-setting period.

The percentage change shall be rounded at least to the fifth decimal point.

The latest available publication prior to July 1 rate setting shall be used to determine the inflation indexes.

f. Annually, the state department shall redetermine the median per diem cost based upon the most recent cost reports filed during the period ending December 31 of the prior year.

g. The health care limit for health care reimbursement shall be changed effective July 1 of each year and individual facility rates shall be adjusted accordingly.

8.443.7.C. CLASS I HEALTH CARE PER DIEM LIMITATION ON HEALTH CARE

GROWTH

For the fiscal year beginning July 1, 2009, and for each fiscal year thereafter, any increase in the direct and indirect health care services and raw food costs shall not exceed eight percent (8%) per year. The calculation of the eight percent per year limitation for rates effective on July 1, 2009, shall be based on the direct and indirect health care services and raw food costs in the as-filed facility’s cost reports up to and including June 30, 2009. For the purposes of calculating the eight percent limitation for rates effective after July 1, 2009, the limitation shall be determined and indexed from the direct and indirect health care services and raw food costs as reported and audited for the rates effective July 1, 2009.

8.443.7.D. CLASS I HEALTH CARE PER DIEM REIMBURSEMENT RATES AND

MEDICAID CASE MIX INDEX (CMI):

For the purpose of reimbursing a Medicaid-certified class I nursing facility provider a per diem rate for the cost of direct and indirect health care services and raw food, the State Department shall establish an annually readjusted schedule to pay each nursing facility provider the actual amount of the costs. This payment shall not exceed the health care limit described at Section 8.443.7.B. The health care per diem reimbursement rate is the lesser of the provider’s acuity adjusted health care limit or the provider’s acuity adjusted actual allowable health care costs.
The state department shall adjust the per diem rate to the nursing facility provider for the cost of direct health care services based upon the acuity or case-mix of the nursing facility provider’s residents in order to adjust for the resource utilization of its residents. The state department shall determine this adjustment in accordance with each resident's status as identified and reported by the nursing facility provider on its federal Medicare and Medicaid minimum data set assessment. The state department shall establish a case-mix index for each nursing facility provider according to the resource utilization groups system, using only nursing weights. The state department shall calculate nursing weights based upon standard nursing time studies and weighted by facility population distribution and Colorado-specific nursing salary ratios. The state department shall determine an average case-mix index for each nursing facility provider's Medicaid residents on a quarterly basis 3. Acuity information used in the calculation of the health care reimbursement rate shall be determined as follows:

a. A facility’s cost report period resident acuity case mix index shall be the average of quarterly resident acuity case mix indices, carried to four decimal places, using the facility wide resident acuity case mix indices. The quarters used in this average shall be the quarters that most closely coincide with the cost reporting period.

b. The facility’s Medicaid resident acuity case mix index shall be a two-quarter average, carried to four decimal places, of the Medicaid resident acuity average case mix indices. The twoquarter average used in the July 1 rate calculation shall be the same two quarter average used in the rate calculation for the rate effective date prior to July 1.

c. The statewide average case mix index shall be a simple average, carried to four decimal places, of the cost report period case mix indices for all Medicaid facilities calculated effective each July 1.

d. The normalization ratio shall be determined by dividing the statewide average case mix index by the facility’s cost report period case mix index.

e. The facility Medicaid acuity ratio shall be determined by dividing the facility’s Medicaid resident acuity case mix index by the facility cost report period case mix index.

f. The facility overall resident acuity ratio shall be determined by dividing the facility cost report period case mix index by the statewide average case mix acuity index.

The annual facility specific direct health care maximum reimbursement rate shall be determined as follows:

a. The percentage of the normalized per diem case mix adjusted nursing cost to total health care cost shall be determined by dividing the normalized per diem case mix adjusted nursing cost by the sum of the normalized per diem case mix adjusted nursing cost and other health care per diem cost.

b. The statewide health care maximum allowable reimbursement rate (calculated at Section 8.443.7.B) shall be multiplied by the percentage established in the preceding paragraph to determine the amount of the statewide health care maximum allowable reimbursement rate that is attributable to the case mix reimbursement rate component.

c. The facility specific maximum reimbursement rate for case mix adjusted nursing costs shall be determined by multiplying the facility specific overall acuity ratio by the amount of the statewide health care maximum allowable reimbursement rate that is attributable to the case mix reimbursement rate component as established in the preceding paragraph.

The annual facility specific indirect health care maximum allowable reimbursement shall be determined as follows:

a. The percentage of the indirect health care per diem cost to total health care cost shall be determined by dividing the indirect health care per diem cost by the sum of the normalized per diem case mix adjusted nursing cost and other health care per diem cost.

b. The facility specific in direct health care maximum reimbursement rate shall be determined by multiplying the statewide health care maximum allowable reimbursement rate by the percentage established in the preceding paragraph.

The case mix reimbursement rate component shall be determined as follows:

a. The case mix reimbursement rate component shall be established using the facility Medicaid resident acuity ratio.

b. This ratio shall be multiplied by the lesser of the facility’s allowable case mix adjusted nursing cost or the facility specific maximum reimbursement rate for case mix adjusted nursing costs. The resulting calculation shall the case mix reimbursement rate component.

The indirect health care reimbursement rate shall be the lesser of the facility’s allowable other health care cost or the facility specific other health care maximum reimbursement rate.

8.443.7.E DETERMINATION OF THE HEALTH CARE SERVICES MAXIMUM

ALLOWABLE RATE (LIMIT) FOR CLASS II AND IV (ICF/IID) FACILITIES

For class II (ICF/IID) facilities, one hundred twenty-five percent (125%) of the median actual costs of all class II (ICF/IID) facilities;
For non-state administered class IV (ICF/IID) facilities, one hundred twenty-five percent (125%) of the median actual costs of all class IV (ICF/IID) facilities.
State-administered class IV (ICF/IID) facilities shall not be subject to the health care limit. The Med-13s of the state-administered class IV (ICF/IID) facilities shall be included in the health care limit calculation for other class IV (ICF/IID) facilities.
The determination of the reasonable cost of services shall be made every 12 months.
Determination of the health care limit beginning on July 1 each year shall utilize the most current MED-13 cost report filed in accordance with these regulations, by each facility on or before May 2.
The MED-13 cost report shall be deemed submitted if actually received by the Department’s designee or postmarked by the U.S. Postal Service on or before May 2nd.
If, in the judgment of the Department, the MED-13 contains errors, whether willful or accidental, that would impair the accurate calculation of reasonable costs for the class, the Department may:

a. Exclude part, or all, of a provider’s MED-13; or b. Replace part, or all, of a provider’s MED-13 with the MED-13 the provider submitted in its most recent audited cost report adjusted by the change in the “medical care” component of the Consumer Price Index published for all urban consumers (CPI-U) by the United States Department of Labor, Bureau of Labor Statistics over the time period from the provider’s most recent audited cost report.

State-administered class IV (ICF/IID) facilities shall not be subject to the maximum reasonable rate ceiling. The Med-13s of the state-administered class IV (ICF/IID) facilities shall be included in the maximum rate calculation for other class IV (ICF/IID) facilities.
The maximum reasonable rate and the data used in that computation shall be subject to administrative appeal only on or before the expiration of the thirty (30) day period following the date the information is made available.
The maximum rate for reimbursement shall be changed effective July 1 of each year and individual facility rates shall be adjusted accordingly.

8.443.8 REIMBURSEMENT FOR ADMINISTRATIVE AND GENERAL COSTS 8.443.8.A. Administration Costs means the following categories of reasonable, necessary and patient-related costs:

The salaries, payroll taxes, worker compensation payments, training and other employee benefits of the administrator, assistant administrator, bookkeeper, secretarial, other clerical help, hall monitors, security guards, janitorial and plant staff and food service staff. Staff who perform duties in both administrative and health care services shall maintain contemporaneous time records or perform a time study in order to properly allocate their salaries between cost centers. Time studies used must meet the criteria described in Section 8.443.7.A.1.
Any portion of other staff costs directly attributable to administration.

a. Universal Care Workers or Shahbazim are a certified nursing aid who additionally performs non-medical care services such as dietary or housekeeping functions in a green house or green house like setting. Expenses for these staff (salaries, payroll taxes, worker compensation payments, training and other employee benefits) shall be split 70% health care and 30% administration.

b. If a facility employee or a management company/home office employee or owner has dual health care and administrative duties, the provider must keep contemporaneous time records or perform time studies to verify hours worked performing health care related duties. If no contemporaneous time records are kept or time studies performed, total salaries, payroll taxes and benefits of personnel performing health care and administrative functions will be classified as administrative and general. Licenses are not required unless otherwise specified. Periodic time studies in lieu of contemporaneous time records may be used for the allocation. Time studies used must meet the following criteria:

i. A minimally acceptable time study must encompass at least one full week per month of the cost reporting period.

ii. Each week selected must be a full work week (Monday to Friday, Monday to Saturday, or Sunday to Saturday).

iii. The weeks selected must be equally distributed among the months in the cost reporting period, e.g., for a 12 month period, 3 of the 12 weeks in the study must be the first week beginning in the month, 3 weeks the 2nd week beginning in the month, 3 weeks the 3rd, and 3 weeks the fourth.

iv. No two consecutive months may use the same week for the study, e.g., if the second week beginning in April is the study week for April, the weeks selected for March and May may not be the second week beginning in those months.

v. The time study must be contemporaneous with the costs to be allocated. Thus, a time study conducted in the current cost reporting year may not be used to allocate the costs of prior or subsequent cost reporting years.

iv. The time study must be provider specific. Thus, chain organizations may not use a time study from one provider to allocate the costs of another provider or a time study of a sample group of providers to allocate the costs of all providers within the chain.

vii. Punch cards/timesheets or any method of tracking hours is acceptable and preferred.

Advertising and public relations.
Recruitment costs and staff want ads for all personnel.
Office supplies.
Telephone costs.
Purchased services: accounting fees, legal fees; computer network infrastructure fees. Computers and software used in administrative and general departments, including but not limited to human resources and benefits managements software.
Management fees and home office costs, except as described in

Section 8.443.7.A.13.

Licenses and permits (except health care licenses and permits) and training for administrative personnel, dues for professional associations and organizations.
All business-related travel of facility staff and consultants, except that required for transporting residents to activities or for medical purposes.
Insurance, including insurance on vehicles used for resident transport, and professional liability loss settlements, deductibles, associated legal fees and claims will be included in administrative.

a. Professional liability insurance premiums and brokerage surplus and stamping fees, whether self-insurance or purchased, is a health care cost.

Facility membership fees and dues in trade groups or professional organizations.
Miscellaneous general and administrative costs.
Purchase or rental of motor vehicles and related expenses for operating or maintaining the vehicles. However, such costs shall be considered health care services to the extent that the motor vehicles are used to transport residents to activities or medical appointments. Such use shall be documented by contemporaneous logs.
Purchases (including depreciation and interest), rentals, repairs, betterments and improvements of equipment utilized in administrative departments, including but not limited to the a. Resident room furniture and decor, excluding beds and mattresses;

b. Office furniture and décor;

c. Dining room and common area furniture and décor;

d. Lighting fixtures;

e. Artwork; and f. Computers and related software used in administrative departments.

Allowable audited interest not covered by the fair rental allowance or related to the property costs listed in Sections 8.443.8. B. and C. below.
All other reasonable, necessary and patient-related costs which are not specifically set forth in the description of “health care services” above, and which are not property, room and board, food or capital-related assets.
Background checks and flu or hepatitis shots and uniforms for personnel listed in (1) above.
Provider fees for Class I nursing facilities. 8.443.8.B Property costs include:
Depreciation costs of non-fixed equipment (i.e., major moveable equipment and minor equipment not used for direct health care);
Rental costs of non-fixed equipment (i.e., major moveable equipment and minor equipment not used for direct health care);
Property taxes;
Property insurance;
Mortgage insurance;
Interest on loans associated with property costs covered in this section;
Repairs, betterments and improvements to property not covered by the fair rental allowance; and 8. Repair, maintenance, betterments or improvement costs to property covered by the fair rental allowance payment which are to be expensed as required by the regulations regarding expensing of items. 8.443.8.C Room and board includes:
Dietary, other than raw food, and salaries related to dietary personnel including tray help, except registered dieticians which are health care;
Laundry and linen;
Housekeeping;
Plant operation and maintenance (except removal of infectious material or medical waste which is health care); and 5. Repairs, betterments and improvements to equipment related to room and board services. 8.443.8.D Determination of the Administrative and General Maximum Allowable Rate (Limit) for Class II and IV (ICF/IID) Facilities.
The determination of the reasonable cost of services shall be made every 12 months. The maximum allowable reimbursement of administration, property and room and board costs, excluding raw food, land, buildings and fixed equipment, shall not exceed:

a. For class II (ICF/IID) facilities, one hundred twenty percent (120%) of the median actual costs of all class II facilities.

b. For class IV (ICF/IID) facilities, one hundred twenty percent (120%) of the median actual costs of all class IV (ICF/IID) facilities.

c. Determination of the rates beginning on July 1 each year shall utilize the most current MED-13 cost report filed, in accordance with these regulations, by each facility on or before May 2.

d. The MED-13 cost report shall be deemed submitted if actually received by the Department’s designee or postmarked by the U.S.

Postal Service on or before May 2.

e. If, in the judgment of the Department, the MED-13 contains errors, whether willful or accidental, that would impair the accurate calculation of reasonable costs for the class, the Department may:

i. Exclude part, or all, of a provider’s MED-13; or ii. Replace part, or all, of a provider’s MED-13 with the MED-13 the provider submitted in its most recent audited cost report adjusted by the change in the “medical care” component of the Consumer Price Index published for all urban consumers (CPI-U) by the United States Department of Labor, Bureau of Labor Statistics over the time period from the provider’s most recent audited cost report to May 2.

f. State-administered class IV (ICF/IID) facilities shall not be subject to the maximum reasonable rate ceiling. The Med-13s of the state-administered class IV (ICF/IID) facilities shall be included in the maximum rate calculation for other class IV (ICF/IID) facilities.

g. The maximum reasonable rate and the data used in that computation shall be subject to administrative appeal only on or before the expiration of the thirty (30) day period following the date the information is made available.

h. The maximum rate for reimbursement shall be changed effective July 1 of each year and individual facility rates shall be adjusted accordingly. 8.443.8.E. Class I Administrative and General Per Diem Reimbursement Rate 1. For the purpose of reimbursing a Medicaid-certified class I nursing facility provider a per diem rate for the cost of its administrative and general services, the Department shall establish an annually readjusted schedule to pay each facility a reasonable price for the costs.

a. Determination of the class I rates beginning on July 1 each year shall utilize the most current MED-13 cost report submitted, in accordance with these regulations, by each facility on or before December 31 of the preceding year.

b. The reasonable price shall be a percentage of the median per diem cost of administrative and general services as determined by an array of all nursing facility providers.

i. For facilities of 60 licensed beds or fewer, the reasonable price shall be one hundred ten percent (110%) of the median per diem cost for all class I facilities.

ii. For facilities of 61 or more licensed beds, the reasonable price shall be one hundred five percent (105%) of the median per diem cost for all class I facilities.

iii. For facilities offering private room setting for all residents, the reasonable price shall be one hundred twenty percent (120%) of the median per diem cost for all class I facilities.

c. In computing per diem cost, each nursing facility provider shall annually submit cost reports to the Department.

d. Actual days of care shall be counted rather than occupancyimputed days of care.

e. The cost reports used to establish this median per diem cost shall be those filed during the period ending December 31 of the prior year following implementation.

f. Amounts contained in cost reports used to establish this median shall be adjusted by the percentage change in the Skilled Nursing Facility Market Basket (without capital) inflation indexes published by Global Insight, Inc., measured from the midpoint of the reporting period of each cost report to the midpoint of the payment-setting period.

i. The percentage change shall be rounded at least to the fifth decimal point.

ii. The latest available publication prior to July 1 rate setting shall be used to determine the inflation indexes.

g. For each succeeding fourth year, the Department shall redetermine the median per diem cost based upon the most recent cost reports filed during the period ending December 31 of the prior year.

h. The reasonable price established by the median per diem costs determined each succeeding fourth year will be adjusted annually at July 1st for the three intervening years. The reasonable price shall be adjusted by the annual percentage change in the Skilled Nursing Facility Market Basket (without capital) inflation indexes published by Global Insight, Inc. The percentage change shall be rounded at least to the fifth decimal point. The latest available publication prior to July 1 rate setting shall be used to determine the inflation indexes. 8.443.8.F For the purpose of reimbursing class II (ICF/IID) facilities a per diem rate for the cost of administrative and general services, the Department shall establish an annually readjusted schedule to reimburse each facility, as nearly as possible, for its actual or reasonable cost of services rendered, whichever is less, its case-mix adjusted direct health care services costs and a fair rental allowance for capital-related assets.

In computing per diem cost, each class II and class IV (ICF/IID) facility provider shall annually submit cost reports to the Department.
The per diem reimbursement rate will be total allowable costs for administrative and general and health care services (actual or the limit per

Section 8.443.7.D) divided by the higher of actual resident days or occupancy imputed days per Section 8.443.3.

An inflation adjustment per Section 8.443.4B will be applied to the per diem administrative and general and health care reimbursement rates.
An incentive allowance for administrative and general costs may be included per Section 8.443.5.
Each facility will be paid a per diem for capital-related assets per Section 8.443.9.A.

8.443.9 FAIR RENTAL ALLOWANCE FOR CAPITAL-RELATED ASSETS

8.443.9.A. FAIR RENTAL ALLOWANCE: DEFINITIONS AND SPECIFICATIONS

For purposes of this section concerning fair rental allowance, the following definitions shall apply:

a. Appraised value” means the determination by a qualified appraiser who is a member of an institute of real estate appraisers, or its equivalent, of the depreciated cost of replacement of a capitalrelated asset to its current owner. The depreciated replacement appraisal shall be based on the valuation system as determined by the Department.

i. The depreciated cost of replacement appraisal shall be redetermined every four years by new appraisals of the nursing facilities.

b. Base value means:

i. The appraised value of a capital-related asset for the fiscal year 1986-87 and every fourth year thereafter.

ii. The most recent appraisal together with fifty percent of any increase or decrease each year since the last appraisal, as reflected in the index, for each year in which an appraisal is not done pursuant to subparagraph (i) of this paragraph (b).

iii. For the fiscal year 1985-86, the base value shall not exceed twenty-five thousand dollars per licensed bed at any participating facility, and, for each succeeding fiscal year, the base value shall not exceed the previous year’s limitation adjusted by any increase or decrease in the index.

iv. An improvement to a capital-related asset, which is an addition to that asset, shall increase the base value by the acquisition cost of the improvement.

c. Capital-Related Asset means the land, buildings, and fixed equipment of a participating facility.

d. Fair Rental Allowance means the product obtained by multiplying the base value of a capital-related asset by the rental rate.

e. Fair Rental Allowance per diem rate means the fair rental allowance described above, divided by the greater of the audited patient days on the provider’s annual cost report or ninety percent (90%) of licensed bed capacity on file. This calculation applies to both rural and urban facilities.

f. Fiscal Year means the State fiscal year from July 1 through June 30.

g. Fixed equipment means building equipment as defined under the Medicare principle of reimbursement as specified in the Medicare Provider Reimbursement Manual CMS Publication #15-1, part 1,

section 104.3. Specifically, building equipment includes attachments to buildings, such as wiring, electrical fixtures, plumbing, elevators, heating systems, air conditioning systems, etc. The general characteristics of this equipment are:

i. Affixed to the building and not subject to transfer; and ii. A fairly long life but shorter than the life of the building to which it is affixed.

h. Index means the square foot construction costs for nursing facilities in the Means Square Foot Costs Book, which shall be the most recent publication of RSMeans data that is updated quarterly (section M.450, “Nursing Home”), hereafter referred to as the Means Index.

i. Rental Rate means the average annualized composite rate for United States treasury bonds issued for periods of ten years and longer plus two percent; except that the rental rate shall not exceed ten and three-quarters percent nor fall below eight and one-quarter percent.

In the case of facilities for which an appraisal was completed pursuant to RFP GB 347 (October 21, 1985) and no major physical plant expansions or additions were completed prior to the Department’s reappraisal of the property, the following data shall remain unchanged through following appraisals:

a. Average story height;

b. Gross floor area;

c. Total perimeter;

d. Construction classification;

e. Construction quality; and f. Year built.

In the case of those facilities that have completed a major physical plant expansion, addition or deletion, the initial appraisal measurements and data specified in paragraph 2 above shall be modified only to the extent of the relevant appraisal data specific to the new expansion, addition or deletion.
The appraisal shall take into consideration the economic impact the addition, deletion or use modification may have had on the overall value of the entire facility.
The variables from the nationally-recognized valuation system determined by the Department that are to be calculated/determined by the Department or its designee, and which will be incorporated into the Request for Proposal (RFP) which defines the scope of the appraisals, include:

a. Record information: State identification number of the nursing facility as provided by the Department;

b. Property owner: Name of nursing facility;

c. Street, address, city;

d. Zip code;

e. Land value;

f. Section number: Assign lowest to oldest section and have basements immediately follow the section they are beneath;

g. Occupancy: Primarily nursing facility or basement;

h. Construction classification i. Number of stories;

j. Gross floor area: The determination of the exterior dimensions of all interior areas including stairwells of each floor. In addition, interior square footage measurements shall be reported for (a) nonnursing facility areas; (b) shared service area by type of service; and (c) revenue-generating areas so that these non-nursing facility portions of the facility can be omitted from the total square footage or allocated based on their nursing facility related use;

k. Construction quality;

l. Year nursing facility was built;

m. Building effective age;

n. Building condition;

o. Exterior wall material;

p. Total perimeter: Common walls between sections shall be excluded from both sections;

q. Average story height;

r. Roof material;

s. Roof pitch;

t. Heating System;

u. Cooling system;

v. Plumbing fixtures (Basements only);

w. Passenger Elevators: Actual number;

x. Freight elevators: Actual number;

y. Sprinkler system: Percent of gross area served;

z. Manual Fire Alarm System: Percent of gross area served;

aa. Automatic fire detection: Percent of gross area served;

bb. Floor finish;

cc. Ceiling finish;

dd. Total partition walls (Basement only);

ee. Partition wall structure;

ff. Partition wall finish;

gg. Miscellaneous additional items: All components not included in the preceding list and also not automatically calculated by the nationally-recognized valuation system determined by the Department shall be included here. The appraiser shall use professional judgment when valuing such items. Items shall be entered at depreciated value;

hh. Site improvements: Items shall be included at depreciated value, except landscaping, to be determined by the appraiser based upon professional judgment. Depreciation for site improvements, in many instances, is different from the depreciation for the structure. A list of site improvements and corresponding values shall be retained with the appraiser's work papers; and ii. User adjustment factor: Used in those cases where facilities are appraised in total and only partly used as a nursing facility, i.e., hospital and nursing facility combined or a residential and nursing facility combined.

The fair rental allowance shall only be adjusted due to the following:

a. The base value of a facility shall be increased in subsequent cost reports due to improvements. Construction-in-progress will not be considered an improvement until the project is complete and the asset is placed into service;

b. At the start of a new state fiscal year by a new rental rate amount or additional indices;

c. The base value of a facility can be decreased by a change in either the physical (structural) condition and/or use modification of the facility;

d. The provider has constructed and occupied a new physical plant and is no longer using the old structure for providing care to nursing facility residents. Base value shall be a new appraisal conducted by the Department or its designee at the time the new physical plant is ready for occupancy. i The provider shall continue to be reimbursed at the old fair rental allowance rate until the first scheduled MED-13 after the move sets a new rate. ii A new appraisal shall be performed to coincide with the filing of the next scheduled cost report following the move.

8.443.9.B FAIR RENTAL ALLOWANCE PER DIEM REIMBURSEMENT RATES

In addition to the reimbursement components paid pursuant to Section 8.443.7 (Health Care Services) and 8.443.8 (Administrative and General Costs), a per diem rate constituting a fair rental allowance for capitalrelated assets shall be paid to each nursing facility provider as a rental rate based upon the nursing facility's appraised value.

a. For the purpose of reimbursing Medicaid-certified nursing facility providers a per diem rate for capital-related assets, the state department shall establish an annual per bed limit.

b. The annual per bed limit established July 1, 1985 is $25,000 per bed plus the percentage rate of change in the Means Index.

i. Effective for cost reports establishing a July 1, 2028, rate, the bed limit will be doubled for facilities that provide private room settings for all residents.

Residents choosing to share a room shall not disqualify a facility that is otherwise eligible for the doubled bed cap.

c. The Means Index means the square foot construction costs for nursing facilities in the RSMeans Square Foot Costs Book, a publication of Gordian that is updated annually (section M.450, “Nursing Home”).

d. The per bed limit shall be changed effective July 1 of each year and individual facility rates shall be adjusted accordingly.

e. The fair rental allowance will be calculated for each facility using the lesser of the Base Value plus non-appraisal year modifications to the physical structure due to improvements or a change in the condition and/or use of the facility subsequent to the appraisal increased or decreased by fifty percent (50%) of the change in the Means Index or the annual per bed limit.

f. In computing the fair rental allowance per diem rate, the fair rental allowance is multiplied by the rental rate to obtain the annual allowable fair rental payment.

g. The rental rate is the average annualized composite rate for United States treasury bonds issued for periods of ten years and longer plus two percent; except that the rental rate shall not exceed ten and three-quarters percent nor fall below eight and one-quarter percent.

h. The resulting fair rental payment amount is divided by the greater of the audited patient days based on the provider’s annual cost report or ninety percent (90%) of licensed bed capacity on file.

This calculation applies to both rural and urban facilities.

8.443.10 COGNITIVE PERFORMANCE SCALE, PREADMISSION SCREENING

AND RESIDENT REVIEW II, AND MEDICAID UTILIZATION SUPPLEMENTAL

PAYMENTS

8.443.10.A COGNITIVE PERFORMANCE SCALE SUPPLEMENTAL PAYMENT

The Department shall pay a supplemental payment to nursing facility providers who have residents with moderate to very severe mental health conditions, cognitive dementia, or acquired brain injury, based upon the resident's score on the Cognitive Performance Scale (CPS).

a. Annually, the Department shall calculate the payment by multiplying a CPS per diem rate by CPS Medicaid days.

b. The CPS per diem rate is calculated based on the number of standard deviations a nursing facility provider’s CPS percentage is above the statewide average CPS percentage. The CPS per diem rate shall be determined in accordance with the following table:

Standard Deviation Above Statewide Average CPS Per Diem Average + 1 Standard 1x Average + 2 Standard 2x Average + 3 Standard 3x i. The CPS per diem rate multiplier (x) shall equal an amount such that the total statewide CPS supplemental payment divided by total statewide CPS Medicaid days equal two percent of the statewide average July 1 Core Component per diem rate.

c. The CPS percentage is the sum of Medicaid residents with a CPS score of 4, 5, or 6 divided by the sum of Medicaid residents.

i. Medicaid residents with a CPS score of 4, 5, or 6 are determined using the Department utilized case mix classification system and reported on the MDS form.

ii. The determination of Medicaid residents with a CPS score of 4, 5, or 6 shall be made using the April MDS roster.

d. CPS Medicaid patient days shall equal the count of Medicaid residents with a CPS score of 4, 5, 6, or equivalent, multiplied by the days in the year.

e. The Department shall perform these calculations annually to 8.443.10.B PREADMISSION SCREENING AND RESIDENT REVIEW II SUPPLEMENTAL PAYMENT 1. The Department shall pay a supplemental payment to nursing facility providers who have residents with severe mental health conditions or developmental disabilities that are classified at Level II by the Medicaid program's preadmission screening and resident review assessment tool (PASRR II).

a. Annually, the Department shall calculate the payment by multiplying a PASRR II per diem rate by Medicaid PASRR II days.

b. Medicaid PASRR II days shall equal the count of PASRR II residents on May 1, multiplied by the days in the year.

c. The PASRR II per diem rate shall equal four percent of the statewide July 1 Core Component per diem rate.

d. The Department shall pay an additional PASRR II supplemental payment to facilities that offer specialized behavioral services to residents who have severe behavioral health needs. These services shall include enhanced staffing, training, and programs designed to increase the resident’s skills for successful community reintegration.

e. The additional PASRR II supplemental payment for nursing facility providers that have an approved specialized behavioral services program shall be calculated using the methodology described in

Section 8.443.10.B.1 through Section 8.443.10.B.3.

f. The Department shall perform these calculations annually to 8.443.10.C MEDICAID UTILIZATION SUPPLEMENTAL PAYMENT 1. The Department shall pay a supplemental payment to nursing facility providers for care and services rendered to Medicaid residents.

a. Annually, the Department shall calculate the payment by multiplying the percentage of Medicaid patient days by the provider fee as described in Section 8.443.17.

b. The percentage of Medicaid patient days shall be Medicaid patient days divided by total patient days.

c. Medicaid patient days shall be determined using Medicaid paid d. Total patient days shall be reported by a nursing facility provider to the Department for the calendar year ending prior to July 1. The Department shall annualize or estimate total patient days for nursing facility providers reporting less than a full year.

e. The Department shall perform these calculations annually to coincide with the July 1 rate-setting process.

8.443.11 CORE COMPONENT AND ADJUSTED CORE COMPONENT

SUPPLEMENTAL PAYMENTS

8.443.11.A CORE COMPONENT SUPPLEMENTAL PAYMENT

The Department shall pay a supplemental payment to nursing facility providers for the difference between the Core Component per diem rate and the MMIS per diem reimbursement rate.

a. Annually, the Department shall calculate the payment by taking the difference between the MMIS per diem reimbursement rate and the Core Component per diem rate, both described in Section 8.443.1.B, multiplied by applicable Medicaid patient days.

b. Applicable Medicaid patient days shall equal Medicaid patient days divided by the days in the year, multiplied by the days the Core Component per diem rate was effective.

c. Medicaid patient days shall be determined using Medicaid paid d. The Department shall perform these calculations annually to 8.443.11.B ACUITY ADJUSTED CORE COMPONENT SUPPLEMENTAL PAYMENT 1. The Department shall pay a supplemental payment to nursing facility providers for the difference between the Core Component per diem rate and the adjusted Core Component per diem rate for the prior year.

a. Annually, the Department shall calculate the payment by taking the difference between the prior year Core Component per diem rate and the prior year adjusted Core Component per diem rate, multiplied by applicable Medicaid patient days.

b. Applicable Medicaid patient days shall equal Medicaid patient days divided by the days in the prior year, multiplied by the days an adjusted Core Component per diem rate was effective.

c. Medicaid patient days shall be determined using Medicaid paid d. The Department shall perform these calculations annually to 8.443.12 PAY-FOR-PERFORMANCE SUPPLEMENTAL PAYMENT 1. The Department shall pay a supplemental payment to those Class I nursing facilities that provide services resulting in better care and higher quality of life for their residents.

a. Annually, the Department shall calculate the payment by multiplying a Pay-for-Performance (P4P) per diem rate by Medicaid patient days.

b. The P4P per diem rate for a Class I nursing facility is determined using their P4P points. The per diem rates are tiered such that Class I nursing facilities with greater points receive a higher per diem rate than facilities with lesser points. There are five tiers delineating the per diem rates with each tier assigned a certain points range. For each tier, the per diem rate increases by a multiplier.

c. The multiplier and point range for each tier are:

P4P Points Per Diem Rate 0 – 20 points 0(x) 21 – 45 points 1(x) 46 – 60 points 2(x) 61 – 79 points 3(x) 80 – 100 points 4(x)

d. For SFY 2024-25 and 2025-26, the P4P per diem rates shall equal an amount such that total P4P payments made to all Class I nursing facilities shall be no less than twelve percent (12%) of the total of all annual Provider Fee supplemental payments. For SFY 2026-27 and all subsequent years, the P4P per diem rates shall equal an amount such that total P4P supplemental payments made to all Class I nursing facilities shall be no less than fifteen percent (15%) of the total of all annual Provider Fee supplemental payments.

e. The P4P points shall be based on a completed and verified/audited application including performance measures in the domains of quality of life, quality of care, and nursing facility management.

f. The application includes the following:

i. The number of points associated with each performance measure;

ii. The criteria the nursing facility must meet or exceed to qualify for the points associated with each performance measure.

g. The prerequisites for participating in the program are as follows:

i. The facility must perform a resident/family satisfaction survey in the manner determined by the department and published annually on the pay for performance application published to the department’s website.

i. A nursing facility will receive one half of the calculated payment if the facility has received substandard quality of care deficiencies on a regular annual, complaint, or any other CDPHE survey.

h. To apply for a P4P supplemental payment, the nursing facility must have the requirements for each Domain/sub-category in place at the time of submitting an application for additional payment. The nursing facility must maintain documentation supporting its representations for each performance measure for which the facility represents it meets or exceeds the specified criteria.

Additionally, the nursing facility must submit with its application the required documentation for each performance measure as identified on the application.

i. Applications and supporting documentation shall be considered complete as received. No post receipt or additional information shall be accepted after submission of the application. Facilities shall be selected for onsite verification of performance measures representations based on risk.

j. A nursing facility may accumulate a maximum of 100 points by meeting all performance measures indicated on the application.

k. Medicaid patient days shall be determined based on claims data from the MMIS and/or information provided by the nursing facility for the most recently completed calendar year ending prior to the calculation of the supplemental payment.

l. The supplemental Medicaid payment shall be divided by twelve and reimbursed monthly to Class I nursing facilities. For state administered Class I nursing facilities the amount shall be divided by four and reimbursed quarterly.

8.443.13 RATE EFFECTIVE DATE 8.443.13.A For cost reports filed by Class 1 nursing facility providers, a July 1 Core Component per diem rate and subsequent adjusted Core Component per diem rates shall be established by the Department based on the last day of the cost reporting fiscal year end.

Core Component per diem rates shall be established as follows:

a. On July 1 in accordance with the table below.

b. On the first day of the 23rd month following the end of the facility’s cost reporting period.

c. On the first day of the 6th month following the 23rd month rate effective date.

d. If the 23-month or 6-month rate coincide with July 1, only a July 1 and a January 1 rate shall be established e. If the 6-month rate is after the July 1 rate set by the subsequent cost report, only a July 1 and 23-month rate shall be established.

Cost Report Fiscal Year End July 1 Rate Effective 23 Month 6 Month 01/31/Year 1 07/01/Year 12/01/Year 2 06/01/Year 3 02/28/Year 1 07/01/Year 01/01/Year 3 (N/A) 03/31/Year 1 07/01/Year 02/01/Year 3 (N/A) 04/30/Year 1 07/01/Year 03/01/Year 3 (N/A) 05/31/Year 1 07/01/Year 04/01/Year 3 10/01/Year 3 06/30/Year 1 07/01/Year 05/01/Year 3 11/01/Year 3 07/31/Year 1 07/01/Year 06/01/Year 3 12/01/Year 3 08/31/Year 1 07/01/Year (N/A) 01/01/Year 4 09/30/Year 1 07/01/Year 08/01/Year 3 02/01/Year 4 10/31/Year 1 07/01/Year 09/01/Year 3 03/01/Year 4 11/30/Year 1 07/01/Year 10/01/Year 3 04/01/Year 4 Cost Report Fiscal Year End July 1 Rate Effective 23 Month 6 Month 12/31/Year 1 07/01/Year 11/01/Year 3 05/01/Year 4 8.443.13.B For 12-month cost reports filed by the State-administered Class IV nursing facility (ICF/IID) providers, the rate shall be effective on the first day covered by the cost report. 8.443.13.C Any delay in completion of the audit of the MED-13 that is attributable to the provider, shall operate, on a time equivalent basis, to extend the time in which the Department shall establish the Schedule of Core Components Reimbursement Rates, under the provisions set forth in Section 8.443.13.A above. 8.443.13.D Delay in completion of the audit that is attributable to the provider shall include, but not be limited to, the following:

Failure of the provider to meet with the contract auditor at reasonable times requested by the auditor;
Failure of the provider to supply the contract auditor with information reasonably needed to complete the audit, including the Medicare cost report that the provider most recently filed with the Medicare fiscal intermediary or other Medicare information approved by the Department.
The time period that elapses during completion of the procedures described Section 8.442.1.

8.443.14 RATES FOR NEW FACILITIES 8.443.14.A. A new nursing facility means a facility:

That has not previously been certified for participation under Title XIX of the Social Security Act (42 U.S.C. section 1396r); or 2. That has not participated in Title XIX for a period in excess of 30 days prior to the effective date of the current Title XIX certification; or 3. That has changed from one class designation to another. 8.443.14.B. Nursing facilities that have undergone a transfer of ownership are not new nursing facilities provided the previous owner had participated in Title XIX in the last 30 days prior to ownership change. 8.443.14.C. A new nursing facility shall receive a per diem rate equal to the most recent average weighted rate for the appropriate nursing facilities class at the time the new facility begins business as a Medicaid provider.
This per diem rate shall remain in effect until a new rate is established based on the first cost report submitted as specified below.
The average weighted rate shall be calculated by the Department on the 30th of each month and shall not be revised when new rates are established which would retroactively affect the calculation.
The average weighted rate paid a new facility shall be adjusted on July 1 each year by the average weighted rate in effect on July 1. 8.443.14.D. New nursing facilities shall submit MED-13s during their initial year of operation as follows:
The first cost report shall be for a period covering the first day of operation through the facility’s fiscal year end.

a. If the first cost report for the period covers a period of 90 days or more, imputed occupancy shall be applied as described in Section 8.443.3.A.

b. If the first cost report for the period covers a period of 90 days or more, the first cost report shall set the base for limitations on growth of allowable costs as described in Section 8.443.11.A.

If the first cost report for the period specified above covers a period of 89 days or less, the facility’s first cost report shall not be submitted until the next fiscal year end.
The next cost report shall be submitted for the twelve-month period following the period of the first cost report.
A new nursing facility shall advise the Department of the date its fiscal year will end and of the reporting option selected. 8.443.14.E. Imputed occupancy shall be applied to the first cost report submitted by a new class II (ICF/IID) facility. The facility shall be entitled to the higher of the imputed rate or the monthly weighted average rate computed by the Department. 8.443.14.F. Imputed occupancy shall be applied to the second cost report submitted by a new class II (ICF/IID) facility. The rate for the new facility shall not be lower than the 25th percentile nursing facility rate as computed by the Department in median computation.

8.443.15 CHANGE OF OWNERSHIP, CHANGE IN TAX ID ONLY, OR

WITHDRAWAL FROM MEDICAID 8.443.15.A. A licensed nursing facility owner(s) that intends to change the ownership of a Medicaid nursing facility, change in tax ID only, or that intends to terminate its participation in the Medicaid program, shall notify the Department in writing at least 45 calendar days in advance of the proposed change or termination.

The advance written notice shall include a specific date for the proposed change or termination and shall be delivered to the Department.
The exact date of the change of ownership or termination of Medicaid participation shall be subject to approval by the Department.
If the facility is terminating participation with the Medicaid program, and there is no successor owner, the licensed nursing facility must maintain documentation and contact with the Department until the closing audit can be performed per Section 8.424.
If the change does not require a change in tax ID, the licensed nursing facility billing provider number and NPI will continue.
If the change requires a change in tax ID, and maintains the same owner, the facility must submit a new enrollment application with the Department, with a new NPI number to obtain a new billing provider number.
If the change is to a successor owner, the transferring owner must disenroll after the change of ownership effective date, as determined by a. The successor owner must submit an enrollment application to obtain a new billing provider number.

b. The successor owner shall not bill for services using the transferring owner’s billing provider number, and any such payments are subject to recoupment.

c. The successor owner must obtain all resident records and documents from the transferring owner. Records and documents must be available for review by the Department.

A change of ownership or closing audit is required under Section 8.424.

a. The Department may withhold all or part of any monies due the prior nursing facility licensee until the change of ownership or closing audit is completed.

The transferring owner must perform a Personal Needs Account reconciliation prior to transferring funds to the successor owner per

Section 8.482.52.C. 8.443.15.B. In the case of a change of ownership which does require a new license from CDPHE:

The transferring owner's Medicaid certification shall be assigned to the successor owner. The assignment of the Medicaid certification shall not be effective prior to the effective date of the successor owner's nursing facility license from CDPHE..
Prior to the termination of the transferring owner's Medicaid provider agreement, the Department shall have the discretion to withhold reimbursement to the transferring owner for whatever period of time is necessary to recover overpayments or other debts owed to the Department by the transferring owner.
The successor owner shall file a new application for a Medicaid provider agreement with the Department or its designated agent. The Department may delay the effective date of the successor owner's Medicaid provider agreement until the expiration of the withholding period described in the preceding paragraph 2, or until the Department has approved alternative payment arrangements or security for the transferring owner's debts. 4, No Medicaid reimbursement shall be paid to the successor owner until the application for a Medicaid provider agreement has been approved, regardless of the effective date of the successor owner's license from CDPHE.

E. 8.443.15.C. An assigned Medicaid certification shall be subject to all applicable statutes and regulations and to the terms and conditions under which it was originally issued, including but not limited to the following:

Any existing plan of correction;
Any expiration date for a Class II provider agreement;
Compliance with applicable health and safety requirements;
Compliance with the ownership and financial interest disclosure requirements, and any other requirements described elsewhere in this staff manual;
Compliance with the civil rights requirements cited in the provider agreement; and 6. At the discretion of the Department, payment of any debts or other obligations, whether known, fixed, definite, liquidated, or not, owed to the Department by the transferring owner. Such liability may also apply, at the discretion of the Department, to any debts or obligations that arose under any earlier, assigned provider agreement(s).
The assignment of liability described in the preceding paragraph 6 shall not prejudice the Department's right to pursue any remedy against a previous facility owner or owners for repayment of the assigned debts or obligations. 8.443.15.F. A licensed nursing facility owner that transfers ownership or terminates its Medicaid participation shall submit a final MED-13 covering the period from the ending date of the last previous report through the date of the transfer or termination.
The initial rate for the successor owner shall be the rate which would have been paid to the previous owner based on the audited final cost report.
If the previous owner's final cost report is for a period of less than 89 days, that report shall be disregarded and the previous owner's last cost report for a twelve (12) month period shall be used to set a rate for the successor owner.

8.443.16 STAT E-OPERATED ICF/IID (CLASS IV) 8.443.16.A State-operated ICF/IID (class IV) shall be reimbursed based on the actual costs of administration, property, including capital-related assets, and room and board, and the actual costs of providing health care services. Actual costs will be determined on the basis of information on the MED-13 and information obtained by the Department or its designee retained for the purpose of cost auditing.

These costs shall be projected by such facilities and submitted to the state department by July 1 of each year for the ensuing twelve-month period.
Reimbursement to state-operated Intermediate Care Facilities for Individuals with Intellectual Disabilities shall be adjusted retrospectively at the close of each twelve-month period.
The retrospective per diem rate will be calculated as total allowable costs divided by total resident days.

8.443.17 CLASS I NURSING FACILITY PROVIDER FEES 8.443.17.A The Department shall charge and collect provider fees on health care items or services provided by nursing facility providers for the purpose of obtaining federal financial participation under the state’s medical assistance program. The provider fees shall be used to sustain or increase reimbursement for providing medical care under the state’s medical assistance program for nursing facility providers.

A Class I nursing facility provider that is licensed in this State shall pay a fee assessed by the Department.
The following nursing facility providers are exempt from the provider fee:

a. A nursing facility provider operated as a continuing care retirement community (CCRC) that provides a continuum of services by one operational entity providing independent living services, assisted living services and skilled nursing care on a single, contiguous campus. Assisted living services include assisted living residences as defined in C.R.S. § 25-27-102(1.3), or that provide assisted living services on-site, twenty-four hours per day, seven days per week;

b. A nursing facility provider owned and operated by the state;

c. A nursing facility provider that is a distinct part of a facility that is licensed as a general acute care hospital; and d. A nursing facility provider that has forty-five or fewer licensed beds.

Annually, the Department shall calculate the provider fee by multiplying a per diem fee by non-Medicare patient days.
The per diem fee shall equal the previous year per diem fee increased by an inflation factor.

a. The inflation factor shall be based on a national skilled nursing facility market basket index. The inflation factor is the inflation index at the midpoint of the current year divided by the inflation index at the midpoint of the previous year.

b. The Department shall lower the per diem fee for nursing facility providers with 55,000 total patient days or more to meet the requirements of 42 C.F.R. § 433.68(e). The 55,000 total patient day threshold may be modified to meet the requirements of 42 C.F.R. § 433.68(e).

Non-Medicare patient days shall be reported by a nursing facility provider to the Department for the calendar year ending prior to July 1.

a. A nursing facility provider’s non-Medicare patient days shall be estimated to determine the provider fee if and only if one of the following conditions exist:

i. A new nursing facility provider, ii. A nursing facility provider that will close during the rate year, iii. A nursing facility provider that has had a change of certification or licensure.

b. The nursing facility provider shall have non-Medicare patient days estimated for each model year until the nursing facility provider has twelve months of data for the calendar year preceding the calendar year ending prior to July 1.

c. If a nursing facility provider’s non-Medicare patient days are estimated, the Department shall compare estimated non-Medicare patient days to actual non-Medicare patient days in the subsequent year. If a nursing facility provider’s actual non- Medicare days differ by more than five percent from estimated non-Medicare patient days, the Department shall multiply the difference by the prior year per diem fee and add it in the current year provider fee.

These calculations will be performed annually to coincide with the July 1 rate setting process.
The Department shall assess the provider fee monthly.
The fee assessed pursuant to this section is due at most thirty days after the end of the month for which the fee was assessed. 8.443.17.B All provider fees collected pursuant to this section by the state department shall be transmitted to the state treasurer, who shall credit the same to the Medicaid nursing facility cash fund, which fund is hereby created and referred to in this section as the “fund.”
All monies in the fund shall be subject to federal matching as authorized under federal law and subject to annual appropriation by the general assembly for the purpose of paying the administrative cost of collecting and maintaining nursing facility provider fees.
Following payment of the amounts described above, the moneys remaining in the fund for the purpose of paying nursing facility provider fee payments.3. Any monies in the fund not expended for these purposes may be invested by the state treasurer as provided by law.

a. All interest and income derived from the investment and deposit of moneys in the fund shall be credited to the fund.

b. Any unexpended and unencumbered moneys remaining in the fund at the end of any fiscal year shall remain in the fund and shall not be credited or transferred to the general fund or any other fund but may be appropriated by the general assembly to pay nursing facility providers in future fiscal years. 8.443.17.C The Department shall establish administrative penalties for the late payment by a nursing facility of a fee assessed pursuant to this section.

The state department may recoup any payments made to nursing facilities providing services pursuant to the Medicaid program up to the amount of the fees owed as determined pursuant to this section and any administrative penalties owed if a nursing facility fails to remit the fees and administrative penalties owed within 30 days after the date they are due.

Before recoupment of payments pursuant to this section, the state department may allow a nursing facility that fails to remit fees and administrative penalties owed an opportunity to negotiate a repayment plan with the state department. The terms of the repayment plan may be established at the discretion of the state department. 8.443.17.D The Department will prepare an annual reconciliation of provider fees received and payments made. Any shortfall or excess in the provider fee cash fund will be used to increase or reduce provider fees in the following year. Except that in the event the state department determines there is not enough provider fee available, the state department may reduce payments to facilities proportionately to the amount of provider fee available. The state department can, at its discretion, establish a provider fee fund minimum balance or cash reserve.

8.443.18 RATES FOR RECEIVERSHIP 8.443.18.A. The following rate provisions apply for a facility where a receiver has been appointed by a court of competent jurisdiction, pursuant to C.R.S. § 25-3-108, at the request of CDPHE:

During the Receivership a. During the term of the receivership, the facility shall be reimbursed the rate payable to the previous operator.

i. The Department may increase the rate if it finds that the patient-related, necessary and reasonable costs of the facility operation are not covered by the rate payable to the previous operator.

ii. The Department's analysis of necessary, patient related and reasonable costs incurred by the receiver shall not include any previous unpaid expenses of the prior owner or the mortgage costs of the facility.

b. The receiver shall submit a cost report for the time beginning when the receiver is appointed until the time the receiver is no longer operationally in control of the nursing facility operation.

i. This cost report shall set a rate payable to the receiver for the date the receiver took operational control of the facility.

ii. This retrospective rate may set a rate higher or lower than the initial rate established and paid to the receiver in which case the under or over payment shall be either paid to or collected from the receiver.

iii. The retrospectively set rate shall not exceed the established maximum allowable rates for that period.

New providers after the receivership period a. The new operator shall receive the rate paid to the prior owner until the new provider submits a cost report unless the new operator chooses the retrospective option described below where a new operator takes control and ownership of a nursing facility from the receiver.

b. The new operator may elect to have a retrospective rate set for the initial three months of operation.

i. In order to exercise this option, the new operator shall file a cost report for the first three months of operation.

ii. The first day of operation shall mean the first day of licensure of the new operator. The last day of the initial three months of operation shall be the last day of the month in which the 90th day occurs.

iii. The cost report shall be filed within 90 days of the end of the initial three months of operation.

c. The retrospective rate established from the three-month cost report shall be in effect from the first date of licensure of the new owner until the last day of the month in which the 90th day occurs. This rate shall be a prospectively paid rate to the new operator beginning with the first day of the month after the three-month cost reporting period.

d. The initial rate paid to the new operator shall be the prior owner's rate.

i. The retrospective rate established by the three-month cost report shall replace the initial rate paid to the operator.

ii. The retrospective rate may be higher or lower than the initial rate established and paid to the new operator in which case the under or over payment shall be either paid to or collected from the new operator.

iii. The retrospectively established rate shall not exceed the maximum reasonable cost rates for that period.

e. The three-month cost report shall establish the prospective rate for the period established by the regulations at Section 8.443.13.

f. The provider shall file the first cost report after the three-month cost report. If the first cost report filed for the period immediately following the three-month cost report demonstrates a reduction in per diem costs more than five percent which is caused by a reduction in per diem costs and not an increase in census, the following special provision shall apply:

i. The provider's prospective per diem rate driven by the threemonth cost report shall be retroactively reduced to the per diem rate as determined by the actual costs of the provider.

ii. The Department shall recover the difference between the provider's actual costs and the prospective rate paid to the provider. This recovery shall not apply to the three-month retrospective rate as established by the initial three-month cost report. 8.443.18.B. These special provisions do not apply when the receiver is appointed at the request of any other party such as the previous operator, landlord or other interested party.

8.443.19 PAYMENT FOR OUT OF STATE NURSING FACILITY CARE 8.443.19.A. Payments for out-of-state nursing facility care shall be made to providers when:

The nursing facility services are needed because of a medical emergency.
A physician has verified in the resident’s medical records that the resident's health would be endangered if they were required to travel to Colorado.
The Department determines, on the notification from the client’s primary care physician, the needed medical services or necessary supplementary resources, are not available in Colorado but are available in another state;

a. The Department’s State Utilization Review Contractor may review the appropriateness of care plan and documentation that the resident will demonstrate significant improvement. 8.443.19.B. Where the resident needs rehabilitation services, the resident shall meet all of the following criteria:

The resident's medical condition, as documented by the physician, shall be stable to the extent that the resident's primary need is no longer for acute medical care but for intensive, multi-disciplinary rehabilitation care.
The resident's disability shall be within 12 months of admission. 8.443.19.C. The out-of-state nursing facility shall send the following to the Department monthly:
Problem list and rehabilitation goals;

a. Treatment plan relative to each rehabilitation goal;

b. Time frame for goal achievement; and 2. Statement of expected discharge status (e.g., timing and the resident's condition on discharge). 8.443.19.D. Residents without need for rehabilitation services must meet admission requirements set forth at Sections 8.402.01 through 8.402.10, and can be admitted if:

It is general practice for residents in a particular locality to use nursing facility services in another state; or 2. The resident of an out-of-state nursing facility is found eligible for Colorado Medicaid due to the inability to indicate their intended state of residence. 8.443.19.E. The out-of-state nursing facility shall:
Enroll as a provider in the Colorado Medicaid Program;
Submit a copy of the re-certification survey yearly upon completion done by the survey and certification and/or licensure agency in their state;
Submit a copy of the following documentation with the claims:

a. The current Medicaid provider agreement with the state where it is located;

b. The provider number in the state where it is located; and c. Their Medicaid rate, at the time services were rendered, in the state where it is located. 8.443.19.F. Payment shall not exceed 100 percent of audited Medicaid costs as determined by the Department or its designee. Audited costs shall be based on Medicaid costs in the state where the facility is located. 8.443.19.G. If the facility is not a Medicaid participant in the state where it is located, it shall submit to the Department an audited Medicare cost report. The payment shall not exceed 100 percent of audited Medicare costs.

8.443.20 CLASS II AND CLASS IV (ICF/IID) NURSING FACILITY PROVIDER FEE 8.443.20.A. The Department shall charge and collect provider fees on services provided by all class II and class IV (ICF/IID) nursing facility providers for the

purpose of obtaining federal financial participation under the state’s medical assistance program. The provider fees and federal matching funds shall be used to sustain reimbursement for providing medical care under the state’s medical assistance program for class II and class IV (ICF/IID) nursing facility providers.

Each class II and class IV (ICF/IID) nursing facility that is licensed in Colorado shall pay a fee assessed by the Department.
To determine the amount of the fee to assess pursuant to this section, the Department shall establish a fee rate on a per patient day basis.

a. The total annual fees due for class II and class IV (ICF/IID) nursing facilities will be calculated such that they do not exceed the federal limits as established in 42 C.F.R. § 433.68(f)(3)(i)(A), or five percent of the total costs for all class II and class IV nursing facilities, whichever is lower. 42 C.F.R. § 433.68(f)(3)(i)(A) (2025) is hereby incorporated by reference. This regulation is available from the federal Government Printing Office at www.gpo.gov. The incorporation of 42 C.F.R. section 433.68(f)(3)(i)(A) excludes later amendments to, or editions of, the referenced material. The Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 303 East 17th Avenue, Suite 1100, Denver, CO 80203.

Certified copies of incorporated materials are provided at cost upon request.

b. The total annual fees will be divided by annual patient days for class II and class IV (ICF/IID) facilities from the most recently available MED-13 cost reports to establish the per patient day fee.

c. The Department may use estimated patient days in the per patient day fee calculation to adjust for expected changes in utilization.

d. When final audited MED-13 cost reports are available, the Department will review the fees charged during each state fiscal year to ensure that the fee amount was less than five percent of the total costs for all class II and class IV (ICF/IID) nursing facilities five percent statutory limit. If the fees were greater than five percent of the total costs for all class II and class IV (ICF/IID) nursing facilities, the Department will retroactively adjust the fees.

The Department shall calculate the fee to collect from each class II and class IV (ICF/IID) nursing facility by August 1 for the state fiscal year.

a. The Department shall notify the providers of their fee obligation in writing at least 30 days prior to due date of the fee.

b. The Department shall assess the provider fee on a monthly basis.

i. Each facility’s annual provider fee amount will be divided by twelve to determine the facility’s monthly amount owed to the ii. The monthly fee is due by last day of the month for which the fee was assessed iii. Fees may be paid through intragovernmental transfer, Automated Clearing House, or check.

8.443.23 SUPPLEMENTAL PAYMENT FOR DISPROPORTIONATELY HIGH

MEDICAID UTILIZATION OR GEOGRAPHICALLY CRITICAL TO ENSURING

ACCESS TO CARE

A. The Department shall pay a supplemental payment to Class 1 nursing facilities either with disproportionately high Medicaid utilization or that are geographically critical to ensuring access to care for Colorado residents. Annually, based on the previous calendar year, the Department shall calculate the percentage of Medicaid patient days to total patient days for each facility participating in the Medicaid program to determine qualification for the high Medicaid utilization B. The Medicaid utilization shall be calculated by dividing Medicaid patient days by total patient days from the previous calendar year, and exempting days with no payor source or paid by the Veterans Health Administration.

Medicaid patient days shall be determined from the MMIS for the calendar year prior to the state fiscal year. Total patient days shall be determined from the nursing facility provider for the calendar year ending prior to the state fiscal year.

C. Facilities will qualify for a tiered payment based on the following factors:

Tier 1: Having a Medicaid utilization of 85% of greater based on the above calculation.
Tier 2: Having a Medicaid utilization of 75% to 84.99% based on the above calculation or being the only Medicaid nursing home provider in the county.

D. Tier 1 facilities will be paid a $10/Medicaid day supplemental payment. Tier 2 facilities will be paid a $5/Medicaid day supplemental payment. Both payments will be calculated according to Section 8.443.23.A. and -B. and paid annually with the following proration:

For the non-state administered nursing facility providers, the amount shall be divided by twelve and reimbursed monthly via ACH transaction or check.
For state administered nursing facility providers the amount shall be divided by four and reimbursed quarterly via intergovernmental transfer.

E. The payment will only be made if there is available federal financial participation under the Upper Payment Limit (UPL). For the purposes of UPL limitations, this payment will be prioritized after all provider fee related supplemental payments but prior to all other nursing facility supplemental payments.

8.443.24 NURSING FACILITY PAROLEES SUPPLEMENTAL MEDICAID

PAYMENT

A. The Department shall make a supplemental Medicaid payment to Class I nursing facilities that admit residents directly from the Colorado Department of Corrections (DOC) who are released on parole due to compassionate care or medical release.

B. Eligible population includes individuals discharged from the DOC whose medical, behavioral, or social needs are beyond the scope of what is provided in a typical nursing facility setting, which limits their access to care options under the standard nursing home reimbursement rate. The payment for each individual shall be prior authorized for tiered reimbursement, based on their needs.

Tiered reimbursement add-ons include:

a. Tier I add-on for individuals who require one or more of the i. Enhanced staff training/education cost;

ii. Psychosocial supports;

iii. Community readjustment and reintegration supports/resources;

iv. A secure unit or neighborhood;

v. Specialty intervention;

vi. Medically complex needs;

vii. Personal needs items;

viii. Psychiatry;

ix. Guardianship needs; and x. Sex offender treatment (if needed).

b. Tier II add-on for individuals who meet Tier I criteria and additionally meet one or more of the following criteria:

i. 1:1 behavioral health support;

ii. High behavioral health needs that require a private room;

iii. Higher acuity needs; and iv. High-cost medication or specialty equipment needs.

C. Quarterly, the Department shall complete a count of Medicaid patient days for the eligible population. Medicaid-covered patient days shall be pulled from the MMIS.

The supplemental payment shall be calculated by multiplying the actual dates of care provided to the eligible population by the applicable per-diem rate. Per-diem rates for Tier I and Tier II individuals shall be published in the Colorado Medicaid Provider Bulletin found on the Department’s website at: www.Colorado.gov/hcpf/bulletins. The payment may be adjusted, subject to the following limitations:

The per diem rate shall not exceed fifty percent (50%) of the statewide average MMIS per diem reimbursement rate, 2. Payments shall be withheld or reduced subject to available UPL reimbursement, and 3. Payments may be adjusted to account for data corrections in previous payments.

D. The DOC will have a licensed physician review each eligible individual being discharged on parole to verify each individual meets criteria. The licensed physician will document the services needed and submit a prior authorization request to the Department for approval. Both the Department and DOC administration will approve the prior authorization of each individual being discharged on parole prior to the Department authorizing payment to a nursing 8.450 FINANCIAL TRANSPARENCY REPORTING REQUIREMENTS 8.450.A Definitions 1. Audited Financial Statements means a company’s financial statements that have been examined by an independent auditor and received an opinion signed by a Certified Public Accountant (CPA). An audit provides the highest level of assurance that the applicable financial statements are free from material misstatement.

Reviewed Financial Statements means a company’s financial statements that have been examined by an independent auditor and received a review report signed by a CPA. A review provides a limited assurance that the applicable financial statements are free from material misstatement.
Managing Entity means any entity that provides administrative or management support to a group a facility. This includes management companies, home offices or back-offices.
Common Ownership means one of more individuals directly or indirectly possesses a 5% or greater ownership interest, as defined in Section 8.441.5.B, in both the nursing facility and the institution or organization serving the nursing 8.450.B Financial Reporting Requirements Beginning with fiscal year end cost reports submitted during State Fiscal Year 2025, all Medicaid certified nursing homes and management entities must annually provide the following documentation in accordance with C.R.S § 25.5-6-202 (13):
Audited Financial Statements a. Audited financial statements for each nursing facility and management entity, including management companies, home office or back-office entities, directly or indirectly accepting Medicaid funds in Colorado; or b. Audited consolidated financial statements for any organization or company operating or managing multiple facilities within Colorado. Consolidated financial statements must include a supplemental schedule that specifies facility level income statement data as well as statements from the managing entity (including management companies, home office or backoffice entities), the revenue and expense stated on the supplemental schedule for each facility must reconcile to the MED-13; or c. Any combination of (a) and (b) that is necessary to include all applicable nursing facilities and managing entities should the managing entity not have common ownership with all individual facility under its management.

i. Annual facility and managing entity audit dates may differ based on their specific entity’s fiscal year end.

A disclosure of nursing facility ownership or affiliation with other corporations, foundation, etc., including an explanation of the type or relationship for each facility operator, management entity and real estate investment trust (REIT) associated with each facility accepting Medicaid funds.
Identification of all related parties engaged in a financial transaction with the nursing facility or management entity, and the sum of all annual transactions.
At its discretion, the Department may require:

a. Details on transactions between related parties.

b. Additional audited financial statements for related parties determined to be of material value in transaction volume.

c. Individual ownership details of any corporate level ownership provided as

part of disclosures required in this section. 8.450.C Waiver Process 1. The Department may allow for the waiver of certain requirements at its discretion.

Waivers should be limited in duration and will only be granted based on atypical or unexpected occurrences that prevent the facility from meeting all compliance requirements. To receive a waiver, the facility or management entity must:

a. Provide evidence of a good faith effort to comply with all applicable transparency requirements in this section, b. Identify and explain the specific requirement requested to be waived, c. Provide a timeline in which full compliance can be regained, and d. Submit compliance documentation to the greatest extent possible to meet the intent of this section in lieu of the item being waived (i.e. submission of reviewed financial statement in lieu of audited financial statements).

In limited circumstances an organization’s structure may require the submission of combined financial statements rather than consolidated financial statements.

This waiver additionally requires:

a. An explanation why combined financial statements are being requested.

b. A summary of the nature of any business entities omitted from financial reporting c. Omitted business entities must not have any financial transactions with nursing home related entities 3. For SFY 2025 only, the Department will accept reviewed financial statements in lieu of audited financial statements for compliance with Section 8.450.2 (A).

8.470 HOSPITAL BACK UP LEVEL OF CARE

8.470.1 DEFINITION

The Hospital Back Up (HBU) Program is a long-term care program that provides hospital level care in a skilled nursing facility (SNF) setting. Residents who no longer need acute care in a hospital but require 24-hour monitoring and life sustaining technology for complex medical conditions may apply to receive long-term care in an HBU certified facility.

8.470.2 PROGRAM ELIGIBILITY

In order to be eligible for the hospital back up program, a resident shall:

A. Meet level of care (LOC) Screen eligibility for long term care as determined by the appropriate Single Entry Point agency (SEP); and B. Meet the resident clinical eligibility requirements as identified in Section 8.470.3 as determined by the State Utilization Review Contractor (SURC); and C. Be medically stable in a chronically acute state; and D. Be in a hospital, long-term acute care facility, or other institutional inpatient setting, prior to approval; or E. Be in an HBU skilled facility under a qualified Medicare stay.

8.470.3 RESIDENT CLINICAL ELIGIBILITY

A. Eligibility Categories. All prospective residents must meet the requirements of at least one of the following seven categories in the clinical eligibility criteria to participate in the Hospital Back Up Program:

Complex Wound as outlined in 8.470.3.B;
Ventilator Dependent as outlined in 8.470.3.C;
Medically Complex as outlined in 8.470.3.D;
Bariatric as outlined in 8.470.3.E;
Disorders of consciousness as outlined in 8.470.3.F;
Severe neurological decline as outlined in 8.470.3.G; or 7. Combination of the above impairments equal in severity requiring HBU level of care as outlined in 8.470.3.H. 8.470.3.B. Complex Wound Care means the resident must meet all the following criteria:
At least one stage 3-4 pressure ulcer or injury, second- or third-degree burns, or a Medicare “pressure relieving support surface” rating of 2-3 to heal or prevent skin breakdown; and 2. Documentation of extensive skin loss, active infection, compromised blood flow, sloughing, tunneling, fistulae, or undermining of surrounding tissue or necrosis with potential extension to underlying fascia; and 3. Documentation of nutritional deficiencies including:

a. Identification of diagnostic markers and specific nutritional deficiencies; and b. A plan of treatment to address underlying conditions such as malabsorption or excess loss of nutrients; and c. The modality of supplementation: oral, intramuscular or intravenous; and 4. Documentation of at least one of the following:

a. Full thickness wound graft surgery; or b. Negative pressure wound therapy, electromagnetic therapy, compression therapy or hyperbaric oxygen therapy; or c. Debridement (surgical, mechanical, chemical, autolytic or larval biotherapy); or d. Advanced dressings with growth factors, silver/alginates, hyaluronic acid or collagens.

Evidence of inability to access care in a standard skilled nursing facility. 8.470.3.C. Ventilator dependent residents must meet all requirements in at least one of the following three subsections and section number 4:
If the resident is actively weaning off the ventilator, the resident must:

a. Require direct assessment and monitoring of weaning at least 2 hours each day by a respiratory therapist; and b. Require supportive care at least 12 hours a day by a respiratory therapist or pulmonary trained nurse (under the supervision of a respiratory therapist) for ventilator management; and c. Require physical therapy, occupational therapy, speech therapy, or a combination of such therapies at least 5 days per week; and d. Have documented rehabilitation potential and a plan of treatment by a respiratory therapist in place at the time of the HBU referral;

e. Have clinical documentation including (but not limited to) arterial bloods gas labs, standard breathing and capping trial results, pulmonary function tests, capnography, respiratory and speech language pathology progress notes and any other documentation to support active weaning efforts.

If active weaning fails, the resident must:

a. Have documentation of failed weaning efforts by a respiratory therapist and a plan of treatment with prognosis for liberation from a respiratory therapist or pulmonologist; and b. Require continuous ventilator support at least 8 hours per day and skilled respiratory care at least 3.5 hours per day to remain medically stable; and c. Meet Nursing Facility Level of Care as determined by the LOC 3. If the resident has successfully weaned off the ventilator and is actively working to reduce oxygen levels and/or removal of the tracheostomy tube, the resident must:

a. Meet Nursing Facility Level of Care as determined by the LOC Screen; and b. Have documentation from a respiratory therapist and pulmonologist verifying the resident has been weaned off active ventilation and/or is working to have a further reduction to standard home oxygen levels (1-6 LPM); and c. Require the support of a respiratory therapist under the supervision of a pulmonologist at least 3.5 hours a day to remain medically stable and/or show progress toward decannulation; and d. Be capable of managing basic tracheostomy care or respiratory hygiene.

Evidence of inability to access care in a standard skilled nursing facility. 8.470.3.D. Medically complex residents include ventilator dependent individuals and individuals successfully weaned off the ventilator with co-morbidities. To be deemed medically complex under the HBU program, residents must meet all of the following requirements:
Meet Nursing Facility Level of care as determined by the LOC Screen; and 2. Require on-site assessment by a rounding physician or subspecialist at least once a week to remain stable; and 3. Require artificial nourishment to be administered by registered nurse, including but not limited to a gastro-intestinal tube (G tube or NG tube) and/or jejunostomy tube (J tube), total parenteral nutrition (TPN) with or without lipids, or central line in active use for fluids or medication (excluding TPN); and 4. Require documentation of rehabilitative therapies including physical, occupational and speech language therapy, and/or skilled nursing notes documenting assessment, monitoring and intervention at a greater frequency than is provided in a Class I nursing facility; and 5. Require suctioning and/or airway maintenance at least every four hours by a respiratory therapist or pulmonary trained nurse under the supervision of a respiratory therapist for ventilator dependent residents or residents with a tracheostomy; and 6. Physician documentation of life limiting disease which will require ongoing care in the HBU skilled nursing facility; and 7. Documentation of quarterly updates to plan of treatment, prognosis, status evaluation, care conference and/or palliative consult; and 8. Evidence of inability to access care in a standard skilled nursing facility. 8.470.3.E. Bariatric residents must meet all of the following requirements:
A minimum body mass index (BMI) of at least 50; and 2. Suffer from at least one life limiting illness including but not limited to pulmonary, cardiac, gastrointestinal, endocrine, or cancer; and 3. Documented need for specialized equipment (bariatric beds, lifting equipment, reinforced or wider frames for walkers and wheelchairs, specialized blood pressure cuffs, gowns and respiratory support devices) or additional staffing supports for transfers or mobility; and 4. Physician documentation of BMI and life-threatening medical problem which will require ongoing care in the HBU skilled nursing facility; and 5. Evidence of inability to access care in a standard skilled nursing facility. 8.470.3.F. Disorders of consciousness [comatose, Unresponsive Wakefulness Syndrome (UWS)] residents must meet one of the following three requirements:
Coma: A state where the person is not aroused, unaware of self and environment, and unable to respond to any stimuli; or 2. Unresponsive Wakefulness Syndrome (UWS): The person demonstrates basic wakefulness with a restored sleep-wake cycle, but there is no awareness of surroundings and no purposeful interaction; or 3. Physician documentation of a disorder of consciousness, and if applicable life limiting illness, which will require ongoing care in the HBU skilled nursing facility; and 4. May also suffer from at least one life-threatening medical problem; and 5. Evidence of inability to access care in a standard skilled nursing facility. 8.470.3.G. Neurological diseases with severe neurological deficits residents must meet the following criteria:
Have a non-dementia related neurological condition, causing a need for additional staffing supports atypical for nursing facility care, and is permanent, progressive, or terminal in nature including problems with thinking, memory, learning, or processing information; and 2. Suffer from significant permanent impairments in the functions of the nervous system, including the brain and requiring extensive medical care and rehabilitation; and 3. Physician documentation of a neurological disease with severe neurological deficits, which will require ongoing care in the HBU skilled nursing facility; and 4. Evidence of inability to access care in a standard skilled nursing facility. 8.470.3.H. Residents who do not meet the HBU level of care criteria listed above may qualify for HBU if they meet the following criteria::
Documentation of two or more of the impairments listed in Sections B through G that, in combination, are equivalent to the HBU level of care;
Physician documentation of life-threatening medical problems which will require ongoing care in the HBU skilled nursing facility; and 3. Documentation of quarterly updates to plan of treatment, prognosis, status evaluation, care conference and/or palliative consult; and 4. Evidence of inability to access care in a standard skilled nursing facility.

8.470.4 INITIAL ELIGIBILITY DETERMINATION AND ADMISSION 8.470.4.A. State Utilized Review Contract (SURC) Review for Initial Hospital Eligibility Determination Upon receipt of the completed Hospital Back Up Application, patient choice form and the LOC Screen, the SURC nurse reviewer shall:

Conduct a program eligibility review to determine whether the resident meets the hospital back up level of care criteria and may successfully be treated in the requested skilled nursing facility;
Review the LOC Screen by the SEP;
Provide initial assessment for secondary review by SURC physician reviewer;
Request additional medical documentation deemed necessary to make such determination;
Notify the Department of final eligibility determination;
Document all final physician determinations and maintain these records for the Department;
Issue a denial letter to the Department and referring provider within 10 business days of determination if the prospective resident does not meet HBU level of care;
Notify the Department in writing within 10 days of determination if the SURC determines the resident meets HBU level of care; and 9. Issue a 90-day initial length of stay letter to the resident and skilled nursing facility within 24 hours of approval from the Department, in accordance with the criteria specified below in subsection 8.470.4.C. 8.470.4.B. Hospital Back Up Skilled Nursing Facility Requirements Upon receipt of a new resident referral, the hospital back up skilled nursing facility shall:
Conduct a face to face assessment with the resident and current care provider and review clinical documentation to determine if the hospital back up skilled nursing facility can provide the appropriate level of care for the resident;
Notify the SURC and Department that it is considering admitting the resident to the hospital back up skilled nursing facility;
Prepare a care plan and provide this to the SURC and Department for review;
Verify the status of the resident’s enrollment in Health First Colorado LTC Medicaid;
Notify the Department of date of transfer and arrange for secure transport of resident;
Maintain the HBU approval letter for the Single Entry Point (SEP) and County to initiate services and payment for the resident;
Provide to the Department a monthly status report on the last business day of each month for all Hospital Back Up Program residents admitted to or residing in the hospital back up skilled nursing facility during the preceding month.
Failure to provide a status report each month could result in a temporary cessation of payment to the hospital back up skilled nursing facility. 8.470.4.C. 90-Day Initial Length of Stay 1. The 90-day initial length of stay letter issued by the SURC nurse reviewer in accordance with subsection 8.470.4.A shall provide prior authorization for the initial length of stay in the hospital back up skilled nursing facility not to exceed 90 days.
15 days before the end of each hospital back up resident’s 90-day initial length of stay, the SURC nurse shall conduct a virtual review for each resident, which will determine if:

a. The resident continues to meet the hospital back up level of care criteria;

b. The resident’s care needs are being adequately met in the hospital back up skilled nursing facility;

c. The hospital back up skilled nursing facility has updated the existing plan of treatment to reflect any change in the resident’s condition; and d. The appropriate level of care and services are being provided and documented in the resident’s record.

The SURC nurse shall report the results of the virtual visit to the SURC physician reviewer within 24 hours of completion of the visit.
The SURC shall notify the Department and the hospital back up skilled nursing facility of the final determination in writing within 10 business days of the virtual visit and include supporting documentation for this determination.
If the resident continues to meet the hospital back up program level of care, the SURC shall issue a continued stay letter to the hospital back up skilled nursing facility and resident within 24 hours of approval from the 6. If the SURC physician reviewer determines that the resident no longer meets the hospital back up level of care criteria or the nursing facility fails to provide documentation to support level of care and services provided, the SURC shall notify the hospital back up nursing facility administrator in writing within 24 hours of the determination and reimbursement for the resident’s stay shall be reduced to the nursing facility Class I rate within 60 days of receipt of the letter.
The Department shall notify the resident in writing of the SURC determination and appeal rights as outlined in Section 8.057.
The SURC shall maintain all records for eligibility determinations and provide these documents upon request to the Department for contract reporting and resident appeals. 8.470.4.D. Annual Continued Stay Review 1. The SURC nurse shall conduct a virtual continued stay review for each hospital back up resident 15 days prior to the end of the resident’s currently approved annual stay.
The SURC may conduct an unscheduled virtual review at any time during the length of stay for resident clinical change of condition or at the request of the Department.
The SURC shall observe the same review criteria and determination requirements as outlined in 8.470.4.C of the 90-day initial eligibility criteria for determining ongoing annual eligibility.
A new LOC Screen must be completed annually by the SEP agency. The nursing facility shall provide a current LOC Screen to the SURC as part of the annual eligibility assessment.
If the SURC determines that the resident no longer meets the hospital back up level of care criteria or the nursing facility fails to provide documentation to support level of care and services provided, the SURC shall notify the Department within 24 hours of completion of the eligibility review.
The SURC shall observe the same determination and notification requirements as outlined in 8.470.4.C.6 and .7 of the 90-day initial eligibility criteria for determining ongoing annual eligibility.

8.470.5 RESIDENT TRANSFERS AND DISCHARGES FROM THE HBU PROGRAM 8.470.6.A. Requirements for HBU skilled nursing facility discharges 1. If a hospital back up skilled nursing facility receives CSR denial letter that a resident ceases to meet hospital back up level of care criteria, the hospital back up skilled nursing facility must continue to provide care to the resident under the standard nursing facility Class I rate unless the resident also meets the criteria for transfer/discharge under 42 C.F.R. § 483.15(c), which is hereby incorporated by reference.

The discharging skilled nursing facility shall adhere to all applicable state and federal rules, including, but not limited to:

a. Section 8.057.1.D and E, governing notification requirements for residents receiving Colorado Medicaid;

b. Requirements for transfers/discharges under 42 C.F.R. § 483.15(c), which is hereby incorporated by reference; and c. The Colorado Department of Public Health and Environment’s (CDPHE) rules regarding resident discharge or transfer as outlined in 6 CCR 1011-1, Chapter V, Section 15, which is hereby incorporated by reference. 8.470.5.A. Requirements for HBU transfers within participating HBU Program facilities 1. If a resident requests a transfer to another hospital back up skilled nursing facility and the individual’s care needs may be met by another hospital back up skilled nursing facility, each nursing facility must notify the Department of their intent to transfer the resident.

A new plan of treatment and must be provided by the accepting nursing facility to the SURC for review prior to transfer and the SURC shall notify the Department of the eligibility determination within 10 business days of review of the plan of treatment.
The SURC will issue a new approval letter to the accepting nursing facility, with change of billing effective on the date of transfer stated in the letter.
The accepting facility is responsible for arranging medical transport and notifying the SEP and County of the transfer for their records.

8.470.6 NURSING FACILITY REQUIREMENTS FOR PARTICIPATION IN THE

HBU PROGRAM 8.470.6.A In order to be reimbursed under the Hospital Back Up Program, the nursing facility shall submit a letter of intent to the Department that demonstrates the nursing facility:

Is Medicaid certified and licensed to provide skilled care;
Is financially stable;
Can provide skilled nursing facility services 24 hours a day;
Has staff stability;
Has a history of survey compliance with no regular annual, complaint, or any other CDPHE survey with a substandard quality of care within the previous two years;

a. “Substandard quality of care” means one or more deficiencies related to participation requirements set forth at 42 C.F.R. § 483.12, Freedom from Abuse, Neglect, and Exploitation, 42 C.F.R. § 483.24, Quality of Life, or 42 C.F.R. § 483.25, Quality of Care (which are hereby incorporated by reference) that constitute either immediate jeopardy to resident health or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm.

Complies with the direct resident care regulations administered by CDPHE as outlined in 6 CCR 1011-1 Chapter 2: General Licensure Standards and “Chapter 5: Nursing Care Facilities,” which are hereby incorporated by reference;
Has a recommendation from CDPHE for the nursing facility to participate in the hospital back up level of care program.
Has the desired number of beds available to be designated for the HBU Program. 8.470.6.B. The Department may request evidence of financial stability and survey compliance at any time during the nursing facility’s participation. 8.470.6.C. The Department may limit the number of residents for which a nursing facility may receive HBU reimbursement based on staffing, survey compliance and/or financial stability. Additionally, the Department may deny or revoke authorization of a nursing facility to be reimbursed as a hospital back up level of care facility if they do not meet the requirements outlined in section 8.470.7.A.
A nursing facility may appeal any limitation, denial, or revocation consistent with Section 8.050.3. 8.470.6.D. If the nursing facility has applied to admit residents who are ventilator dependent, the nursing facility shall also meet the following additional requirements:
Maintain clinical care staff trained in critical care and/or pulmonary medicine on the ventilator unit 24 hours a day, 7 days a week;
Have a back-up generator capable of providing heat, cooling and continuous electricity for needed equipment in the event of power outages;
Maintain 24-hour on-site coverage by a respiratory therapist, who shall monitor any resident weaning off of a ventilator and adjust ventilator settings as needed.

8.470.7 REIMBURSEMENT OF NURSING FACILITIES FOR PARTICIPATING

RESIDENTS WHO MEET HOSPITAL BACK UP LEVEL OF CARE 8.470.7.A. Medicaid reimbursement for services provided to a hospital back up level of care nursing facility member shall be updated annually by HCPF based upon the Patient Driven Payment Model (PDPM) nursing facility components classification determined through the member’s minimum data set (MDS) resident assessment as transmitted to and accepted by the Centers for Medicare and Medicaid services (CMS).

The Medicaid reimbursement for each resident shall correspond to the PDPM case mix adjusted federal PDPM reimbursement rate prior to the application of any wage index component determined from a resident’s CMS accepted resident assessment and related PDPM classification.
All HBU facilities will receive a 60-day interim rate after the admission of the resident to the facility.

a. The interim rate will be the average PDPM case mix adjusted federal PDPM reimbursement rates for all residents enrolled in HBU and will be recalculated annually.

b. All claims billed during the interim rate payment period will be retroactively mass adjusted to reflect the permanent Medicaid reimbursement rate assigned to the resident’s PDPM classification.

c. The HBU facility must complete an MDS resident assessment accepted by CMS no later than 60 days post admission.

d. The nursing facility must assign a PDPM classification determined by the MDS resident assessment no later than 60 days postadmission.

e. If no MDS resident assessment has been accepted by CMS within 60 days post admission, the Department shall withhold all future payments until the assessment has been accepted by CMS.

Medicaid reimbursement for a resident who meets HBU level of care shall not be based upon or related to the audited, cost-based reimbursement for a nursing facility’s Class I residents.
The appeals rights and procedures applicable to the Department’s determination of a nursing facility’s Class I rate shall not apply to the reimbursement the Department offers or pays for a resident who meets HBU level of care criteria.
If a member’s third party coverage (private insurance, LTC insurance, or Medicare) will cover the cost of the member’s care in either a hospital or nursing facility, the Medicaid payment under this program shall be approved only after utilization of third party benefits. 8.470.7.B Providers shall bill for drugs and oxygen separately from the per diem rate as fee-for-service claims. 8.470.7.C Twice yearly, the Department’s contractor shall audit and validate all MDS resident assessments and related PDPM classifications that have been utilized to set Medicaid reimbursement rates for HBU residents.
Audit and validation will occur each June and December.
The contractor shall report all invalid MDS resident assessment scores to the Department and the facility.
For any score identified as invalid, the Department will adjust the rate to reflect the validated MDS resident assessments and corresponding PDPM reimbursement rate retroactively to the date of the previous validated MDS; claims will be reprocessed to reflect the corrected PDPM reimbursement rate. 8.470.7.D In the event the facility disputes the contractor’s determination of the PDPM classification, the facility may file an informal reconsideration related to the PDPM classification in accordance with Section 8.050.
The Department must receive a request for informal consideration of a disputed PDPM classification in writing within 30 days of the date of the contractor’s notice of the disputed PDPM classification.
The request shall state, with specificity, each error disputed in the PDPM classification.
Requests that do not comply with the requirements of this section shall be considered incomplete and denied.
The Department will notify the facility of the final determination of the disputed PDPM classification within 45 days of the receipt of the request for informal reconsideration.
The facility may file an appeal of the final informal reconsideration determination of the disputed PDPM classification with the Office of Administrative Courts within 30 days from the date of the Department’s notice of final determination of the informal reconsideration. 8.470.7.E Each month, the HBU facility must report the status of every HBU resident in the facility using the Department’s approved reporting form.
The HBU facility shall report all discharges, whether permanent or temporary, the death of a resident, all changes in status, or no changes in status.
Reports must be submitted by no later than 5:30 p.m. on the last day of the month.
If no report is received by the deadline, the Department will notify the facility that payment will be immediately suspended until the facility submits the required status report, and will immediately suspend all HBU payments to the facility.

8.470.8 REPORTING ON THE MED-13 FORM 8.470.8.A The Medicaid reimbursement for residents who meet the hospital back up level of care (hereafter referred to in this paragraph as “hospital level reimbursement”) shall not impact the Medicaid per diem cost and rate set for the nursing facility’s Class I Medicaid residents based on the Med-13 cost reporting process. 8.470.8.B The hospital level reimbursement shall be reported on the Med-13 cost report form in the following manner so that it does not impact the Class I Medicaid per diem rate established by the cost report:

The hospital level reimbursement shall be included on the appropriate line in columns 1 through 8 on Schedule C; and 2. Offset of the hospital level reimbursement shall be on Schedule B with a detailed supplemental schedule attached.

8.470.9 INCORPORATIONS BY REFERENCE

Throughout the above regulations, standards and requirements of an outside organization have been adopted and incorporated by reference. The following regulations are hereby incorporated by reference:

Colorado Department of Public Health and Environment (CDPHE) regulations at 6 CCR 1011-1 Chapters 2 and 5. These regulations may be accessed online at https://www.coloradosos.gov/CCR. 42 C.F.R. § 483.15, “Admission, Transfer, and Discharge Rights,” which may be accessed at https://www.ecfr.gov/current/title-42 42 CFR § 483.12, “Freedom from Abuse, Neglect, and Exploitation,” which may be accessed at https://www.ecfr.gov/current/title-42 42 C.F.R. § 483.24, “Quality of Life” which may be accessed at https://www.ecfr.gov/current/title-42 42 C.F.R. § 483.25, “Quality of Care” which may be accessed at https://www.ecfr.gov/current/title-42 6 CCR 1011-1 Chapter XXIV. These regulations may be accessed online at https://www.coloradosos.gov/CCR.

The material incorporated by reference cited herein includes only those versions that were in effect on January 29, 2026, and no later amendments to the incorporated materials. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17 Ave., Denver, CO, 80203. Certified copies of incorporated 8.482 RESIDENT INCOME AND POSSESSIONS 8.482.1 PURPOSE AND LIMITATIONS Personal needs funds, whether contributed or direct, shall be used for the care of the resident, as set forth in Section 8.482.5.

No person, institution, partnership, corporation or other entity shall divert resident income from the control and exclusive use of the resident, without proper legal authorization or power.

Refer to Section 8.440.1 for services and items included in the per diem payment and to

Section 8.440.2 for services and items not included in the per diem payment.

8.482.2 DEFINITIONS

A. “Contributed income” is defined as the amount of income of parent or unseparated spouse, over and above the needs of such spouse or parent, which is contributed toward the needs of the resident.

B. “County Department” is defined as the County Departments of Social/Human Services.

C. “Department” is defined as the Colorado Department of Health Care Policy and Financing.

D. “Direct income” is defined as payments made directly to the resident, or to a conservator or guardian for the exclusive use of the resident. Examples of such income are Social Security benefits, supplementary security income, railroad or other retirement benefits.

E. “Nursing facility” is defined as an intermediate or skilled care facility, the owners, administrators, and staff thereof.

F. “Personal needs allowance (PNA)” is the amount specified in Section 8.110.7.V. to be deducted from resident income, and used for the exclusive benefit of the resident prior to application of income to nursing facility care.

G. “Resident income” is defined as all income used in the determination of eligibility for Medicaid payments.

H. “Patient payment” is defined as the payment made by the resident for nursing facility care, after the personal needs allowance is deducted.

I. “Responsible Party” is defined as any of the persons below, who accepts the responsibility for a resident's funds, mail or personal possessions and is willing to sign a written declaration of such responsibility:

a legally appointed guardian, conservator or trustee; or 2. relative or friend; or 3. the county department; or 4. the resident if they are competent to manage their own affairs.

J. “Post Eligibility Treatment of Income (PETI)” is defined as the reduction of resident payment to a nursing facility, for the costs of care provided to an individual by the amount that remains after certain deductions are applied to reduce the individual's total income. The individual is liable to pay the remaining amount to the institution.

K. “PETI-IME” is defined as nursing facility post eligibility treatment of income – incurred medical expenses, as further defined at Section 8.482.33.

8.482.3 RESIDENT INCOME

The control of resident income is vested in the resident, or in such person as the resident may designate. A designee may be a conservator, administrator, family member or other representative. The resident’s income is to be used by the resident, or on behalf of the resident. No designee, or any other person or institution, shall convert any of these monies to their own use or use the income on behalf anyone for any reason, except the resident.

8.482.31 DETERMINATION OF INCOME

A. The initial determination of resident income shall be made by the county department. The county department shall then notify the nursing facility of current resident income as detailed in 10 CCR 2505-10 section 8.482.34.B.

B. The nursing facility must notify the county immediately of any changes in resident income. And, if the facility is authorized to receive the resident's income, the facility has the duty and obligation to verify the amount of resident income.

C. If the nursing facility is not authorized to receive the payments for resident income, it is the responsibility of the resident, or the person administering such income on behalf of the resident, to report all changes in such income, as required by the Colorado Department of Human Services Income Maintenance Staff Manual, Volume 3, under the penalties set forth in 10 CCR 2505-10 section 8.482.45.

8.482.32 COLLECTION OF INCOME

A. Responsibility of Nursing Facility 1. It shall be the responsibility of the nursing facility to collect from the resident, or from the resident's family, conservator or administrator, all income which is to be applied to the cost of resident care. The Department is not responsible for any deficiency in patient payment accounts, due to failure of the nursing facility to collect such income.

If, however, the nursing facility is unable to collect such funds, through refusal of the resident or the resident's family, conservator, or administrator to release such income, the nursing facility shall immediately notify the county department.

B. Responsibility of County Department When notified by the nursing facility of the refusal of the resident or the resident's family, conservator or administrator to release resident income due, the County Department shall immediately contact the refusing party. If, after such contact, the party still refuses to release such income, the action shall be deemed a failure to cooperate, and the county department shall proceed to discontinue Medicaid benefits for the resident.

C. The County or nursing facility must report suspected financial exploitation to a law enforcement agency in accordance with C.R.S. § 18-6.5-108. 8.482.33 Nursing Facility Post Eligibility Treatment of Income – Incurred Medical Expenses (PETI-IME)

Effective April 8, 1988, with respect to the post-eligibility treatment of income of individuals who are institutionalized there shall be taken into account amounts for incurred expenses for medical or remedial care that are not subject to payment by Colorado Medicaid or third party insurance, including health insurance premiums, deductibles or co-insurance; hearing aids, supplies, and care; corrective lenses, eye care, and supplies; and other incurred expenses for medical or remedial care that are not subject to payment by a third party.

A. All PETI-IME expenses shall be prior authorized by the Department or its designee. The purpose of the prior authorization process is to verify the medical necessity of the services or supplies, to validate that the requested expense is not a benefit of the Medicaid program, and to determine if the expenses requested are a duplication of expenses previously prior authorized.

B. Prior Authorization Request Process:

For allowable PETI-IME expenses costs shall be prior authorized by the Department or its designee. The process is as follows:

Prior authorization requests must be submitted to the Department as prescribed by the State through the Provider Web Portal. In addition to the information requested on the web portal form, the following attachments must be included:

a. For All PETI-IME requests: The medical necessity form legibly signed by the physician (and the physician name legibly written) and resident or resident representative.

b. For All PETI-IME requests: An itemized invoice with codes and fees for the service or supply being requested.

c. Additionally, for hearing aids: a current audiogram test less than one year old.

d. Additionally, for medical health Insurance: premium statement to identify the type of plan, monthly fee and copy of health Insurance card (front and back). 2 Prior authorizations will be certified by the Department based on the following criteria:

a. The request is not a benefit of the Medicaid program.

b. The cost of the request does not exceed the basic Medicaid rate for such services or supply.

c. The special medical service or supply is medically necessary, approved and signed by a physician.

The Department or its designee shall review and approve/deny the Prior Authorization Request within fifteen working days of receipt. The Provider Web Portal shall reflect the status of the request.
Upon receipt of the approved Prior Authorization Request (PAR), the nursing facility shall submit the PETI-IME reimbursement on the following month's Medicaid billing or on the nursing facility's next billing cycle.

a. PETI-IME PAR requests must be submitted within the timely filing period of 365 days from the date of service.

b. For approved PETI-IME PARs requested prior to services rendered, the Department has the discretion to close the PAR if reimbursement is not requested within 12 months from the date of Department approval.

C. Private health insurance premiums, deductibles, or co-insurance as defined by state law.

Monthly premium payment paid by the resident for private health insurance.

a. If premium payments exceed the patient payment amount for one month, a monthly average is calculated by dividing the total premium by the number of months of coverage. The resulting amount is to be applied as a monthly PETI-IME expense for each month of coverage until spent.

Medical health insurance premiums will be allowed for the resident only.

This does not include prescription drug, vision, dental or life insurance.

Private Health insurance premiums, deductibles, and coinsurance must be reviewed by the Department or its designee yearly for final approval.

a. If duplicate coverage has been purchased, only the cost of the least expensive policy will be allowed. Premiums, deductibles and coinsurances which the Department or its designee determine to be too expensive in relation to coverage purchased shall not be allowed.

b. Upon approval, private medical health insurance premiums are billable for 12 months.

D. The allowable expenses for special medical services are subject to the following criteria:

General Instructions (applies to all special medical services).

a. If the resident does not make a patient payment; then no PETI-IME will be allowed. The resident must be Medicaid approved and not in pending status for any PETI-IME service request to be approved.

b. Costs will be allowed only if they are not a benefit of the Medicaid program, or not a benefit of other insurance coverage the resident may have.

c. All allowable costs must be for items that are medically necessary as described in Section 8.076.1.8, and medical necessity must be documented by the attending physician. The physician statement must be current, within one year of the authorization.

d. The resident or resident representative must agree to the purchase of the service/equipment and related charge, with signed authorization in the resident’s record.

e. Nursing facilities or providers are not permitted to assess a surcharge or handling fee to the resident’s income.

f. The allowable costs for services and supplies may not exceed the basic Medicaid rate.

g. In the case of damage or loss of supplies, replacement items may be requested with relevant signed documentation. If the damage or loss is due to negligence on the part of the nursing facility, the nursing facility is responsible for the cost of replacement.

h. Costs will not be allowed if the equipment, supplies or services are for cosmetic reasons only.

i. Monthly PETI-IME payments may not exceed the monthly patient payment. Approval for reimbursement shall only be allowed if the provider agrees to accept installment payments.

j. For special medical services/supplies provided but not yet paid for, the encumbrance agreement and monthly payment schedule must be documented in the resident's record, as well as receipts of 2. Hearing Aid Instructions a. All referrals for hearing aids must be authorized by the attending physician, and must include an evaluation for suitability and specifications of the appropriate appliance performed by a licensed audiologist.

b. Purchase of new hearing aids to replace pre-existing hearing aids must include documentation of necessity of replacement of the pre-existing hearing aid. New hearing aids are a benefit after five (5) years with appropriate documentation.

c. Documentation attached to the prior authorization request should include the signed medical necessity form, itemized invoice with codes and fees and current (within one (1) year) audiogram.

Corrective Lenses Instructions PETI-IME expenses for corrective lenses will be limited to services not covered under Section 8.203 Vision Services. Corrective lenses are limited to one (1) pair per twenty-four (24) month period under Section 8.203.4.B. For a change in vision within twenty-four (24) months, an eye exam is required to show the change in vision.

a. The evaluation of the need for corrective eyeglasses (lenses) must be a part of a comprehensive general visual examination conducted by a licensed ophthalmologist or optometrist.

b. The medical necessity for prescribed corrective lenses should not be based on the determination of the refractive state of the visual system alone, but should be identified by the current procedural terminology in the Physician Current Procedures Terminology (CPT) Code as established by the American Medical Association.

i. Documentation attached to the prior authorization request should include the signed medical necessity form and itemized invoice.

All documentation of the incurred expenses must be available in the client's financial and medical record for audit purposes by the Department or its designee. Lack of documentation shall cause the PETI-IME to be disallowed and shall be considered an overpayment subject to recovery by the Department. Documentation shall include:

a. Printed copy of approved PAR.

b. Copy of all attachments to the PAR.

c. Yearly nursing facility tracking activity log that includes the vision and PETI-IME reimbursement activity. Specifically:

Member number and name receiving the service;
Type of service requested;
Date service was requested by the member;
Date PAR was added to Provider Web Portal:
Date PAR was approved by the Department;
Date facility received payment from Medicaid for service;
Date service provider was paid by the facility;
Date service was rendered to the member;
When/if the member’s personal needs funds were used;
When applicable, documentation that the member’s personal needs account was reimbursed;
Documentation that the member was still at the facility when the service was rendered;

d. All documentation shall be retained for six years and is subject to audit by the Department or its designee.

8.482.34 THE “STATUS OF NURSING FACILITY CARE” FORM, AP-5615

A. Responsibilities of the Nursing Facility 1. The AP-5615 form is to be completed by the nursing facility for all admissions, readmissions, transfers from private pay or Medicare, discharges, deaths, changes in income and/or patient payment, and leaves of absence.

Each form must include the date completed and the actual signature of the nursing facility administrator or their authorized representative.
All copies of the AP-5615 must be submitted to the appropriate county department and the Department at HCPF_LTC_FinCompliance@state.co.us within five working days of the action which is being reported, or in the case of a change in resident income, within five working days of the time the change becomes known, in order to expedite reimbursement.
The nursing facility will be responsible for assuring that the patient payment, as shown on the AP-5615 and approved by the County Department, is identical to that claimed on the monthly nursing facility, billing form. Failure to enter the latest patient payment data on the billing form will render the nursing facility liable for any discrepancies.

B. Responsibilities of the County Department On receipt of Form AP-5615, the county department will, within five working days:

For an admission, a readmission or a transfer from/to private pay or Medicare:

a. Verify and correct, if necessary, data entered by the nursing facility.

b. List and/or verify the resident's monthly income; and compute patient payment.

c. Verify and correct the automated system to indicate the nursing facility name and provider number and to reflect the current distribution of income. Submit the AP-5615 to the nursing facility and the Department at HCPF_LTC_FinCompliance@state.co.us.

(1) The CBMS system shall be updated to reflect the resident’s current nursing facility name and provider number to ensure residential placement is accurately reported in the system.

(2) Any report generated by the county reflecting a current list of residents residing in a single facility shall be accurate. This includes, but is not limited to, the yearly cost of living adjustment (COLA) report generated by the county.

For change in patient payment with respect to changes in resident income:

a. Verify changes in resident income and correct if necessary. All such corrections must be initialed, b. Correct the AP-5615 and submit to the nursing facility and the department at HCPF_LTC_FinCompliance@state.co.us.

For change in patient payment with respect to the Medicare premium deduction allowance, the county department shall:

a. Review the AP-5615 for Medicare premium deduction allowances for the first two months of admission of readmission.

b. If the member is enrolled in the Medicare Buy-In program, do not: adjust patient payment on Form 5615 for the Medicare premium deduction. If member is not on the Buy-In program, adjust Form 5615 for the Medicare premium deduction for the first two months of nursing facility eligibility.

For resident leave of absence:

a. Non-Medical/Programmatic Leave. Verify adherence to the restrictions and conditions of 10 CCR 2505-10 section 8.482.44.

b. Medical Leave. Verify that the charges made to the resident or the resident's family are correct and that no Medicaid payment is requested for the period. See also 10 CCR 2505-10 section 8.482.43.

For discharge or death of resident:

a. Verify the date of death or discharge and verify the correct patient payment (or resident's monthly income) for the discharged month, and the amount calculated by per diem. All corrections must be initialed.

b. Note if the resident entered another nursing facility and, if so, provide the name of the new nursing facility. This information is needed to assure that duplicate payment will not be made.

c. In the event the resident may return to the same facility, the AP- 5615 may be completed at the end of the month for discharges due to hospitalization.

d. Make necessary changes on the automated system to reflect the appropriate circumstances. Submit the AP-5615 to the nursing facility and the Department at (1) The Colorado Benefits Management System (CBMS) system must be updated with the resident’s current nursing facility name and provider number to ensure the yearly COLA report for the county includes all residents residing in nursing facilities located in their county.

Failure to submit the correct form may result in the refusal of the Department to reimburse such nursing facility care.
General Instructions:

a. The AP-5615 form must be verified and the original returned to the nursing facility and the Department at b. The AP-5615 form must be signed and dated by the director of the County Department, or by their designee.

c. AP-5615 forms may be initiated by either the nursing facility or County Department. If the County Department is aware of information requiring a change in financial arrangements of a resident, and a new AP-5615 form is not forthcoming from the nursing facility, the County Department may initiate the revision to the AP-5615. In such case, one copy of the AP-5615 showing the changes, will be sent to the nursing facility and the Department at 8. The Department may deduct excess payments from the county administrative reimbursement as stated in the Colorado Department of Human Services Finance Staff Manual, Volume 5 if the County Department fails to:

a. Perform the duties as detailed in section B; or b. Adhere to the limitations on $0.00 patient payment; as detailed in 10 CCR 2505-10 section 8.482.34.D.; or c. Notify the nursing facility immediately of any changes in resident income, provided the nursing facility is not authorized to receive the resident's income; and excessive Medicaid funds are paid to the nursing facility as a result of this negligence.

C. Calculating Partial Month Payments 1. Whenever a resident is in the nursing facility on the first day of the month, and remains a resident for each day of the month, the total resident income in excess of the amount reserved for personal needs allowance, less adjusted earned income, less spousal, and dependent care allowance, less home maintenance allowance, will be used as the patient payment. If the resident is in the facility less than this period, the rate is computed using the calculation below.

In figuring the number of days for payment, the day of admission is included, but not the day of discharge (i.e., the resident dies or leaves the facility).
In order to calculate the patient payment:

a. Determine the amount of available resident income for the month (see subsection 1. above).

b. Subtract the cost of the care provided to the resident during that month (computed by multiplying the number of days in the facility times the per diem cost of care).

If the cost of care exceeds the available resident income, Medicaid will pay the difference. If the available resident income exceeds the cost of care, the excess income is the property of the resident (Section 8.482.3) and must be refunded to the resident or the legal guardian/designated responsible party.
When patient payment is calculated by per diem, the final amount shown on the AP-5615 will be that amount to be paid by the resident, not the amount to be returned to the resident.
If, at the time the resident is discharged or dies, the patient payment for that month is greater than the properly computed per diem patient payment, the following rules apply:

a. If the resident is discharged to another nursing facility, or to the resident's own home, the excess patient payment and personal needs fund must be forwarded to the resident in their own home or in the transferred nursing facility, within 45 working days of the date of discharge.

b. If the resident is discharged to a hospital, other medical institution, or if the resident dies, the excess patient payment must be immediately refunded to the resident's personal needs account.

These funds should be disbursed as detailed in Section 8.482.52.F. If the nursing facility does not handle the resident’s personal needs funds, the excess patient payment must be immediately returned to the responsible party.

However, if the resident is discharged from the nursing facility to a hospital or other medical institution and is admitted with Medicaid as the primary source of funding, the patient payment in excess of the amount due to the discharging nursing facility may be due to the hospital or medical institution. Any excess patient payment should be sent to the hospital at the end of the month (see Section 8.300.10). If the resident discharged to a hospital or other medical institution is not readmitted to the nursing facility, the resident's personal needs funds, either excess patient payment or resident personal needs funds, must be lawfully disposed of as indicated in Section 8.482.52.F.
If the resident dies in the nursing facility or is discharged to a hospital or other medical institution where they subsequently die, the resident's funds entrusted to the nursing facility must be transferred as indicated in Section 8.482.52.F.

(3) If resident personal needs funds are unable to be transferred due to an uncashed check after ninety (90) days, the resident personal needs funds must be submitted to the Department with a copy of the cancelled check as indicated in Section 8.482.52.F.3.

Changes of financial status within the facility:

a. Residents transferring from private pay to Medicaid may have a patient payment liability for the Medicaid-funded portion of the month depending on the amount of income applicable to care, as determined on the AP-5615 form.

If the resident's income exceeds the cost of care paid for the private resident portion of the month, the excess income is applicable to the remaining Medicaid portion of the month.

b. The same patient payment calculation applies for residents transferring from Medicaid to private pay status. The patient payment is first applied to the Medicaid portion of the month and any excess is then applied to the remaining private pay days.

D. Zero Patient Payment 1. Patient payment may be waived and zero $0.00 patient payment applied only under the following conditions:

a. A resident's income is equal to or less than the personal needs allowance (see Section 8.100.7.V.3.); or b. A resident's income is equal to or less than the personal needs allowance, less earned income (if appropriate), less spousal and dependent care allowance, or less home maintenance allowance, or less allowable expenses for Medicare premiums as defined in

Section 8.100.7.V.3.; or c. A resident is admitted to the nursing facility from their home and the resident's funds are committed elsewhere for that month; or d. The resident is admitted from their home, where their funds were previously committed, to the hospital, and subsequently to the nursing facility, in the same calendar month; or e. The resident is discharged to their home, and the county department determines that the income is necessary for living expenses; or f. The resident is admitted from another nursing facility or from private pay within the facility and has committed the entire patient payment for the month in payment of care already provided in the month of admission.

Patient payment may not be waived (other than for the exceptions provided for in Section 8.482.34.D.1.) in the following instances:

a. A resident with income in excess of the personal needs allowance, less earned income (if appropriate), less spousal and dependent care allowance, or less home maintenance allowance, or less allowable expenses for Medicare premiums as defined in Section 8.100.7.V.3., except as provided in the Colorado Department of Human Services Income Maintenance Staff Manual Volume 3, concerning increased personal needs allowance; or b. Transfers between nursing facilities; or c. Discharges from nursing facility to a hospital or other medical institution; or d. Changes from private pay within the facility and patient payment not already committed for care provided; or e. The death of the resident.

The amount of SSI benefits received by a person who is institutionalized is not considered when calculating patient payment.

8.482.4 NO DUPLICATE OR ADDITIONAL PAYMENTS

8.482.41 DUPLICATE PAYMENTS

A. “Duplicate payment” is defined as:

Payment to two or more facilities, hospitals or other institutions for per diem or room and board care for the same resident for the same time period;
Payment from two sources, including but not limited to, Medicare and Medicaid, for the same service to the same resident. Supplementary payments in which each source pays a portion (not overlapping) of the total due, is not considered duplicate payment.

B. Duplicate payment shall not be made:

To a hospital and a nursing facility for the same period of time for care of any one resident;
To two or more nursing facilities for the same period of time for the care of any one resident;
For any other instance, whether billed by the provider in good faith or in error.

C. Any provider billing for such duplicate services for any period of time during which the resident was not actually in the facility or the resident did not actually receive any facility billing for services will be subject to the penalties as set forth in 10 CCR 2505-10 section 8.482.45.

D. In any instance in which duplicate billings result in Medicaid reimbursement to both providers, a recovery shall be made by the Department against one or both providers.

8.482.42 ADDITIONAL PAYMENTS

A. “Additional payments” are defined as payments made by the resident, or by a resident's family, conservator or administrator for items which are not a benefit of the Medicaid program, such as:

Items covered in Section 8.440.2.A., Services and items not included in the Per Diem Rate (chargeable to resident personal needs account).
Room reservations for medical leave in accordance with Section 8.482.43.
Room reservations for non-medical and/or programmatic leave days in excess of 42 days per calendar year in accordance with Section 8.482.44.

B. Additional payment for resident care and services which are to be furnished within the nursing facility per diem rate (Section 8.440.1) are specifically prohibited. The nursing facility can neither solicit additional funds for such care and services nor accept voluntary monetary contributions for them, from residents or responsible parties. Any such monies collected or accepted by the nursing facility shall render such facility liable for the penalties set forth in Section 8.482.45.

C. Additional payments may be charged for:

Services and items not included in the per diem rate, as specified in

Section 8.440.2. These items may be billed to the resident, to the resident's estate or other responsible party, subject to the restrictions set forth in Section 8.440.2.

Room reservations. “Room reservation” is hereby defined as that charge made to a resident or to a resident's family, conservator or administrator, or other responsible party, to retain the resident's room and provide space for clothing and other personal items during the time which the resident is absent from the facility. Room reservation charges may be made under the circumstances outlined at 10 CCR 2505-10 sections 8.482.43 and 8.482.44.

a. Medical leave. See 10 CCR 2505-10 section 8.482.43 for conditions and restrictions.

b. Non-medical and/or programmatic leave. See 10 CCR 2505-10

section 8.482.44.

D. Failure to comply with the following restrictions on additional payment will render the nursing facility liable for repayment of any such funds, or to prosecution as set forth in 10 CCR 2505-10 section 8.482.45, or both:

Exact physician's orders on the nursing facility charts, for such additional care or services;
Fully itemized billings to the resident or responsible party;

E. Additional payments by persons other than the resident shall not be regarded as income to the resident, and shall not affect the eligibility of the resident for the Medicaid program.

F. Additional payments may not be deducted from the resident's personal needs account, nor may they be applied to a PETI deduction as described in Section 8.482.33, unless authorized by the resident or the party responsible for the resident. The authorization must be a separate written authorization for each billing from the nursing facility.

8.482.43 MEDICAL LEAVE FROM NURSING FACILITY

A. Definition. “Medical Leave” is defined as absence of the resident from the nursing facility due to admission to a hospital or other institution.

B. Medical Leave is subject to the following restrictions:

The resident’s absence must be on the orders of a physician, as noted in the resident's chart;
The resident plans to return to the nursing facility;
The nursing facility must prepare an AP-5615 showing the dates the Medical Leave commenced and ended. See Section 8.482.34.
The resident, or the responsible party, must be advised, in writing, that payment for holding the nursing facility room cannot be made by Medicaid.

In addition, the resident, or responsible party, must give written consent to the additional charge, including the daily rate and the anticipated number of days. If the resident is absent from the facility longer than the anticipated number of days shown on the consent form, the nursing facility must obtain agreement on another consent form before continuing to charge for medical leave. The consent form(s) must be retained with the resident’s records and be subject to audit.

C. Room reservation charges for Medical Leave:

The per diem charge for room reservations for Medical Leave cannot exceed the per diem rate currently authorized for the nursing facility, less total food and linen service costs. In no case shall the charge be greater than the current per diem rate less $2.
The specific bed which the resident had occupied prior to leave must be reserved. No other resident may occupy the reserved bed.
If no source of payment, other than the resident's funds, are available, and the nursing facility's current occupancy is less than 90 percent of capacity, the room must be reserved at no charge to the resident.
Revenues to the nursing facility from room reservations must be used in reduction of related expenses, on the MED-13 form.
If no other funds are available, the room reservation charges may be deducted from the resident's personal needs account, subject to the restrictions in Section 8.482.42. However, the resident's personal needs account must maintain a balance of at least $10 at all times, if used for room reservations payment. In case of death of the resident, the entire resident personal needs account may be used, if necessary. 8.482.44 Room Reservations for Non-Medical and/or Programmatic Leave Medicaid will pay a nursing facility to hold a bed for non-medical and/or programmatic leave days up to a combined total of 42 days per resident per calendar year.

Non-medical leave days are defined as days of leave from the nursing facility for nonmedical reasons. Programmatic leave days are days of leave prescribed by a physician for therapeutic and/or rehabilitative reasons. Programmatic leave may entail visits to family, friends or guardians, or leave to participate in approved therapeutic and/or rehabilitative programs. A leave day is considered to have been incurred for any day during which the resident is absent from the nursing facility for therapeutic and/or rehabilitative purposes and does not return by midnight of that day.

Before Medicaid payment is made for room reservation costs for non-medical and/or programmatic leave, the attending physician must approve each leave and affirm that such leave is not contrary to the resident's written plan of care. In the case of programmatic leave, this approval must be in writing and noted on the resident's chart and/or Individual Habilitation Plan (IHP). In addition, the physician must affirm that the resident's programmatic leave is of therapeutic and rehabilitative value and consistent with the overall plan of care and/or Individual Habilitation Plan developed for the If the resident has the approval of the attending physician in writing, and such approval is noted on the resident's chart, room reservations for non-medical and/or programmatic leave may be paid for by the resident, after the allowable 42 days per calendar year has been paid from Medicaid funds. Charges to residents for this leave are subject to the following restrictions:

A. Such charges must not commence until after 42 days of non-medical and/or programmatic leave in any one calendar year.

B. The Medicaid Program has not been billed for such leave. Billing both Medicaid and the resident for the same leave period will subject the nursing facility to the penalties as set forth in10 CCR 2505-10 section 8.482.45.

C. The resident or the resident's family must be advised that payment for the nursing facility room cannot be paid from Medical Assistance funds after the resident's allowable leave has been consumed. In addition, the resident and/or legal guardian must give written consent to the room reservation charges, both the daily rate and the anticipated number of days. The consent form must be retained with other resident records and subject to audit.

D. The maximum allowable charge for non-medical and/or programmatic leave is the same as stated for medical leave in paragraph C of 10 CCR 2505-10 section 8.482.43.

E. The specific bed which the resident occupied prior to leave must be reserved. No other resident may occupy a bed so reserved.

F. Revenues to the nursing facility from room reservations must be used in reduction of related expenses, on the MED-13 form.

G. In no case shall the nursing facility deduct non-medical and/or programmatic leave charges from the resident's personal needs account, unless specific authorization has been received, in writing, from the resident and/or legal guardian.

8.482.45 ENFORCEMENT BY THE DEPARTMENT

The Department shall assess, enforce, and collect penalties for noncompliance with regulations, in accordance and as authorized under C.R.S. §25.5-6-205(1)(a), including but not limited to the following:

A. Obtaining vendor payments fraudulently, as outlined in C.R.S. § 25.5-4-305.

B. Obtaining additional payments from residents, or resident's families, as outlined in C.R.S. § 25.5-4-301.

C. License revocation or provisional license according to the provisions of C.R.S. § 25-3-103.

D. Fraudulent acts to assist any person in obtaining public assistance, vendor payments, medical assistance, or child care assistance to which the person is not entitled to as outlined in C.R.S. § 25.5-4-301.

E. Overpayments or incorrect payments due to omission, error or fraud as outlined in C.R.S. §25.5-4-301(2).

F. Duty of resident to report changes in income as outlined in C.R.S. § 26-2-128.

G. Crimes against at-risk persons as outlined in C.R.S. § 18-6.5-103 H. Illegal retention and use of resident personal needs account as outlined in C.R.S. § 25.5-6-206.

I. Rules as defined in this section 8.400 through 8.482.

8.482.46 UTILIZATION OF MEDICARE BENEFITS

A. Part “B” deductible and co-insurance amounts for Medicare-eligible Medicaid recipients will be reimbursed by Medicaid. Reimbursement will be made for any service covered by Part “B” of the Medicare program, as described in 42 CFR § 405, Subpart B, even though that service is not ordinarily covered under the medical assistance program. The services paid by Medicare cannot be included in costs for calculation of the nursing home provider's daily reimbursement rate. If Medicare Part “B” type services are provided by the facility and the facility has a provider number which it used to bill Medicare, then the following entries must be made to the cost report (MED-13):

The cost of the care reimbursed by Medicare and/or Medicaid crossover for residents who are Medicaid recipients may be deducted from Schedule “C” of the MED-13 Schedule “B” if the costs for providing that care are determinable and auditable; or 2. The Medicare and/or Medicaid crossover revenue for residents who are Medicare eligible will be deducted from Schedule “C” on Schedule “A”.

B. When the facility provides Medicare Part “B” type services to non-residents of the facility, the following entries must be made to the cost report (MED-13):

Cost of the care reimbursed by Medicare and/or Medicaid crossover for non-residents of the facility must be deducted from Schedule “C” of the MED-13 on Schedule “B” if the costs for providing that care are determinable and auditable; or 2. The Medicare and/or Medicaid crossover revenue for non-residents of the facility must be deducted from Schedule “C” on Schedule “A”.

C. Co-insurance and deductible costs for the following services (which are covered by Medicare Part “B”) may be billed to the Medicaid program without prior authorization:

Laboratory Services 2. Medical Supplies 3. Durable Medical Equipment 4. Speech Therapy 5. Occupational and Physical Therapy 6. Practitioner Services D. Facilities or their suppliers when billing the Medicaid program for those services reimbursed by Medicare, must use the Medicare/Medicaid crossover system of billing. The facility, in order to bill through the Medicare/Medicaid crossover system, needs to complete a Medicare billing form and indicate on that form that they wish to “accept assignment.” A Medicare claim form for a Medicare/Medicaid patient, indicating acceptance of assignment, will cross over to Medicare, and coinsurance and/or deductibles will be paid on a Medicaid remittance advice.

8.482.5 RESIDENT'S PERSONAL NEEDS ACCOUNTS

8.482.51 STATEMENT OF POLICY

A. All residents receiving nursing facility care are allowed to retain the amount of income specified in Section 8.100.7.v.3. as personal needs funds, to purchase necessary clothing or incidentals as specified in Section 8.440.2.A.. These funds may not be used to supplement the Medicaid nursing facility payment, and such funds cannot be used for any other purpose whatsoever by the nursing facility.

B. Personal needs funds are for the exclusive use of the resident as they desire.

The resident or relatives may not be charged for such items as Chux, tripads, toilet paper, or other nursing facility maintenance items because these items are included in the audited cost described in Section 8.442. Other charges which could be disallowed are as follows:

Nursing facility maintenance items and nursing care supplies and 2. Charges without the following documentation:

a. vendor receipts;

b. signed cash receipts; or c. statement signed by the resident for any specifically requested over-the-counter drug.

Charges which constitute a duplicate payment as defined in Section 8.482.41.
Charges which constitute an additional payment as defined in Section 8.482.42.
Handling charges, such as personal needs account bank service fees.

C. Items not covered by Medicaid, as described in Section 8.440.2.A.,such as personal items, clothing, etc., may be charged to the resident’s personal needs account. However, all of the restrictions in Section 8.442.1 apply. In addition, only those items actually requested by the resident may be charged to the personal needs funds, and there must be a signed, dated receipt for each item or service signed by the resident, the resident's conservator, guardian or relative, or by a responsible party, retained in the resident's personal needs accounts file.

Acceptable signed consent formats:

a. Petty cash receipt form signed by the resident, responsible party or two facility witnesses, if the resident is unable to sign.

b. Email from the responsible party on file for the resident.

Copy or original itemized receipt for purchase obtained at time purchased item(s) is/are delivered to the resident. Receipt must be attached to the signed consent form.
Disallowed consent forms include text messages and verbal approvals.

D. Facility is responsible to document and maintain procedures for handling resident personal needs accounts and reporting fraud and/or financial exploitation E. Facility is responsible to report to a law enforcement agency any suspected mistreatment of at-risk elders as described in C.R.S. § 18-6.5-108.

F. Resident personal needs accounts are subject to audit by the Department or its designee. Any deficiencies identified may result in corrective action plans, recoupment of funds, including interest, to the Department from the facility, forfeiture of the surety bond, or any penalty listed in Section 8.482.45.

Any instances of insufficient documentation or misuse of funds identified during an audit may be referred to the County Department.

8.482.52 RESPONSIBILITIES OF NURSING FACILITIES

A. General Accounting Practices 1. Nursing facilities must administer a resident personal needs account for those residents who are unable to or have no desire to handle their own personal needs funds. The nursing facility is obligated to exercise due care in the handling of resident funds per federal regulations.

If a resident elects to have the nursing facility handle their personal needs funds, a resident personal needs account agreement must be entered into and signed by the resident or the resident's legal personal representative.

This agreement creates a fiduciary relationship between the nursing facility and the resident which includes the legal rights and responsibilities provided for in C.R.S. §15-1-101. As a condition of the resident personal needs account agreement, the nursing home is allowed to return the personal needs allowance portion of the resident's income. (See Section 8.100.7.V.3.).

If the resident or responsible party does not elect to have the facility handle the personal needs funds, the resident or responsible party must enter into and sign a resident personal needs account exclusion agreement with the facility.
If the total personal needs fund balance is less than $50.00, the resident's personal needs fund may be held in either an interest or non-interestbearing account with a depository institution or in cash at the facility as described at 42 C.F.R. § 483.10(f)(10)(ii)(B).
If the total personal needs fund balance is $50.00 or more, the resident's personal needs funds must be kept in an interest-bearing account. The account can be a checking account, a savings account, or a certificate of deposit as described at 42 C.F.R. § 483.10(f)(10)(ii)(B).
The bank account must be designated as “resident personal needs account.”
The funds in the depository institution (most often a bank) must be insured (bonded) per Part B below.
The personal needs funds must not be commingled with either the operating funds of the facility or with any other individual's fund who is not a resident of the facility.
The personal needs funds of more than one resident can be commingled in the same bank account as long as separate accounting records (i.e., subsidiary ledgers) are maintained.
No charge for handling such accounts may be made to the recipient or to the estate of the recipient at any time. Such expenses should be included as a part of the audited costs as determined in Section 8.440.
A subsidiary ledger, as specified by the Department, must be kept for each resident for recording resident personal needs account transactions.
A reconciliation of the sum of the ledger balances to the bank balance (plus petty cash, if applicable) must be performed on a monthly basis.
Deposits and disbursements from the resident personal needs account must be recorded in an accurate amount and in accordance with Section 8.482.51.B for purchases and Section 8.482.52.F for refunds.
Any interest income must be recorded on the ledgers. If the resident personal needs account funds are pooled in one interest - bearing account, the interest earned on the accounts must be allocated to each resident's account proportionately (i.e., by dividing the individual resident's account balance by the total personal needs account fund balance then multiplying that quotient times the amount of interest income).
The resident shall be notified when their personal needs account fund balance reaches $200 less than the SSI resource limit.
This accounting system must be adequate for audit by the the Department, and in accordance with generally accepted accounting principles.
All such accounts, original bank statements, and supporting documentation must be available for audit by any authorized employee of the county department, Department, or agent of the Department at any time.
Personal needs funds are the property of the residents and all accounting records, bank accounts and other documents must remain with the nursing facility when ownership is transferred.

B. Bonding Requirements 1. An additional condition of nursing facility participation in the Medicaid program is the purchase of a surety bond as required by C.R.S. § 25.5-6- 206(3)(c). The sum of the surety bond must not be less than the resident’s personal needs accounts funds liability as computed quarterly during interest proration, or the licensed operator (“licensee”) shall otherwise demonstrate to the satisfaction of the Department that the security of the residents' funds is assured. State owned/operated facilities are bonded separately under the risk management program up to $100,000 and are exempt from this requirement.

The effective dates of the surety bond shall be from January of each calendar year through December 31 of the following calendar year.
A copy of the Surety Bond Patient Needs Fund (Form MED-181), or the Certificate of Insurance (Surety Bond), fully executed, signed and sealed, shall be filed each year with the Department within 15 days prior to the effective date thereof.

a. Each year, upon surety bond renewal, a copy of the renewed surety bond shall be filed with the Department within thirty (30) calendar days of the renewal date at 4. Upon the termination of Medicaid participation of a nursing facility provider for any reason, either voluntarily or through Departmental action, the bond must be kept in effect until the final audits of resident personal needs account funds and nursing facility billing accounts can be completed by the Department, and until any adjustments required by such audits have been made.

C. Change in Licensed Operator, Change in Ownership - Requirements 1. When the licensed operator (“licensee”) of a nursing facility is changed, as described in Section 8.443.15, it shall be the duty of the new licensee:

a. To execute a new resident personal needs account agreement on behalf of Medicaid residents, as required by this section. The new licensee shall furnish proof to the Department that it has properly established resident's personal needs accounts and carried forward the proper balance remaining in each resident's ledger.

b. To post a surety bond as required by C.R.S. § 25.5-6-206 (3)(c) and

Section 8.482.52.B., or to otherwise demonstrate to the satisfaction of the Department that the security of residents' personal needs accounts is assured.

c. Upon notice to the Department that a nursing facility's licensed operator will change or Medicaid participation will be terminated as required in Section 8.443.15, the Department may withhold all or part of any monies due the prior nursing facility licensee until the resident personal needs accounts have been determined to be correct. If such accounts are found to be deficient, the amount of the bond established by the prior licensee shall be forfeited to the Department. The Department will, in such cases, assume the responsibility for proper distribution of such monies to the deficient resident accounts.

It shall be the duty of the prior licensee to provide the new licensee written verification, by a public accountant, of the amount of personal needs funds being transferred for each resident's personal needs account. This verification shall include a statement that this amount corresponds to the total of the balances shown on the resident's individual ledger D. New Admission When a patient is admitted to a nursing facility for the first time, or transferred from Medicare or private pay, the nursing facility shall set up a new account for personal needs funds, which lists a beneficiary or beneficiaries (with percentages), as specified in A. of this subsection..

E. Readmissions, Transfers from Another Nursing Facility.

Upon readmission or transfer of a resident, the nursing facility shall determine the amount of personal needs funds currently in the resident's account in the previous facility, make every effort to obtain such funds, and show this amount as a balance forward in the current ledger.

Reconfirmation of the listed beneficiary or beneficiaries shall also be done at this time.

Failure to make such effort shall be considered a breach of agreement, and may be cause for cancellation of the participation agreement.
If, upon making every effort, the current nursing facility is unable to obtain the balance of funds from the resident's previous facility, the current nursing facility should notify the Department immediately. Failure to do so may be construed as a failure to make every effort.

F. Discharge from a Nursing Facility 1. Upon discharge of a resident to the resident's home, to another nursing facility or to the care of a responsible party, the nursing facility shall determine the amount remaining in the resident’s personal needs account within 45 days, and make payment of this amount to the resident, responsible party, or transfer these funds to the current nursing facility, if appropriate. Failure to so dispose of the resident's personal needs funds shall render the nursing facility liable for cancellation of the participation agreement or to the penalties as set forth in Section 8.482.45, or both. All patient's personal possessions shall also be relinquished, as required by

Section 8.482.6.

At the end of the month in which a resident is discharged to a hospital, the nursing facility shall:

a) set aside the personal needs allowance amount for the resident;

b) apply the balance of any patient liability amount to the established Medicaid rate for the number of days the resident lived in the c) if there is still a balance, transfer the funds to the receiving hospital, if Medicaid is the primary funding source.

If the resident returns to the same nursing facility, no additional accounting is necessary. If the resident does not return to the same facility, however, disposition of the personal needs funds shall be made as specified in this

section.

Death of a resident.

a. The nursing facility shall distribute the balance of the resident personal needs account in the following order:

(1) Pay outstanding debt due the facility related to uncollectible patient payment for room and board;

(2) Transfer the personal needs amount and a final accounting of the funds to the person responsible for settling the resident’s estate. The responsible party may be a Public Administrator or other interested or appointed person. The facility can accept the Collection of Personal Property by Affidavit pursuant to C.R.S. § 15-12-1201 if the estate assets are under the published threshold for that year, the Letters Testamentary, or Letters of Administration. Transfer of funds shall occur within 60 days from the date of death. The facility shall provide written notice to the Department that funds were transferred to the person responsible for settling the resident’s estate. Notice shall include the patient’s name, Medicaid State ID, amount transferred, name of person that received the funds, and the contact information for the person that received the funds. Upon receipt of the notice, the Department may initiate action to recover the funds pursuant to C.R.S. § 25.5-4-302.

(3) Pay remaining funds to the Public Administrator of the county according to the provisions of C.R.S. §15-12-620(4).

The Clerk of the District Court should be contacted to obtain the name of the current Public Administrator appointed for the county. The facility shall provide written notice to the Department that funds were transferred to the Public Administrator for settling the resident’s estate. Notice shall include the patient’s name, Medicaid State ID, amount transferred, county, and the name of the Public Administrator.

(4) The facility shall have defined policies and procedures to determine whether the balance of a resident’s personal needs account should be remitted to a burial or funeral service provider for outstanding costs. The facility shall follow the burial assistance rules of the Colorado Department of Human Services per 9 CCR 2503-5 § 3.570.43. The facility should ensure that the value of the member’s estate, including any cash or property, is identified and subtracted from the burial grant per 9 CCR 2503-5 §3.570.43.D.2 and that payments from the decedent’s estate are paid directly to the service provider per 9 CCR 2503-5 § G;

(5) If the facility is unable to properly disposition the deceased resident’s personal needs funds in any of the means described in the above provisions, the facility may transfer the funds to the Department for collection to offset the medical assistance paid on the member’s behalf.

Any failure of the nursing facility to properly dispose of the resident personal needs account within 90 days of death or discharge will be considered a breach of resident personal needs account agreement and may be cause for cancellation of the participation agreement, forfeiture of the required surety bond, and prosecution under the penalties provided in

Section 8.482.45.

8.482.53 RESPONSIBILITIES OF COUNTY DEPARTMENT

A. It shall be the responsibility of the county department, to explain to the resident the various options for handling the personal needs funds, as well as the resident's rights to such funds. If the resident chooses to allow the nursing facility to hold such funds in a resident personal needs account, the county department is responsible for assuring that the resident assigns all income to the nursing facility. See Section 8.482.52.A.2.

8.482.54 RESPONSIBILITIES OF THE STATE DEPARTMENT

A. It shall be the responsibility of the Department to accept and to properly dispose of residual personal needs funds, upon the death of the resident, in any of the following conditions:

The resident dies intestate (i.e., without a will), but with known relatives or a listed beneficiary for whom current addresses are unknown;
There is no Public Administrator in the county and there are no listed relatives or beneficiaries;
The nursing facility is unsure of the existence of a will, or whether there are known relatives.

B. The facility shall be obligated to provide explanation for withholding personal needs funds beyond 90 days after the death of a resident. The Department may apply any or all of the following remedies:

Demand immediate return of such funds,- 2. Order an audit of all resident personal needs accounts;
Cancel the participation agreement of such nursing facility.

C. Perform periodic audits of nursing facility accounts. Audits may be performed at such intervals as determined necessary by the Department. Audits will always be performed when a nursing facility is discontinued from the Medicaid program for any reason and when a change of ownership or management occurs.

D. If an audit of a resident personal needs account reveals discrepancies the Department, on behalf of the resident, may take administrative action as outlined in Sections 8.040 and 8.482.45, Recoveries from Providers.

E. If the nursing facility cannot offer proof that any apparent discrepancies identified in an audit have been corrected the Department may withhold payment of nursing care costs in the amount shown due and payable by the audit.

8.482.55 MANAGEMENT OF PERSONAL NEEDS FUNDS BY OTHER THAN

RESIDENT

A. For residents unable to manage their own funds due to a physical or mental condition, a conservator, guardian, or other responsible person may carry out these acts for the resident.

B. Personal needs funds shall not be turned over to persons other than the resident’s authorized agent when establishing the resident personal needs account.

With resident’s written consent (if able and willing to give such consent) the administrator may authorize the purchase of specific items on behalf of the resident.
An itemized, dated, and signed receipt is required for the purchase.
A copy or original itemized receipt must be submitted to facility at the time the purchase is delivered to the resident.
The facility must verify purchased items were delivered to the resident.
The Facility will only reimburse the responsible party for items the resident requested.

C. Refer to Section 8.482.51 for the account management policy and Section 8.440.2.A.2 for the acceptable purchases policy.

8.482.6 PATIENT'S PERSONAL POSSESSIONS

A. The Department’s rules and regulations are designed to insure that clothing and other property of each resident shall be properly safeguarded and reserved for personal use, and to comply with standards established by CDPHE.

B. The nursing facility shall be responsible for safeguarding personal possessions (including money) and to:

Provide a method of identification of the resident's suitcases, clothing, and other personal effects, listing the items on an appropriate form attached to the resident's nursing facility record at the time of admission. Such listings are to be kept current. Any personal effects released to a relative or designated representative of a resident must be delineated in a signed receipt.
Provide adequate storage facilities for the resident's personal effects.
Exercise careful judgment in the release of resident's personal property to anyone other than the actual owner, and to secure an itemized statement of release, the signature of the resident, duly authorized agent, or responsible party.
Ensure that all mail is delivered unopened to the resident to whom it is addressed, except for those residents who have a legal guardian or conservator, other legal arrangement, or have voluntarily given written consent to allow opening such mail, in which case the mail is held, unopened, until delivered to the resident.

C. In the event of death of a resident in the nursing facility, or in a medical institution or on medical leave from a nursing facility, the following rules apply:

The nursing facility shall provide the deceased resident's executor, administrator or successor claiming under the Small Estates Act (See

Section 8.482.52.F.3.d) with a copy of the resident's personal needs account ledger.

The nursing facility shall turn over to the responsible party all of the deceased resident's personal property in its possession. All items shown by the resident personal needs account ledger as purchased by or in behalf of the resident must be returned to the responsible party.
The responsible party claiming the possessions must sign a dated, itemized receipt for all such items before removal of the items from the nursing facility.

D. In the event of discharge of a resident, all personal possessions and a copy of the resident personal needs account ledger signed and dated by the administrator shall be turned over to the patient, or to the responsible party, as is required for a deceased patient in C above.

8.482.7 NURSING FACILITY RESPONSIBILITY FOR ESTABLISHING

RESIDENT PERSONAL NEEDS ACCOUNT

Many nursing facility residents are either unable or unwilling to manage their personal funds and the residents or their families or guardians wish this responsibility to be assumed by the nursing facility. Because nursing facility residents who are Medicaid members often have income from Social Security, Supplemental Security Income, Railroad Retirement, or other sources, it is necessary for participating nursing facilities to maintain a system of accounting for Medicaid funds, resident income, and resident's personal needs accounts. This system shall be maintained in accordance with standards required by the Department, and subject to audit. The following sections outline a standard system of accounting to be used by participating nursing facilities for these purposes. Any deviation from this system must have written approval of the 8.482.71 REQUIRED ITEMS A. Book of money receipts in triplicate.

B. Cash receipts journal including columns for nursing facility operating and resident personal needs accounts.

C. Checking accounts for nursing facility operating and resident personal needs accounts.

D. Cash Disbursements Journal including columns for nursing facility operating and resident personal needs accounts.

E. General Ledger accounts as follows:

Cash-General or Operating account 2. Cash-Patient Resident Personal Needs Account 3. Cash-Patient Petty Cash (Resident Personal Needs Imprest Fund)
Accounts Receivable - Nursing Care (Control Account.)
Accounts Payable - Personal Needs Liability (Control Account)

(Note: This is not a complete listing of every account which would normally appear in a General Ledger, but includes the accounts necessary for purposes of this system of accounting.)

F. Subsidiary Ledger for Accounts Receivable-Nursing Care sub-classified by resident name.

G. Subsidiary Ledger for Personal Needs sub-classified by resident name.

H. Personal Needs Cash Paid Out and Personal Needs Cash Request Slips for use with Personal Needs Imprest Fund.

I. Forms for Certificate of no responsibility for resident's personal needs funds and Appointment of Agent and authorization to handle resident's personal needs funds.

J. Cash box or other secure place for petty cash used in Personal Needs Imprest Fund.

K. Reconciliation personal needs bank statement with personal needs account records.

8.482.72 GLOSSARY

A. Basic Bookkeeping Terms 1. ACCOUNT -- Basic classification device used in bookkeeping. In a doubleentry bookkeeping system, an account consists of a Debit side and a Credit side. Individual accounts within a ledger serve as the basis for financial statements.

ACCRUAL OR ACCRUED CHARGE -- A charge arising from an individual or business entity providing goods or services to another individual or entity. An accrual or charge is entered on the Debit side of an individual account. A charge may be accrued in advance of the goods or services provided, or may be accrued afterward, depending upon the basis of accounting used (See ACCRUAL BASIS and/or CASH BASIS)
ACCRUAL BASIS -- A basis of accounting wherein revenues are recognized at the time they are “earned” (i.e., at the time goods or services are provided) and expenses are recognized when they are incurred as liabilities. (Opposite of CASH BASIS accounting-See CASH

BASIS.)

BOOK OF ORIGINAL ENTRY -- An accounting book or record which serves as the point of original entry of accounting transactions recorded.

The book of original entry serves as the basis for classification of items to individual accounts. Examples of Books of Original Entry include Cash Receipts Journal, Cash Disbursements Journal, General Journal, etc.

CASH BASIS -- A basis of accounting wherein revenues are recognized for accounting purposes at the time they are collected in cash and expenses are recognized at the time that they are paid in cash (Opposite of ACCRUAL BASIS accounting - See ACCRUAL BASIS.)
CASH DISBURSEMENTS JOURNAL -- A book of original entry in which transactions involving payments of cash are recorded and summarized for later classification to individual accounts. A Cash Disbursements Journal usually consists of one column for entries to a cash account and another column (or columns) for entries to other accounts affected by the transactions recorded.
CASH RECEIPTS JOURNAL -- A book of original entry used to facilitate accounting for receipts of cash by an enterprise. A Cash Receipts Journal usually consists of one column for entries to a cash account and another column (or columns) for entries to other accounts affected by the transactions recorded.
CONTROL ACCOUNT -- A general ledger account which summarizes items which are classified in SUBSIDIARY ACCOUNTS or SUBSIDIARY LEDGERS (See SUBSIDIARY ACCOUNT.) The total of the balances in the subsidiary accounts should equal the balance of the control account in the general ledger.
CREDIT (Abbreviated CR.) -- In a double-entry bookkeeping system, an entry made on the right-hand side of an account is called a “Credit” entry.
DEBIT (Abbreviated DR.) -- In a double-entry bookkeeping system an entry made to the left-hand side of an account is called a “Debit” entry.
DOCUMENTATION - Supporting data or proof explaining an entry in the accounting records; e.g., a payment on account may be “documented” by an invoice, cancelled check, etc.
DOUBLE ENTRY BOOKKEEPING SYSTEM -- A system of bookkeeping wherein at least two entries are made for every transaction recorded; for each entry made to the “debit” side, a corresponding entry (or entries) must be made to the “credit” side. A double-entry system is used for purposes of proof of accuracy of transactions recorded; total of “debits” must be equal to the total of “credits” for the system to be “in balance.”

(See ACCOUNT, DEBIT, and CREDIT.)

GAAP -- Generally Accepted Accounting Principles.
PETTY CASH FUND (Also called IMPREST FUND) -- A fund set up for the

purpose of control over cash transactions; most often used when a large number of small transactions must be made. The balance of an imprest fund is constant, and must consist of either cash or receipts or other documentation showing the use of the cash. An imprest fund is “replenished” periodically when the cash in the fund reaches a low point by removing the receipts, totaling them, and replacing them with the amount of cash spent. An imprest fund is sometimes called a “revolving fund”.

LIABILITY -- An “obligation” or “debit” of an individual or business enterprise to pay a sum of money at some future time. Examples of liabilities are accounts payable, notes payable, bonds payable, monies held in a fiduciary capacity, such as the personal needs funds.
LEDGER -- A grouping of accounts in a bookkeeping or accounting system. For example, a “general ledger” may contain all the accounts of a business enterprise, while a “subsidiary ledger” may consist of subclassifications of one particular account in a “general ledger.” (See SUBSIDIARY ACCOUNT or SUBSIDIARY LEDGER.)
POSTING -- A basic bookkeeping operation wherein information for accounting records is transferred from one place to another; as in “posting” to the general ledger from the cash receipts journal, etc. Posting is usually a preliminary operation to summarization of data for preparation of financial statements, etc.
RECONCILIATION -- An explanation of differences in accounting records for the purpose of ensuring accuracy of the records. An example is the “Reconciliation” of a bank statement balance to the balance in the check book or cash book.
SUBSIDIARY ACCOUNT or SUBSIDIARY LEDGER -- An account or group of accounts sub-classifying a particular account in a general ledger which is used with a CONTROL ACCOUNT. An example is Accounts Receivable. The Accounts Receivable would be represented in the general ledger by a control account and sub-classified by name of debtor in a subsidiary ledger. Each account in the subsidiary ledger has an individual balance, and the total of all the balances in the subsidiary ledger should equal to the balance of the control account in the general ledger.

(See CONTROL ACCOUNT.)

TRIAL BALANCE -- A bookkeeping operation in which balances of all accounts in a ledger are taken and summarized to ascertain that postings of debts equal postings of credits. A “Trial Balance” may also be taken of a subsidiary ledger to be certain that the postings to the subsidiary ledger agree with those to the control account in the general ledger.
FIDUCIARY OR TRUST -- A party who is entrusted to conduct the financial affairs of another person.

B. Terms Related to Nursing Facility Bookkeeping 1. BENEFICIARY -- The listed person/persons/charitable institution or other agency a resident has elected to receive the balance of the resident personal needs account in the event of death.

CENSUS -- A nursing facility record of admissions and/or discharges of residents within a given time period (examples are 24-hour or “midnight” census, monthly census, etc.) The census is used to determine the number of patient days of care provided by the nursing facility.
FISCAL AGENT -- Agency under contract to the State Department of Health Care Policy and Financing for the purpose of disbursing funds to providers of services under the Medicaid Program. The fiscal agent collects eligibility and payment information from the county and state Departments and processes this information for payment to providers (nursing care facilities).
FORM AP-5615 -- For purposes of reporting change in patient status, admissions discharges, changes in resident payments, etc. to the county department(s). Commonly referred to as “5615”s.
GENERAL (OR OPERATING) ACCOUNT -- May describe either an account in the general ledger (as Cash-General or Operating) or a bank account. Used to record monies due to the nursing facility for care or services provided to the resident, are recorded in this account (as distinguished from a resident personal needs account, which is used to account for personal needs funds belonging to residents of a facility).
INTESTATE -- A person who dies without leaving a will is said to have died “intestate.”
MEDICAID (TITLE XIX) PROGRAM -- Program funded by federal and state governments which provides for nursing facility care for the categorically eligible. It is administered in Colorado through the Department of Health Care Policy and Financing.
NURSING CARE (ACCOUNTS RECEIVABLE) ACCOUNT -- Account in a subsidiary patient ledger which is used to record accrued nursing care charges, patient payments, and Medicaid payments for a Medicaid eligible 9. PERSONAL NEEDS ACCOUNT - An account in a subsidiary resident ledger used to record personal needs fund transactions of a resident.

Same as “Patient Trust Fund”.

PERSONAL NEEDS ALLOWANCE (PNA) - is the amount specified in

Section 8.100.7.V. to be deducted from resident income and used for the exclusive benefit of the resident prior to application of income to nursing facility care.

PERSONAL NEEDS LIABILITY - The liability of a nursing facility or its representatives for funds which the facility is managing on behalf of its residents. If the resident elects to have the facility manage these funds, a fiduciary (trust) capacity is established for the resident, and the facility is responsible to the resident for due care of the funds and sufficient accounting of transactions made by the facility on behalf of the resident.
PROVIDER (OR VENDOR) - A nursing facility which provides services to residents under the Medicaid Program. A provider facility must be licensed and certified by various government agencies to become eligible to participate in this program.
PUBLIC ADMINISTRATOR -- An appointed government official with various fiduciary responsibilities, including that of disposition of funds of deceased residents with no known heirs. (Nursing facility residents often die without leaving a will and with no known heirs, and their remaining funds are paid to the Public Administrator.)
RESIDENT PERSONAL NEEDS ACCOUNT – An account in a subsidiary resident ledger used to record personal needs fund transactions of a resident. Most often used as a title for a bank account for residents' personal needs funds.
RESIDENT OR PATIENT PAYMENT - The portion of a nursing facility resident's income which is applied toward their care at the facility (according to state department regulations, all income received by a resident, with the exception of the monthly personal needs allowance, or the allowable cost with respect to the post -eligibility treatment of income as defined in 10 CCR 2505-10 section 8.100.7.V.1., shall be applied toward the resident's care, with the balance paid by Medicaid). A resident's income may be from Social Security, Veterans' Administration, Railroad Retirement, government pensions, an estate or trust, or other sources.

The amount of SSI benefits received by a person who is institutionalized is not considered when calculating patient payment.

“Responsible Party” is any of the persons below, who accepts the responsibility for a resident's funds, mail or personal possessions and is willing to sign a written declaration of such responsibility:

a. a legally appointed guardian, or conservator;

b. relative or friend;

c. the county department; or d. a resident may act as their own responsible party, if they are managing their own affairs.

TESTATE -- A person who dies leaving a will is said to have died “testate.”
UB04 CLAIM FORM -- Form utilized by providers to bill nursing facility 8.497 PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

8.497.1 STATUTORY AUTHORITY AND APPLICABILITY 8.497.1.A. The statutory authority for these rules is set forth in § 25.5-5-412, C.R.S. 8.497.1.B. A PACE organization, as defined herein, must comply with all applicable federal, state, and local statutes, regulations, and laws including but not limited to the following:

Code of Federal Regulations (CFR), Title 42 – Public Health, Chapter IV – Centers for Medicare & Medicaid Services, Department of Health and Human Services, Subchapter E Programs of All-Inclusive Care for the Elderly (PACE), Part 460 – Programs of All-Inclusive Care for the Elderly (PACE). This will be referred to in this regulation as 42 CFR 460. 42 CFR

Part 460 (2024) is hereby incorporated by reference. The incorporation of 42 CFR Part 460 (2024) excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request.

Section 25.5-5-412, C.R.S. 8.497.1.C. A PACE organization must have an agreement with the CMS and the Department, as defined herein, for the operation of a PACE program.

8.497.2 SCOPE AND PURPOSE 8.497.2.A. The purpose of these rules is to implement § 25.5-5-412, C.R.S. which require the Department to establish, administer, and enforce minimum regulatory standards and rules for the PACE program, including for contracted entities of the PACE program, to ensure the health, safety and welfare of PACE participants. 8.497.2.B. Scope and purpose.

General. This regulation sets forth the following:

a. The requirements that an entity must meet to be approved as a PACE organization that operates a PACE program under Medicaid in the State of Colorado;

b. How individuals may qualify to enroll in a PACE program; c.. How Medicaid payments will be made for PACE services;

d. Provisions for State monitoring of PACE programs;

e. Procedures for sanctions, enforcement actions, and terminations.

Program purpose. PACE provides, prepaid, capitated, comprehensive health care services designed to meet the following objectives:

a. Enhance the quality of life and autonomy for older adults who require the level of care provided in a nursing facility;

b. Maximize dignity of, and respect for, older adults;

c. Enable older adults to live in the community as long as medically and socially feasible; and d. Preserve and support the older adult’s family unit by relieving the family of the sole responsibility of coordinating and providing care and services.

8.497.3 DEFINITIONS

As used in this regulation, unless the context indicates otherwise, the following definitions apply:

A. CMS means Centers for Medicare and Medicaid Services.

B. Dementia diseases and related disabilities means a condition where mental ability declines and is severe enough to interfere with an individual’s ability to perform everyday tasks. Dementia diseases and related disabilities include Alzheimer’s disease, mixed dementia, Lewy Body Dementia, vascular dementia, frontotemporal dementia, and other types of dementia.

C. Department means the Colorado Department of Health Care Policy and Financing.

D. Designated Representative means a representative who is designated by the participant to act on the participant’s behalf.

E. Medicaid participant means an individual determined eligible for Medicaid who is enrolled in a PACE program.

F. PACE stands for the programs of all-inclusive care for the elderly.

G. PACE center is a facility which includes a primary care clinic, and areas for therapeutic recreation, restorative therapies, socialization, personal care, and dining, and which serves as the focal point for coordination and provision of most PACE services.

H. PACE contract means the contract between the Department and a PACE I. PACE organization means an entity that has in effect a PACE program agreement to operate a PACE program under this regulation.

J. PACE program means a program of all-inclusive care for the elderly that is operated by an approved PACE organization and that provides comprehensive healthcare services to PACE enrollees in accordance with a PACE program agreement.

K. PACE program agreement means an agreement between a PACE organization, CMS, and the Department.

L. Participant means an individual who is enrolled in a PACE program.

M. Service means all services that could be required under Section 8.497.8.B., including items and drugs.

N. State administering agency means the Department.

O. Survey Agency means either the Colorado Department of Public Health and Environment or any contractor the Department engages to conduct onsite inspections of a PACE center.

P. Subcontractor means a third party contracted with a PACE organization to aid in performance of the PACE contract work.

Q. Telehealth means a mode of delivery of health care services through HIPAAcompliant telecommunications systems, including information, electronic, and communication technologies, remote monitoring technologies and store-andforward transfers, to facilitate the assessment, diagnosis, consultation, treatment, education, care management, or self-management of a covered person's health care while the covered person is located at an originating site and the provider is located at a distant site.

R. Trial period means the first 3 contract years in which a PACE organization operates under a PACE program agreement, including any contract year during which the entity operated under a PACE demonstration waiver program.

8.497.4 PACE ORGANIZATION APPLICATION AND WAIVER PROCESS 8.497.4.A. Purpose.

Applications. This section sets forth the application procedures for the a. An entity that seeks approval from the Department as a PACE b. A PACE organization that seeks to expand its service area or to add a new PACE center.

c. A PACE organization that seeks to expand its service area and to add a new PACE center.

Waiver. This section sets forth the process by which a PACE organization may request waiver of certain regulatory requirements. The purpose of the waivers is to provide for reasonable flexibility in adapting the PACE model to the needs of particular organizations (such as those in rural areas). 8.497.4.B. Application requirements.
In addition to the application requirements set forth in 42 CFR § 460.10 and 42 CFR § 460.12, an entity that seeks to become a PACE organization or a PACE organization that seeks to expand its service area or add a PACE center, must comply with the following requirements:

a. Letter of intent. Submit a letter of intent in the form and manner specified by the Department at least 90 days prior to submitting an application to the Department. The letter must contain, at least, the following information:

i. The name and contact information of the person submitting the letter of intent;

ii. The name of the entity or PACE organization including the state-approved trade name, also known as “doing business as” name, if different;

iii. The proposed service area, including counties, zip codes, and any zip codes that overlap another PACE organization’s service area, if applicable; and iv. The proposed location of the PACE center, if applicable.

b. Market feasibility study. All entities and PACE organizations must submit a market feasibility study of the proposed service area with the letter of intent. The study must include, but is not limited toat least, the following:

i. Estimate of the number of individuals eligible for PACE;

ii. Methodology for calculating potential participants;

iii. Projected market penetration, including assumptions made to support the rate of projected market penetration, and justification that the entity or PACE organization can reasonably serve the potential participants in the proposed service area;

iv. Demonstration of an unmet need for PACE in the proposed service area;

v. Evidence the new PACE center, if applicable, has the capacity to adequately serve the potential participants who reside in the proposed service area;

vi. Evidence, conducted by a qualified actuary, that the applicant will either be cost neutral or save the Department money;

vii. Identification of all competitors and collaborators in the proposed service area;

viii. Mean travel time from the farthest points of the service area to the PACE center;

ix. Demographics of the proposed service area such as age, race, language, and household income; and x. Health outcomes of the proposed service area such as quality of life, social and economic factors, and physical environment.

c. Department-specific application requirements.

i. Submission of application. An individual authorized to act for an entity or a PACE organization that seeks to expand its service area or add a PACE center site must submit to the Department a complete application in the form and manner, including timeframes for submission, specified by the Department, that describes how the entity or PACE organization meets all requirements in this part.

ii. Submission timeframe. An entity or a PACE organization must submit an application to the Department at least 90 calendar days prior to its anticipated CMS application date.

iii. Contents of application. An application to the Department must contain information to demonstrate financial and operational stability, as specified in the Department's application. The application must include, but is not limited to, the following:

Financial assets;
Additional owners and/or financially invested organizations;
Risk reserve;
Reinsurance;
Staff recruitment and retention program.
The Department may allow more than one PACE organization per zip code. 8.497.4.C. Department evaluation of applications. The Department evaluates an application in accordance with the requirements of 42 CFR § 460.18 and Department-specific requirements, including the following information.
Information contained in the application;
Information obtained by the Department or a Survey Agency through onsite visits or any other means;
Use of information from a current or prior PACE program agreement or State of Colorado Contract;
Department and/or state of Colorado budgetary considerations and constraints; and 54. Financial and operational stability of the applicant. 8.497.4.D. Notice of the Department’s determination.
Time limit for notification of determination. Within 90 days, or 45 days for applications set forth in 8.497.4.A.1.b., after an entity submits a complete application to the Department, the Department takes one of the following actions in the form and manner specified by the Department:

a. Approves the application.

b. Denies the application and notifies the entity in writing of the basis for the denial and the process for requesting reconsideration of the denial.

Complete application. An application is only considered complete when the Department receives all information necessary to make a determination regarding approval or denial.
Additional information requested. If the Department determines that an application is not complete because it does not include sufficient information to make a determination, the Department will request additional information within 90 days, or 45 days for applications set forth in 8.497.4.A.1.b., after the date of submission of the application.

a. The time limits in 8.497.4.D.1. do not begin until the Department receives all requested information and the application is complete.

b. If more than 12 months elapse between the date of initial submission of the application and the entity’s response to the Department’s request for additional information, the entity must update the application to provide the most current information and materials related to the application.

Date of submission. For purposes of the time limits described in this

section, the date that an application is submitted to the Department is the date on which the application is delivered to the address designated by 8.497.4.E. Submission and evaluation of waiver requests. A PACE organization, or an entity submitting an application to become a PACE organization, must submit its waiver request in accordance with 42 CFR § 460.26. In addition to the requirements set forth in 42 CFR § 460.26, an entity or PACE organization must submit the request to the Department at least 90 calendar days prior to its anticipated CMS application or waiver submission date.

8.497.5 PACE PROGRAM AGREEMENT 8.497.5.A. A PACE program agreement must meet the requirements set forth at 42 CFR § 460.30. 8.497.5.B. Content and terms of PACE program agreement. The PACE program agreement must include all content required by 42 CFR § 460.32. 8.497.5.C. The duration of the PACE program agreement shall be in accordance with 42 CFR § 460.34. 8.497.5.D. The PACE organization must comply with all requirements of the PACE program agreement. If the PACE program agreement is amended or modified in any way, the amendment or modification must be automatically incorporated herein as of the effective date of the amendment or modification, and the PACE organization must comply with all requirements of the amendment or modification as of that date.

8.497.6 SANCTIONS, ENFORCEMENT ACTIONS, AND TERMINATION 8.497.6.A. Violations for which the Department may impose sanctions.

In addition to other remedies authorized by law or contract, the Department may impose any of the sanctions specified in Section 8.497.6.B., if the Department or a Survey Agency determines that a PACE organization commits any of the violations specified in 42 CFR § 460.40(a) or the following violations:

a. Makes payment to or employs or contracts with any individual or organization that has a criminal conviction as defined in 42 § CFR 460.68(a); or b. Makes payment to individuals and entities excluded by the Office of Inspector General or included on the preclusion list as pursuant to 42 § CFR 460.86.

If the Department or a Survey Agency makes a determination that could lead to termination of a PACE program agreement under Section 8.497.6.C., the Department may impose any of the sanctions specified in

Section 8.497.6.B. If the Department determines that the circumstances in

Section 8.497.6.C.2.a. exist, the Department does not have to determine that the circumstances in Section 8.497.6.C.2.b. exist prior to imposing an enrollment and/or payment suspension. 8.497.6.B. Suspension of enrollment or payment by the Department.

Enrollment Suspension. If a PACE organization commits one or more violations specified in 42 CFR § 460.40(a), the Department may suspend enrollment of Medicaid beneficiaries or place a limit on enrollments after the date the Department notifies the organization of the violation.
Payment Suspension. If a PACE organization commits one or more violations specified in 42 CFR § 460.40(a), for participants enrolled after the date the Department notifies the PACE organization of the violation, the Department may suspend Medicaid payment to the PACE 3. Term of suspension. A suspension or denial of payment remains in effect until the Department is satisfied that the following conditions are met:

a. The PACE organization has corrected the cause of the violation;

b. The violation is not likely to recur.

Restrictions and Conditions. The Department may impose restrictions or conditions on a PACE organization, which may include at least one of the a. Retaining a consultant to monitor the effectiveness of corrective measures for a specific period determined by the Department;

b. Monitoring the effectiveness of corrective measures by the Department for a specific period; or c. Requiring additional training for personnel, owners, or operators of the PACE organization.

Notification and Plan Requirements.

a. If the Department imposes any restriction or condition that is not the result of a serious and immediate threat to the health, safety, or welfare of a PACE participant, the Department shall notify the PACE organization of the restriction or condition in writing.

b. If the Department imposes any restriction or condition that is the result of a serious and immediate threat to the health, safety, or welfare of a PACE participant, the Department shall notify the PACE organization of the restriction or condition in writing, by telephone, or in person during an on-site visit.

i. The PACE organization must remedy the circumstances creating the harm or likelihood of harm immediately upon receiving notice of the restriction or condition.

c. If the Department initially provides notice of a restriction or condition by telephone or in person, the Department shall send written confirmation of the restriction or condition to the PACE d. A PACE organization must complete corrective action as specified in Section 8.497.13.C.1. 8.497.6.C. Termination of a PACE program agreement. The Department may terminate a PACE program agreement for cause, pursuant to 42 CFR § 460.50. 8.497.6.D. Transitional care during termination. The PACE organization must meet the transitional care requirements set forth in 42 CFR § 460.52. 8.497.6.E. Termination procedures.

Except as provided in Section 8.497.6.E.2., if the Department terminates a PACE program agreement with a PACE organization, it will furnish the PACE organization with a reasonable opportunity to develop and implement a corrective action plan to correct the deficiencies that were the

basis of the Department’s determination that cause exists for termination:

The Department may terminate a PACE program agreement and PACE contact without invoking the procedures in Section 8.497.6.E.1. if the Department determines that a delay in termination, resulting from compliance with these procedures before termination, would pose an imminent and serious risk to the health of participants enrolled with the organization..

8.497.7 PACE ADMINISTRATIVE REQUIREMENTS 8.497.7.A. PACE organizational structure. The PACE organizational structure must comply with the requirements set forth in 42 CFR § 460.60. 8.497.7.B. Governing body. The governing body of the PACE organization must comply with the requirements set forth in 42 CFR § 460.62 8.497.7.C. Compliance oversight requirements. The PACE organization must adopt and implement compliance oversight requirements in accordance with 42 CFR § 460.63. 8.497.7.D. Personnel qualifications for staff with direct participant contact. The PACE organization must comply with the personnel qualifications set forth in 42 CFR § 460.64. 8.497.7.E. Training. The PACE organization must comply with the training requirements set forth in 42 CFR § 460.66.

In addition to the general qualification requirements specified in 42 CFR § 460.66, all PACE organization personnel having direct participant contact must complete the following trainings annually. Newly hired personnel must complete the training before working independently:

a. Mandatory reporting of adult mistreatment. Staff members must complete training that includes reporting requirements as specified in C.R.S. § 18-6.5-108;

b. The service determination process as specified in Section 8.497.9.G; and c. Dementia diseases and related disabilities. The training must be culturally competent and include at least the following content:

i. Activities of daily living.

ii. Care planning.

iii. Dementia diseases and related disabilities.

iv. Dementia-related behaviors and communication.

v. Person-centered care.

All orientation, training, competency, and personnel action documentation must be retained in the personnel files. 8.497.7.F. Program integrity. The PACE organization must comply with the program integrity requirements set forth in 42 CFR § 460.68. 8.497.7.G. Contracted services. The PACE organization must comply with the contracted service requirements set forth in 42 CFR § 460.70. 8.497.7.H. Oversight of direct participant care. The PACE organization must oversee direct participant care in accordance with the requirements set forth in 42 CFR § 460.71. 8.497.7.I. Physical environment. The PACE center must meet the physical environment requirements set forth in 42 CFR § 460.72. 8.497.7.J. Infection control. The PACE organization must comply with the infection control requirements set forth in 42 CFR § 460.74. 8.497.7.K Transportation services.
Safety, accessibility, and equipment. A PACE organization's transportation services must be safe, in good working order, accessible, and equipped to meet the needs of the participant population and meet the transportation services requirements set forth in 42 CFR § 460.76.
Maintenance of vehicles. In addition to the requirements set forth in 42 CFR § 460.76(b), PACE organizations must ensure safety inspections include the inspection of items as described in Rules Regulating Transportation by Motor Vehicle, 4 CCR 723-6; § 6103 and § 6104. 4 CCR 723-6; § 6103-6104 (2024) is hereby incorporated by reference. The incorporation of 4 CCR 723-6; § 6103-6104 (2024) excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request.
Drivers.

a. PACE organizations must ensure that each driver meets the following requirements:

i. Drivers must be 18 years of age or older;

ii. Have at least one year of driving experience;

iii. Possess a valid Colorado driver’s license.

iv. Provide a copy of their current Colorado motor driving vehicle record, with the previous seven years of driving history; and v. Complete a Colorado or National-based criminal

history record check.

b. Drivers must be disqualified from serving as drivers for any program participants for any of the following reasons:

i. A conviction of substance abuse occurring within the seven (7) years preceding the date the criminal

history record check is completed;

ii. A conviction in Colorado, at any time, of any Class 1 or 2 felony under Title 18, C.R.S.;

iii. A conviction in Colorado, within seven (7) years completed, of a crime of violence, as defined in C.R.S. § 18-1.3-406(2);

iv. A conviction in Colorado, within four (4) years completed, of any Class 4 felony under Title 18, Articles 2, 3, 3.5, 4, 5, 6, 6.5, 8, 9, 12, or 15, C.R.S.;

v. A conviction of an offense in any other state that is comparable to any offense listed in subparagraphs (f)(II)(A) through (D) within the same time periods as listed in subparagraphs (f)(II)(A) through (D) of Rules Regulating Transportation by Motor Vehicle, 4 C.C.R. 723-6; § 6114. 4 CCR 723-6; § 6114 (2024) is hereby incorporated by reference. The incorporation of 4 CCR 723-6; § 6114 (2024) excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request.;

vi. A conviction in Colorado, at any time, of a felony or misdemeanor unlawful sexual offense against a child, as defined in § 18-3-411, C.R.S., or of a comparable offense in any other state or in the United States at any time;

vii. A conviction in Colorado within two (2) years completed of driving under the influence, as described in § 42-4-1301(1)(f), C.R.S. or driving with excessive alcoholic content, as described in §42-4-1301(1)(g), C.R.S;

viii. A conviction within two (2) years preceding the date the criminal history record check is completed of an offense comparable to those included in subparagraph (f)(III)(B), 4 C.C.R. 723-6; § 6114 in any other state in the United States; and ix. For purposes of 4 C.C.R. 723-6; § 6114(f)(IV), a deferred judgment and sentence pursuant to § 18-1.3- 102, C.R.S., shall be deemed to be a conviction during the period of the deferred judgment and sentence. 8.497.7.L. Dietary services. The PACE organization must comply with the dietary services requirements set forth in 42 CFR § 460.78. 8.497.7.M. Fiscal Soundness. The PACE organization must comply with the fiscal soundness requirements set forth in 42 CFR § 460.80. 8.497.7.N. Marketing.

The PACE organization must comply with the marketing requirements set forth in 42 CFR § 460.82.
Marketing information must be free of material inaccuracies, misleading information, or misrepresentations on all platforms.
The Department retains the right to disapprove previously approved marketing materials if they are subsequently found to be inaccurate, altered, or otherwise non-compliant. 8.497.7.O. Emergency preparedness. The PACE organization must comply with all applicable federal, state, and local emergency preparedness requirements and must establish and maintain an emergency preparedness program that meets the requirements set forth in 42 CFR § 460.84.

8.497.8 PACE SERVICES 8.497.8.A. PACE benefits under Medicare and Medicaid. The PACE organization must comply with the requirements set forth in 42 CFR § 460.90. 8.497.8.B. Required services. The PACE organization must comply with the requirements set forth in 42 CFR § 460.92. 8.497.8.C. Excluded services. The services set forth in 42 CFR § 460.96 are excluded from coverage under PACE. 8.497.8.D. Service delivery.

Access to services. The PACE organization is responsible for providing care that meets the needs of each participant across all care settings, 24 hours a day, every day of the year, and must establish and implement a written plan to ensure that care is appropriately furnished.
Provision of services.

a. The PACE organization must provide services in accordance with 42 CFR § 460.98(b).

b. The PACE organization must visit each participant in-person or via telehealth across all care settings as often as the participant’s condition requires, but no less than once each calendar month.

i. If a participant does not receive a visit during a calendar month, the PACE organization must notify the Department, in writing, within 15 calendar days of the following calendar month. The notice must explain the reason(s) why the participant did not receive a visit.

ii. For the purposes of this requirement, a visit must be provided directly by PACE staff or a contracted specialist.

The delivery of items or medications and services routinely provided by a contracted residential care provider are not considered a visit.

iii. If the PACE organization provides these visits via telehealth, the PACE organization must ensure the telehealth delivery option meets the following requirements:

Participants must have an informed choice between in-person and telehealth services;
The use of the telehealth delivery option will not prohibit or discourage the use of in-person services;
Telehealth will not be used for the provider’s convenience; and 4) Telehealth must be provided using technology compliant with Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security and Breach Notification Rules.

iv. The telehealth permissions in this section do not apply to the in-person assessment and reassessment requirements as described in 8.497.8.G.

Timeframes for arranging and providing services. The PACE organization must comply with the requirements set forth in 42 CFR § 460.98(c).
Minimum services furnished at each PACE center. At a minimum, the PACE organization must provide the services set forth in 42 CFR § 460.98(d) at each PACE center.
PACE center operation. The PACE organization must operate its center(s) in accordance with 42 CFR § 460.98(e).

a. Services at the PACE center must be provided consistent with any applicable standards of practice for that service, and, when applicable, by staff with the requisite qualifications to perform the service.

Center attendance. The frequency of a participant's attendance at a center is determined by the interdisciplinary team, based on the needs and preferences of each participant. 8.497.8.E. Emergency care. The PACE organization must comply with the emergency care requirements set forth in 42 CFR § 460.100. 8.497.8.F. Interdisciplinary team. The PACE organization must comply with the interdisciplinary team requirements set forth in 42 CFR § 460.102. 8.497.8.G. Participant assessment. The PACE organization must comply with the assessment and plan of care requirements set forth in 42 CFR § 460.104. 8.497.8.H. Plan of care.
The PACE organization must comply with the plan of care requirements set forth in 42 CFR § 460.106.
Residential care provider involvement in plan of care. For participants receiving residential care, the PACE organization must seek input from residential care providers in the evaluation of the plan of care and share the plan of care with residential care providers.

8.497.9 PARTICIPANT RIGHTS 8.497.9.A. Bill of rights. The PACE organization must comply with the requirements set forth in 42 CFR § 460.110. 8.497.9.B. Specific rights to which a participant is entitled. The PACE organization must comply with the requirements set forth in 42 CFR § 460.112.

Information disclosure. In addition to the requirements set forth in 42 CFR § 460.112(c), the participant has the following rights:

a. To receive a current list of the employees of the PACE organization who furnish direct care to the participant upon enrollment and upon request. At a minimum, the list must include each discipline of the interdisciplinary team as set forth in 42 CFR § 460.102(b).

b. To have an equal opportunity to receive meaningful communication and to participate fully in discussions involving the PACE program, services, activities, eligibility, enrollment and other benefit information, in the language preferred by the participant. 8.497.9.C. Restraints. The PACE organization must comply with the requirements set forth in 42 CFR § 460.114. 8.497.9.D. Explanation of rights. The PACE organization must comply with the requirements set forth in 42 CFR § 460.116 and must display the contact information for the Colorado PACE Ombudsman in a prominent place in the PACE center. 8.497.9.E. Violation of rights. The PACE organization must have established documented procedures to respond to and rectify a violation of a participant's rights. 8.497.9.F. Grievance process. The PACE organization must comply with the requirements set forth in 42 CFR § 460.120. 8.497.9.G. Service determination process.

The PACE organization must comply with the requirements set forth in 42 CFR § 460.121.
PACE organization decisions to reduce or terminate services.

a. If the PACE organization reduces or terminates a service, without the participant requesting the reduction or termination, the PACE organization must provide written notice to the participant of the right to file a service determination request to continue the service.

b. This requirement does not apply to services with a specified end date. 8.497.9.H. PACE organization's appeals process.

The PACE organization must comply with the requirements set forth in 42 CFR § 460.122.
A PACE participant must exhaust the internal appeals process described in this part prior to requesting a State Fair Hearing as described in Sections 8.497.9.I. and 8.057. 8.497.9.I. Additional Appeal Rights Under Medicare or Medicaid.
A PACE organization must comply with the requirements set forth in 42 CFR § 460.124.
Medicaid participants have the right to a state fair hearing under Section 8.057. Appeals must be filed within 60 calendar days of the date of the notice of action.

8.497.10 QUALITY IMPROVEMENT 8.497.10.A. Quality improvement program and plan. A PACE organization must establish, implement, maintain, and evaluate an effective data-driven quality improvement program and plan, pursuant to 42 CFR § 460.130 and 460.132, that contains all requirements set forth in 42 CFR § 460.134. 8.497.10.B. Internal quality improvement activities. A PACE organization must comply with the requirements set forth in 42 CFR § 460.136. 8.497.10.C. Committees with community input. A PACE organization must comply with the requirements set forth in 42 CFR § 460.138.

8.497.11 PARTICIPANT ENROLLMENT AND DISENROLLMENT 8.497.11.A. Eligibility to enroll in a PACE program. A PACE organization must comply with the requirements set forth in 42 CFR § 460.150. 8.497.11.B. Enrollment process.

A PACE organization must comply with the requirements set forth in 42 CFR § 460.152.
Additional intake process requirements.

a. At least one member of an interdisciplinary team must assess the individual in person in the individual’s place of residence prior to enrollment. This assessment must be completed by one of the following disciplines:

i. Registered Nurse.

ii. Physical Therapist.

iii. Occupational Therapist.

iv. Home Care Coordinator.

v. Other appropriate members of an interdisciplinary team as identified by an interdisciplinary team.

b. The appropriate members of an interdisciplinary team, as identified by an interdisciplinary team, must review and discuss each potential participant and decide to approve or deny the individual’s enrollment based on that review. 8.497.11.C. Enrollment agreement. If the potential participant meets the eligibility requirements and wants to enroll, he or she must sign an enrollment agreement which contains, at a minimum, the information required by 42 CFR § 460.154. 8.497.11.D. Other enrollment procedures. The PACE organization must comply with the requirements set forth in 42 CFR § 460.156. 8.497.11.E. Effective date of enrollment. A participant’s enrollment in the program is effective on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement. 8.497.11.F. Continuation of enrollment.

The PACE organization must comply with the requirements set forth in 42 CFR § 460.160.
In addition to the waiver of annual requirement regulations set forth in 42 CFR § 460.160(b)(1), a participant who continues to meet nursing facility level of care during their first annual recertification, is permanently waived from the annual recertification requirement.
In addition to the deemed continued eligibility regulations set forth in 42 CFR § 460.160(b)(2), the following apply:

a. If the PACE organization believes the participant would be expected to meet the nursing facility level of care within the next 6 months, the organization must submit a request for deemed continued eligibility to the Department in the form and manner specified by b. Upon receipt of all requested information, the Department will make a determination.

c. The Department will notify the PACE organization of the Department’s decision in writing in a timely manner.

d. If the Department determines the participant does not qualify for deemed continuous eligibility, the PACE organization must follow involuntary disenrollment procedures as described in Section 8.497.11.H., unless the participant chooses to voluntarily disenroll. 8.497.11.G. Voluntary disenrollment. The PACE organization must comply with the voluntary disenrollment requirements set forth in 42 CFR § 460.162. 8.497.11.H. Involuntary disenrollment.

The PACE organization must comply with the involuntary disenrollment requirements set forth in 42 CFR § 460.164.
In addition to the reasons for involuntary disenrollment regulations set forth in 42 CFR § 460.164(b), the following applies for involuntary disenrollment:

a. As it relates to 42 CFR § 460.164(b)(1) and 460.164(b)(2), the PACE organization must provide written notice to the participant, designated representative, or both explaining the amount due.

Involuntary disenrollment request requirements.

a. A PACE organization must submit an involuntary disenrollment request to the Department in a timely manner and in the form and manner specified by the Department.

b. Before an involuntary disenrollment is effective, the Department must review it and determine in a timely manner that the PACE organization has adequately documented acceptable grounds for disenrollment. 8.497.11.I. Disenrollment responsibilities. The PACE organization must comply with the disenrollment responsibilities requirements set forth in 42 CFR § 460.166. 8.497.11.J. Reinstatement in Medicaid programs. The PACE organization must comply with the reinstatement in other Medicaid program requirements set forth in 42 CFR § 460.168. 8.497.11.K. Reinstatement in PACE. The PACE organization must comply with the reinstatement in PACE requirements set forth in 42 CFR § 460.170. 8.497.11.L. Documentation of disenrollment. The PACE organization must comply with the documentation of disenrollment requirements set forth in 42 CFR § 460.172.

8.497.12 PAYMENT 8.497.12.A. Medicaid payment.

The PACE organization shall receive Medicaid payments in accordance with 42 CFR § 460.182.
The Department may also recover, at the Department’s discretion, payments made to the PACE organization in error for any reason, including, but not limited to, overpayments, improper payments, and excess funds received by the PACE organization by deduction from subsequent payments as specified in the PACE contract, deduction from any payment due under any other contracts, grants or agreements between Colorado and the PACE organization, or by any other appropriate method for collecting debts owed to the Department.
Payment Reconciliations. A PACE organization must adhere to the terms related to the participant-specific amount reconciliation, participant-specific reconciliation payments, and annual reconciliation as specified in the PACE contract. 8.497.12.B. Post-eligibility treatment of income.
The Department may provide for post-eligibility treatment of income for PACE participants as set forth in Sections 8.482.33 and 8.7202.BB.
Post-eligibility treatment of income is applied, as specified in 42 CFR § 460.184(b). 8.497.12.C. PACE premiums. The PACE organization must comply with the PACE premiums requirements set forth in 42 CFR § 460.186.

8.497.13 STATE MONITORING 8.497.13.A. Monitoring during trial period. During the trial period, the Department conducts comprehensive annual reviews of the operation of a PACE organization, in accordance with the requirements and scope set forth in 42 CFR § 460.190. 8.497.13.B. Ongoing monitoring after trial period. At the conclusion of the trial period, the Department continues to conduct review of a PACE organization, as appropriate, in accordance with the requirements set forth in 42 CFR § 460.192. 8.497.13.C. Corrective action. The PACE organization must comply with the requirements set forth in 42 CFR § 460.194. In addition, as it relates to a corrective action plan, a PACE organization must:

Submit an acceptable corrective action plan in the form, manner and timeframe specified by the Department, when corrective action is deemed necessary by the Department. An acceptable plan must include but is not limited to:

a. The corrective action the PACE organization will take on behalf of the participants affected by the deficient practice;

b. How the PACE organization will identify other participants who could be affected by the same deficient practice;

c. The measures or systemic changes the PACE organization has or will implement to ensure the deficient practice will not recur, including the responsible staff;

d. How the PACE organization will monitor the corrective action to ensure the deficient practice is corrected and the solution is sustained, including the responsible staff; and e. The date each plan was or will be completed. 8.497.13.D. Disclosure of review results. The PACE organization and the Department must comply with the requirements set forth in 42 CFR § 460.196. 8.497.13.E Disclosure of compliance deficiencies. The Department may require a PACE organization to disclose to its PACE participants or potential PACE participants the PACE organization’s performance and contract compliance deficiencies in a manner specified by the Department.

8.497.14 DATA COLLECTION, RECORD MAINTENANCE, AND REPORTING 8.497.14.A. Maintenance of records and reporting of data. The PACE organization must collect data, maintain records, and submit reports as required by the Department and in accordance with 42 CFR § 460.200. 8.497.14.B. Participant health outcomes data. The PACE organization must comply with the requirements set forth in 42 CFR § 460.202. 8.497.14.C. Financial recordkeeping and reporting requirements. The PACE organization must comply with the requirements set forth in 42 CFR § 460.204. 8.497.14.D. Financial statements.

The PACE organization must comply with the financial statement reporting requirements set forth in 42 CFR § 460.208.
Annual financial report. A PACE organization must submit the financial data as specified in the PACE contract. 8.497.14.E. Medical records.
A PACE organization must maintain a single, comprehensive medical record for each participant in accordance with the requirement set forth in 42 CFR § 460.210.
Additional content of medical records. In addition to the medical record content requirements set forth in 42 CFR § 460.210(b), the PACE organization must document whether a service or visit was provided in person or via telehealth. 8.497.14.F. Encounter data submission requirements.
Encounter data submission report. A PACE organization must submit encounter data, as directed by the Department, directly to the Department or its designee.

a. The PACE organization must use the Healthcare Common Procedure Coding System (HCPCS), ICD-10 Procedure Coding System (ICD-10 PCS), and Current Procedural Terminology (CPT) for provided services in each submission of encounter data.

b. A PACE organization must prepare and submit all pharmacy and non-pharmacy encounter data monthly, as specified by the Department, to the Department through its Fiscal Agent. Unless otherwise directed by the Department, encounter data must not be submitted to the Department, or its designated Fiscal Agent, more than 30 days from the final day of the previous month.

i. Submissions must be comprised of encounter records or adjustments to previously submitted records from provider encounter or claim records of any contracted or directly provided services rendered to the participant in the current or any prior months.

ii. Submission of encounter records of services rendered from all providers, including PACE organizations and their respective subcontractors, must have a valid, enrolled National Provider Identifier (NPI) with the Department.

Subcontractors who submit encounter records to the Department must be enrolled and approved through the 1) If a PACE organization’s encounter is not established in the HCPCS, ICD-10 PCS, or CPT, the PACE organization must document the encounter and submit an Encounter Data Submission Report to the Department for review and for coding consideration through a process defined by the Department in collaboration with the PACE organization.

Encounter data submission to the Pharmacy Benefit Management (PBM) vendor. A PACE organization must ensure pharmacy encounters are submitted to the PACE organization’s PBM vendor.

a. If a business need is identified by the Department, or noncompliance is identified, the Department or the Department’s PBM vendor will notify the PACE organization 90 days in advance of any requirement changes that are deemed necessary to ensure compliance, as set forth in the Colorado Pharmacy Benefit Management System Batch Pharmacy Encounters Companion Guide, unless there are unforeseen circumstances that require immediate system changes, in which case the PACE organization will be notified as soon as possible.

Annual signed encounter data certification. The PACE organization must submit an Annual Signed Encounter Data Certification to show that the encounter data submitted through the designated Fiscal Agent is accurate to the best of the PACE organization’s information, knowledge and belief.

a. The encounter data submission must comply with the format prescribed by the Department or its designated Fiscal Agent. The encounter data submission must include:

i. The name and provider ID of any ordering, referring, prescribing, or attending provider and information on the rendering, operating, or other professional.

Generic provider IDs shall be used only when specific Provider IDs remain unknown after reasonable inquiry.
NPI numbers of providers not enrolled in Medicaid must be reported.
If the NPI is not available, the PACE organization must report the tax payer ID.

ii. The PACE organization must require subcontractors and non-contracting providers to provide encounter data to the PACE organization.

b. The PACE organization must obtain an Annual Signed Encounter Data Certification from either the Chief Executive Officer or the Chief Financial Officer, or an individual who has delegated

authority to sign for, and who reports directly to, the Chief Executive Officer or Chief Financial Officer.

c. The PACE organization must provide an Annual Signed Encounter Data Certification to the Department or its designees covering all of the submissions for the preceding year of Encounter Data as specified in the PACE contract. 10 CCR 2505-10, Section 8.400-499, Appendix A: Age Appropriate Guidelines for the Use of ULTC 100.2 Assessment on Children These guidelines provide instructions for using the Uniform Long Term Care (ULTC) – 100.2 assessment to assess the needs of children for the following Home and Community-Based Services (HCBS) Waivers: Children’s Extensive Support (CES), Children’s HCBS (CHCBS), Children’s Habilitation Residential Program (CHRP), Children with Life Limiting Illness (CLLI) and Children with Autism (CWA). Each individual and their circumstances must be considered when completing the assessment. Case Managers must score each child according to his/her age and individual needs.

Please consult evidence based resources and references to further your understanding of child development.

A. What is child development?

Child development refers to the various stages of physical, biological, social, intellectual and psychological changes that occur from birth through the end of adolescence.
Growing process refers to the process of becoming physically larger in size and more mature through natural development.
The following are child development categories:

a. Gross Motor Skill: The ability to coordinate and control large muscles of the body. Some examples of gross motor control are sitting upright, balancing, walking, lifting, kicking and throwing a ball.

b. Fine Motor Skill: The ability to coordinate small muscles for precise small movements involving the hands, wrists, feet, toes, lips and tongue. Some examples of fine motor control are handwriting, drawing, grasping objects, dressing, cutting and controlling a computer mouse.

c. Speech and Language: The ability to both understand and use language to communicate thoughts and feelings through speaking, body language and gestures.

d. Cognitive: The ability to learn, understand, remember, reason, and solve problems.

e. Social and Emotional: The ability to interact with others, have relationships with family, friends, and teachers, exercise self-control, cooperate and respond to the feelings of others.

B. What are developmental milestones?

Developmental milestones refer to abilities achieved by most children by a certain age.

Milestones are used to gauge how a child is developing. Each milestone is associated with a specific age, however, the age when a developing child actually reaches each milestone may vary.

C. What is the Uniform Long Term Care (ULTC) 100.2 Assessment?

The ULTC 100.2 is an assessment to determine the Level of Care of a client by evaluating the client’s ability to independently complete Activities of Daily Living (ADLs).

ADLs are activities performed in the course of a typical day in a person's life such as: bathing, dressing, toileting, mobility, transferring, and eating. ADLs also include behavior and memory supervision activities needed for daily life. The ULTC 100.2 is a foundational component of the Person-Centered Support Planning process that helps:

Determine the appropriate services 2. Determine the care that is necessary to meet clients' needs, and 3. Assist in the selection of long-term care supports and services that meet clients' needs.

The assessment measures what the child is able to do, not what he/she prefers to do. In other words, assess the child’s ability to do particular activities, even if he/she doesn't usually do the activity.

Consider age-appropriate behavior when assessing the child’s ability to complete any ADL. If the child is not able to complete the ADL due to his or her age, then the child will not score in the ADL. However, if a child needs assistance in completing an ADL that is above and beyond the assistance a typically developing peer would require, then a score above 0 may be warranted.

D. Scoring The ULTC 100.2 asks you to give the child a score between 0 and 3 based on the child’s abilities in eight ADL areas. Scoring is completed as follows: 0 = Independent:

The child requires no greater assistance to successfully complete this task than would a child of similar age and stage that does not have a disability or impairment. The child has age-appropriate independence and reliability in the use of adaptive equipment necessary to complete this task, if needed. 1 = Minimal Assistance:

The child is able to perform all essential components of the activity with some impairment, with or without assistive device within a reasonable amount of time.

A score of 1 indicates the child is able to perform most of the essential components of the activity within a reasonable amount of time and may require:

a. Minimal assistance to successfully complete the task compared to a child of similar age and stage.

b. Minimal assistance with adaptation and assistive device(s)/medical equipment(s).

c. Minimal interventions such as occasional standby assistance, oversight and/or cueing. 2 = Moderate Assistance:

The child is unable to perform most of the essential components of the activity even with assistive device, requires a great deal of supervision or exceeds a reasonable amount of time to perform the activity with or without assistive device.

A score of 2 indicates that the child is unable to perform essential components of the activity due to requiring:

a. Hands-on assistance.

b. Hands-on assistance to use assistive device(s)/medical equipment(s).

c. Interventions such as regular line of sight.

d. Significant prompting or step by step cueing to begin a task and to complete it successfully. 3 = Total Assistance:

The child is totally unable to perform the essential components of the activity and needs extensive assistance.

A score of 3 indicates that the child is unable to perform the essential components of the activity due to requiring (but not limited to):

a. Assistance with complex assistive device(s)/medical equipment(s).

b. Extensive for hands-on assistance.

c. A trained attendant to perform ADLs or prevent complications.

E. Justification of Scoring (Due To’s)

All scores must be justified through one or more of the following conditions.

Select all applicable “due to’s” to support the ADL score.

Physical Impairment a. Example: client requires assistance due to paralysis 2. Supervision a. Example: client requires assistance due to lack of awareness 3. Mental Health a. Example: client requires assistance due to hallucinations F. Comment Box (Narratives)

Narratives are required in the “Comment box” to support each score and to help others who read the assessment understand a client’s over all need. Descriptions should be person-centered, meaningful and should justify level of assistance required based on “due to’s.” Comment descriptions should include:

a. How/Source: How the information obtained: Individual/caregiver, Case Manager Observation, or other?

b. What: What type of assistance is required to complete the task and how does the child manage to complete the task?

c. Who: Who is providing assistance?

d. When: How often is the child able or not able to complete the task each day?

e. Why: Why is the child able or not able to complete the activity (task)?

In May 2015, the Department published information on the best practices for what to include in narrative statements in the assessment in the Departments training website as well as in a Dear Administrator Letter. For additional information or examples of narrative statements, please find these resources on our website:

a. Writing Narrative Statements in the Assessment b. Dear Administrator Letter – May 11, 2015 G. Activities of Daily Living (ADL)

BATHING

Definition: The ability to shower, bathe or take sponge baths for the

purpose of maintaining adequate hygiene.

For older children, this includes the ability to get in and out of the tub and/or shower, the ability to turn the faucets on and off, regulate water temperature and to wash and dry. components of the task safely and without assistance at 10 years of age or older.

Considerations for a child from birth to 59 months:

a. A child younger than 12 months is dependent on a caregiver for bathing.

b. A child 12-24 months can typically sit-up in the bath and begin to participate, however, the child still requires assistance and supervision.

c. A child 24-59 months typically participates in bathing, however, still requires assistance and supervision.

Considerations for a child from 5 to 18 years:

a. A child 5-18 years old typically has the ability to bathe and does not require assistance, supervision, and/or help transferring in and out of the tub.

A child may score if the child has a unique medical reason or cognitive impairment that impacts bathing, needs adaptive equipment or skilled/medical care during bathing. Please remember that all children under 4 years of age need some assistance in bathing.

DRESSING

Definition: The ability to dress and undress as appropriate.

This includes the ability to put on and remove basic garments such as underwear, shirts, sweaters, pants, socks, hats, and jackets. It also includes fine motor coordination for buttons, snaps, zippers, and the ability to choose appropriate clothing for the weather. For older children, this activity includes the ability to put on prostheses, braces, anti-embolism hose or other assistive devices. components of the task safely and without assistance at 5 years of age or a. A child younger than 12 months is dependent on a caregiver for dressing.

b. A child 12-24 months can typically pull off hat, socks, and mittens.

c. A child 24-35 months can typically begin to help dress self.

d. A child 36-47 months can typically put on shoes (but cannot tie laces) and dress self with some help (buttons, snaps, zippers).

A child 48-59 months can typically dress self without much help.

a. A child age 5-18 years old typically participates in dressing and may require supervision or reminders with selecting appropriate clothing.

A child may score if the child has physical characteristics that makes dressing difficult such as contractures, hypotonia/hypertonia causing a lack of endurance or range of motion, or paralysis. Consider safety and the need to assist with dressing due to seizure activity, lack of balance or cognitive impairment when scoring a child. Difficulties with a zipper or buttons at the back of a garment is not unusual and does not mean there is a functional deficit.

TOILETING

Definition: The ability to use the toilet, commode, bedpan, or urinal.

This includes independent transferring on and off the toilet, cleansing appropriately, and adjusting clothes. In older children, this activity could include managing their ostomy or catheter.

A child should be able to physically and cognitively perform all essential components of the task safely and without assistance at 5 years of age or a. A child younger than 12 months is dependent on a caregiver for toileting.

b. A child 12-42 months typically requires the use of diapers, though begins to gain some control of bowels/bladder.

c. A child 43-59 months is typically toilet trained; however occasional night time bedwetting or accidents may occur.

a. A child age 5-6 years old may need to have intermittent supervision, cueing, or minor physical assistance and/or; have occasional night time bedwetting or accidents during waking hours.

b. A child age 7-18 years old should have the ability to toilet without A child may score if he/she has cognitive impairment or skilled/medical care needs that affect toileting, such as ostomy, suppositories, or frequent infections. Children younger than 4 years old may still require diapers or need to have intermittent supervision, cueing, or minor physical assistance, or they may have occasional night time bedwetting or accidents during waking hours. Children should have an awareness of being wet or soiled and show interest in toilet training and/or appliances such as ostomies or urinary catheters.

MOBILITY

Definition: The ability to move between locations in the child’s environment inside and outside the home.

This includes the ability to safely maneuver (ambulate) without assistance, go up/down the stairs, kneel without support, and assume a standing position. components of the task safely and without assistance at 3 years of age or a. A child younger than 6 months is dependent on a caregiver for mobility.

b. A child 6-12 months can typically maintain a sitting position, may begin to move by rolling or crawling, and may begin to pull self up using furniture.

c. A child 12-18 months can typically pull self to standing position, sit or stand alone, and move by crawling and/or walking with or without the use of furniture for balance.

d. A child 18-59 months can typically stand and walk without a. A child age 5-18 years old should be totally mobile and have the ability to move between locations without assistance.

A child may score if the child is unable to maintain seated balance, unable to bear weight on one or both legs, has a high risk of falling and/or uses mobility devices. Consideration is given to safety and the need to assist with mobility due to visual concerns, seizure activity, frequent falls, and/or lack of balance.

TRANSFERS

Definition: The physical ability to move between surfaces.

This includes the physical ability to get in/out of bed or usual sleeping place; to transfer from a bed/chair to a wheelchair, walker or standing position; to transfer on/off the toilet; and the ability to use assisted devices for transfers. components of the task safely and without assistance at 3 years of age or beyond the requirements of another child without a disability or impairment at the same age.

a. A child younger than 12 months is dependent on a caregiver for b. A child 12-36 months may require physical assistance with c. A child 36-59 months should require minimal assistance with a. A child age 5-6 years old may still require minimal assistance with b. A child age 7-18 years old should be independent and be able to transfer without physical assistance.

A child may score if the child has limited ability to independently move between two nearby surfaces and/or use assisted devices to transfer.

Consideration is given to safety and the need to assist with transfer due to visual concerns, seizure activity, and awareness to surrounding and/or lack of balance.

EATING

Definition: The ability to eat and drink using routine or adaptive utensils.

This includes the ability to cut, regulate the amount of intake, chew, swallow foods, and use utensils. Note other forms of feeding such as a tube or intravenous on the assessment.

A child should typically be able to physically and cognitively perform all essential components of the task safely and without assistance if 5 years of age or older.

Consider what the parent or caregiver is doing that is above and beyond the requirements of another child without a disability or impairment at the same age.

a. A child younger than 12 months is dependent on a caregiver for feeding.

b. A child 12-24 months can typically eat finger foods and begin to use a utensils and cup.

c. A child 24-47 months can typically feed self solid foods and begin to try new flavors of foods.

d. A child 48-59 months can typically use spoon, fork, and dinner knife independently.

a. A child age 5-6 years old should physically participate in eating, and may need some supervision and/or assistance.

b. A child age 7-18 years old should have the ability to eat without A child may score if the child requires more than one hour per feeding, tube feedings (or TPN), or requires more than three hours per day for feeding or eating. Consideration is given to safety and the need to assist with eating due to choking, dietary restrictions, allergies and eating disorders. Children younger than 5 years of age may require verbal prompting and assistance with cutting food.

SUPERVISION: (Behavioral)

Definition: The ability to engage in safe actions and interactions and refrain from unsafe actions and interactions.

a. A child younger than 48 months requires supervision and surveillance.

b. A child 18-36 months often gets physically aggressive when frustrated.

c. A child 36-59 months should begin to understand and refrain from unsafe actions and interactions.

a. A child 5-18 years old should begin to understand and refrain from unsafe actions and interactions with occasional reminders.

A child may score if the ultimate responsibility for the safety, care, wellbeing, and behavior of dependent children remains with the parent or caregiver. Consideration should be given if the child is not able to manage appropriate behaviors and requires constant supervision/prompting.

Examples of behaviors that may justify scoring a functional deficiency for children over 36 months include:

a. Verbal or physical threats and/or actions against self and/or others.

b. Socially inappropriate or sexually aggressive behaviors.

c. Wandering with little safety awareness.

d. Removing or destroying property.

SUPERVISION: (Memory/Cognition)

Definition: The ability to acquire and use information, communicate, reason, complete tasks, and problem-solve needs in order to care for oneself safely.

a. A child 12-18 months typically says 8-20 words, identifies objects in a book, and follows simple one step directions.

b. A child 18-24 months typically uses two to three word phrases, refers to self by name, and points to parts of face when asked.

c. A child 25-36 months typically enjoys simple make-believe games and enjoys simple stories or songs.

d. A child 36-59 months typically begins counting; identifying colors and letters; and can follow simple rules of a game.

Considerations for a Child from 5 to 18 years:

a. A child 5-9 years old may require occasional supervision necessary to acquire and use information, reason, problem-solve, complete tasks, or communicate needs in order to care for oneself safely.

b. A child 5-18 years old has the ability to recognize and adjust to daily routines, interact with peers and others appropriately, understand directions, understand basic home safety and stranger awareness.

A child may score if the child requires consistent reminding, planning or adjusting for both new and familiar routines; if the child needs preparation and assistance when transitioning between activities; or if the child has impaired ability to assure his or her safety in a strange environment (for example, the child cannot give name or address or would not be aware of dangerous situations).

Examples of behaviors that may justify scoring a functional deficiency for children over 59 months include:

a. Failure to recognize and adjust to daily routines.

b. Inappropriate interactions with peers and other.

c. Lack of basic home safety understanding and stranger awareness.

H. Activities of Daily Living Scores To be eligible for waiver services a child must have deficits in a minimum of two out of six ADLs (2+ score) or a moderate score (2+ score) in Behaviors or Memory/Cognition under Supervision category.

I. Assessment Demographic Check the appropriate box that best identifies the client situation. If one of the categories does not apply, select ‘Other’ and enter a description for the different categories in Assessment Demographics.

J. Summary Summarize the assessment findings and enter any additional comments that provide more information about the client’s situation such as background information, current status, hospital visits, surgeries, seizure activities/frequency or police interactions.

Comments can address issues not already identified by the assessment or expand on information presented in the assessment document. Please do not copy and paste entire assessment in this space.

Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.500 MEDICAL ASSISTANCE - SECTION 8.500 Home Health Services, Hospice, Oxygen, DME {#sec-10-ccr-2505-10-8.500 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.500}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE - SECTION 8.500 HOME HEALTH SERVICES, HOSPICE, OXYGEN, DME 10 CCR 2505-10 8.500 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

8.508.110 MAINTENANCE OF CASE RECORDS

A. CMAs shall maintain all documents, records, communications, notes and other materials for all work performed related to HCBS-CHRP. CMAs shall maintain records for six (6) years after the date a Client discharges from a waiver program.

8.508.121 REASSESSMENT AND REDETERMINATION OF ELIGIBILITY

A. The CMA shall conduct a Level of Care Eligibility Determination and redetermine or confirm a Client’s eligibility for the HCBS-CHRP waiver, at a minimum, every twelve (12) months.

B. The CMA shall conduct a LOC Screen to redetermine or confirm a Client’s individual needs, at a minimum, every twelve (12) months.

C. The CMA shall verify that the child or youth remains Medicaid Eligible at a minimum, every twelve (12) months.

8.508.140 DISCONTINUATION FROM THE HCBS- CHRP WAIVER

A. A Client shall be discontinued from the HCBS-CHRP waiver when one of the following occurs:

The Client no longer meets the criteria set forth in Section 8.508.40;
The costs of services and supports provided in the community exceed the Cost Effectiveness exceeds ICF-IID costs;
The Client enrolls in another HCBS waiver program or is admitted for a long-term stay beyond 30 consecutive days in an Institution; or 4. The Client reaches his/her 21st birthday.
The Client does not receive a waiver service during a full one-month 8.508.160 SERVICE PROVIDERS A. Service providers for habilitation services and services provided outside the Family home shall meet all of the certification, licensing and quality assurance regulations related to their provider type (Respite Service providers that provide community connector, movement therapy, massage therapy, hippotherapy, intensive support, and transition support in the family home must:
Meet the required qualifications as defined in the federally approved HCBS-CHRP waiver.
Maintain and abide by all the terms of their Medicaid Provider Agreement and section 8.130.
Comply with all the provisions of this Section 8.508; and 4. Have and maintain any required state licensure.

B. Service providers shall maintain liability insurance in at least such minimum amounts as set annually by the Department.

C. A Family member may not be a Service Agency for another Family member. A Family member may be reimbursed for certain services as approved in the waiver.

D. Service Providers shall not discontinue or refuse services to a Client unless documented efforts have been made to resolve the situation that triggers such E. Service Providers must have written policies that address the following:

Access to duplication and dissemination of information from the child’s or youth’s records in compliance with all applicable state and federal privacy laws.
How to response to alleged or suspected abuse, mistreatment, neglect, or exploitation. The policy must require immediate reporting when observed by employees and contractors to the agency administrator or designee and include mandatory reporting requirements pursuant to Sections 19-3- 304 and 18-6.5-108, C.R.S.
The use of restraints, the rights of Client’s, and rights modifications pursuant to sections 8.508.101 and 8.508.102.
Medication administration pursuant to Section 8.508.103.
Training employees and contractors to enable them to carry out their duties and responsibilities efficiently, effectively and competently. The policy must include staffing ratios that are sufficient to meet the individualized support needs of each Client receiving services.
Emergency procedures including response to fire, evacuation, severe weather, natural disasters, relocation, and staffing shortages.

F. Service Provides must maintain records to substantiate claims for reimbursement in accordance with Department regulations and guidance.

G. Service Providers must comply with all federal and state program reviews and financial audits of HCBS-CHRP waiver services.

H. Service Providers must comply with requests by the Department to collect, review, and maintain individual or agency information on the HCBS-CHRP waiver.

I. Service Providers must comply with requests by the CMA to monitor service delivery through Targeted Case Management.

8.509.18 STATE PRIOR AUTHORIZATION OF SERVICES

A. Upon receipt of the Prior Authorization Request (PAR), as described at Section 8.509.31(G), the state or its agent shall review the PAR to determine whether it is in compliance with all applicable regulations, and whether services requested are consistent with the Client's documented medical condition and functional capacity, and are reasonable in amount, frequency, and duration. Within ten (10) working days the State or its agent shall:

Approve the PAR and forward signed copies of the prior authorization form to the case management agency, when all requirements are met;
Return the PAR to the case management agency, whenever the PAR is incomplete, illegible, unclear, or incorrect; or if services requested are not adequately justified;
Disapprove the PAR when all requirements are not met Services shall be disapproved that are duplicative of other services that the Client is receiving or services for which the Client is receiving funds to purchase Services shall also be disapproved if all services, regardless of funding source, total more than twenty-four hours per day care.

B. When services are disapproved, in whole or in part the Department or its agent shall notify the case management agency. The case management agency shall notify the Client of the adverse action and the appeal rights on a state-prescribed form, according to Section 8.057, et seq.

C. Revisions received by the Department or its agent six (6) months or more after the end date shall always be disapproved.

D. Approval of the PAR by the Department or its agent shall authorize providers of services under the case plan to submit claims to the fiscal agent and to receive payment for authorized services provided during the period of time covered by the PAR. Payment is also conditional upon the Client's financial eligibility for longterm care medical assistance (Medicaid) on the dates of service; and upon providers' use of correct billing procedures.

E. CALCULATION OF CLIENT PAYMENT (PETI)

The case manager shall calculate the Client payment (PETI) for 300% eligible HCBS-CMHS Clients according to the following procedures:

a. For 300% eligible HCBS-CMHS Clients who are not Alternative Care Facility Clients, the case manager shall allow an amount equal to the 300% standard as the Client maintenance allowance.

No other deductions are necessary and no form is required to be completed.

b. For 300% eligible Clients who are Alternative Care Facility Clients, the case manager shall complete a State-prescribed form which calculates the Client payment according to the following procedures:

An amount equal to the current Old Age Pension standard, including any applicable income disregards, shall be deducted from the Client's gross income to be used as the Client maintenance allowance, from which the stateprescribed Alternative Care Facility room and board amount shall be paid: and 2) For an individual with financial responsibility for only a spouse, an amount equal to the state Aid to the Needy Disabled (AND) standard, less the amount of any spouse's income, shall be deducted from the Client's gross income: or 3) For an individual with financial responsibility for a spouse plus other dependents, or with financial responsibility for other dependents only, an amount equal to the appropriate Temporary Assistance to Needy Families (TANF) grant level less any income of the spouse and/or dependents (excluding income from part-time employment earnings of a dependent child who is either a full-time student of a part-time student as defined at Section 8.100.3.L.2.d.) shall be deducted from the Client's gross income; and 4) Amounts for incurred expenses for medical or remedial care for the individual that are not subject to payment by Medicare, Medicaid, or other third party shall be deducted from the Client's gross income as follows:

a) Health insurance premiums if health insurance coverage is documented in the eligibility system and the MMIS: deductible or co-insurance charges: and b) Necessary dental care not to exceed amounts equal to actual expenses incurred: and c) Vision and auditory care expenses not to exceed amounts equal to actual expenses incurred: and d) Medications, with the following limitations:

(1) The need for such medications shall be documented in writing by the attending physician. For this purpose, documentation on the URC certification form shall be considered adequate. The documentation shall list the medication; state why it is medically necessary; be signed by the physician; and shall be renewed at least annually or whenever there is a change.

(2) Medications which may be purchased with the Client’s Medical Identification Card shall not be allowed as deductions.

(3) Medications which may be purchased through regular Medicaid prior authorization procedures shall not be allowed.

(4) The full cost of brand-name medications shall not be allowed if a generic form is available at a lower price.

(5) Only the amount spent for medications which exceeds the current Old Age Pension Standard allowance for medicine chest expense shall be allowed as a deduction.

e) Other necessary medical or remedial care shall be deducted from the Client's gross income, with the following limitations:

(1) The need for such care shall be documented in writing by the attending physician. For this

purpose, documentation on the URC certification form shall be considered adequate.

The documentation shall list the service, supply, or equipment; state why it is medically necessary; be signed by the physician; and, shall be renewed at least annually or whenever there is a change.

(2) Any service, supply or equipment that is available under regular Medicaid, with or without prior authorization, shall not be allowed as a deduction.

f) Deductions for medical and remedial care may be allowed up to the end of the next full month while the physician's prescription is being obtained. If the physician's prescription cannot be obtained by the end of the next full month, the deduction shall be discontinued.

g) When the case manager cannot immediately determine whether a particular medical or remedial service, supply, equipment or medication is a benefit of Medicaid, the deduction may be allowed up to the end of the next full month while the case manager determines whether such deduction is a benefit of the Medicaid program. If it is determined that the service, supply, equipment or medication is a benefit of Medicaid, the deduction shall be discontinued.

Any remaining income-shall be applied to the cost of the Alternative Care Facility services, as defined at Section 8.495, and shall be paid by the Client directly to the facility;
If there is still income remaining after the entire cost of Alternative Care Facility services is paid from the Client's income, the remaining income shall be kept by the Client and may be used as additional personal needs or for any other use that the Client desires, except that the Alternative Care Facility shall not charge more than the Medicaid rate for Alternative Care Facility services.

Case managers shall inform HCBS-CMHS Alternative Care Facility Clients of their Client payment obligation on a form prescribed by the state at the time of the first assessment visit by the end of each plan period; or within ten (10) working days whenever there is a significant change in the Client payment amount Significant change is defined as fifty dollars ($50) or more. Copies of Client payment forms shall be kept in the Client files at the case management agency, and shall not be mailed to the State or its agent, except as required for a prior authorization request, according to

Section 8.509.31.G, or if requested by the state for monitoring purposes. 8.519.27 Transition Coordination Services 8.519.27.A Definitions 1. At-Risk means a Medicaid member who lives outside of an institutional facility and has either received a Level of Care Screening to access Medicaid nursing facility services or is at risk for institutionalization as determined by the Department.

At Risk Diversion means a Person-Centered process through which services are arranged or provided to enable an At-Risk population member to avoid admission to an institution or institution-like setting to live instead in a less restrictive setting in the community.
Case Management Agency (CMA) means a public, private, or nongovernmental non20 profit agency that meets all applicable state and federal requirements and is certified by the Department to provide case management services for Home and Community-based Services waivers pursuant to sections [25.5-10-209.5 C.R.S.] and pursuant to a provider participation agreement with the state department.
Community Needs and Preferences Assessment means the assessment that is completed by the Transition Options Team (TOT) to ensure a comprehensive understanding of the member’s health conditions, functional needs, transition needs, behavioral concerns, social and cultural considerations, educational interests, risks and other areas that may require services and/or community resource support.
Community Risk Level means the potential for a member living in a community-based arrangement to require emergency services, to be admitted to an institution or institution-like setting, or Intermediate Care Facility for Individuals with Intellectual Disabilities, be evicted from their home or be involved with law enforcement due to identified risk factors.
Corrective Action Plan (CAP) means a written plan by the Transition Coordination Agency (TCA), and approved by the Department, which includes a detailed description of actions to be taken to correct noncompliance with regulations, and/or direction from the Department, and which sets forth the date by which each action shall be completed and the persons responsible for implementing the action. Corrective Action Plans may be requested by the Department at any time.
Post-Transition Monitoring means the activities performed by a Transition Coordination Agency (TCA) that occur after a member has successfully moved into the community or has been diverted from institutionalization and is a recipient of home-and community-based services.
Pre-Transition Coordination means the activities by the 1 TCA that occur before a member has moved into the community to prepare the member for success in community living and integration.
Risk Factors mean factors that include but are not limited to health, safety, environmental, community integration, service interruption, inadequate support systems and substance abuse that may contribute to an individual’s community risk level.
Risk Mitigation Plan means the document that records the risk mitigation planning process. Risk Mitigation Plans are used to complete Pre- Transition and Diversion strategy development, conduct post-discharge monitoring of effectiveness of risk prevention strategies, document identification of additional risk factors, and revise risk incident response plans.
Risk Mitigation Planning means the process of identifying risk factors, developing options and actions to enhance opportunities and prevent adverse consequences that would result if risk is not managed. Risk mitigation planning includes identifying planned actions to take in response to an adverse consequence should a risk be realized.
Community Needs and Preferences Assessment means the process of capturing a comprehensive understanding of the member’s health conditions, functional needs, transition needs, behavioral concerns, social and cultural considerations, educational interests, risks and other areas important to community integration and transition to a home and community-based setting.
Transition Coordination Services means support provided to a member who is transitioning or being diverted from a skilled nursing facility, extended SNF LOC hospital stay, intermediate care facility for individuals with intellectual disabilities, or regional center and includes the following activities: comprehensive assessment for transition or diversion, community risk assessment, development of a transition or diversion plan, referral and related activities, and monitoring and follow up activities as they relate to the transition or diversion.
Transition Coordinator (TC) means a person who provides Transition or Diversion Coordination Services and meets all regulatory requirements for a TC.
Transition Coordination Agency (TCA) means a public or private not-forprofit or for-profit agency that meets all applicable state and federal requirements and is certified by the Department to provide Transition/diversion Coordination Transition or Diversion support pursuant to a provider participation agreement with the Department.
Transition Options Team (TOT) means the group of people involved in supporting and implementing the transition or diversion, to include the person receiving services, the TC, the guardian, may include the homeand community- based services case manager, nursing facility social worker and others chosen by the individual receiving services as being valuable to participate in the transition process. The TOT is convened to work in a cooperative and supportive manner to develop and implement the transition or diversion plan, and to serve in an advocacy role with the member.
Transition period means the period of time in which the member receives Transition Coordination for the purpose of successful integration into community living. A transition period is complete when the member has successfully established community residence and is no longer in need of Transition Coordination based on the member’s community risk level, or the member or guardian requests that TCM-TC services are discontinued.
Transition or Diversion Plan means the written document that identifies person-centered goals, assessed needs, and the choices and preferences of services and supports to address the identified goals and needs; appropriate services and additional community supports; outlines the process and identifies responsibilities of transition options team members; details a risk mitigation plan; and establishes a timeline that will support an individual in transitioning to or remaining in a community setting of their choosing.
Transition or Diversion Planning means the completion of the TCM-TC Community Needs and Preferences Assessment and Risk Mitigation Plan, facilitation of a transition or Diversion Recommendation, and developing a transition or Diversion Plan, in coordination with the TOT.
Transition Rrecommendation means a recommendation made by the TOTtransition options team regarding transition. The recommendation is made solely on availability of necessary supports and services identified by the Community Needs and Preference Assessment and the Risk Mitigation Plan. 8.519.27.B Qualifications of Transition Coordination Agencies 1. In order to be approved as a TCA, the agency shall meet all of the following qualifications:

a. Have a physical location in Colorado.

b. Be a public or private not for profit or for-profit agency.

c. Demonstrate proof the agency has employed staff that meet TC qualifications.

d. Have a minimum of two (2) years of agency experience in assisting at-risk individuals to access medical, social, education and/or other services. Transition coordination agencies providing transition coordination in Colorado prior to December 31, 2018 are exempt from this requirement.

e. Provide transition or diversion coordination to members who select the agency and also reside in the county/counties for which the agency has elected to provide services.

f. Possess the administrative capacity to deliver transition or diversion coordination.

g. Have established community referral systems and demonstrate linkages and referral ability to make community referrals for services with other agencies.

h. Demonstrate ability to meet all applicable requirements contained within Sections 8.519.27, 8.763, the Medicaid State Plan and the provider participation agreement.

i. Financial reserves shall match one (1) month of expenditures associated to the number of members expected through that catchment area and provide stability for TCs, members and service providers.

j. All agencies are required to submit an audited financial statement or 1 equivalent to the Department for review upon request.

k. Possess and maintain adequate liability insurance (including automobile insurance, professional liability insurance and general liability insurance) to meet the Department's minimum requirements. 8.519.27.C Functions of all Transition Coordination Agencies 1. In order to be approved as a TCA, the agency shall perform all of the following functions:

a. TCAs must be in compliance with all required agency performance standards and training guidelines to be in good standing with the Department. Failure to comply with required standards and training guidelines may result in suspension of referrals until a corrective plan is submitted by the TCA and approved by the b. TCAs shall be responsible to maintain sufficient documentation, as defined in TCM-TC training, of all transition or diversion coordination activities performed and to support claims within the Department designated data system and internal agency records.

c. TCAs may not provide guardianship services for any member for whom they provide transition or diversion coordination services.

d. TCAs shall be responsible to maintain, or have access to, information about public and private, state and local services, supports and resources and shall make information available to the member and/or persons inquiring upon their behalf.

e. TCAs shall respond to referrals for transition coordination support within two (2) business days and within one (1) business day for diversion coordination referrals and specify whether the referral is accepted or not by completing the Transition Services Referral Form.

f. TCAs shall assign and meet with the member within ten (10) state business days after accepting a transition referral and two (2) state business days after accepting a diversion referral.

g. TCAs shall assign one (1) primary person who ensures transition or diversion coordination is provided tof the member.

h. TCAs shall provide coordination in accordance with state business days as defined in 24-11-101(1) C.R.S.

i. TCAs shall maintain all documents, records, communications, notes, and other materials that relate to any work performed.

j. TCAs shall possess appropriate financial management capacity and systems to document and track services and costs in accordance with state and federal regulations.

k. TCAs shall maintain and update records of persons receiving transition or diversion coordination in accordance with reporting requirements of the Department’s data system.

l. TCAs shall establish and maintain working relationships with community- based resources, supports, and organizations, hospitals, service providers, and other organizations that assist in meeting the needs of members.

m. TCAs shall have a system for recruiting, hiring, evaluating, and terminating employees. Transition coordination agencies’ employment policies and practices shall comply with all federal and state laws.

n. TCAs shall ensure staff have access to statutes and regulations relevant to the provision of authorized services and shall ensure that appropriate employees are oriented to the content of statutes and regulations. TCAs shall provide transition coordination for members without discrimination on the basis of race, religion, political affiliation, gender, national origin, age, sexual orientation, gender expression, or disability.

o. TCAs shall provide information and reports as required by the Department including, but not limited to, data and records necessary for the Department to conduct operations.

p. TCAs shall allow access by authorized personnel of the Department, or its contractors, for the purpose of reviewing services and supports funded by the Department and shall cooperate with the Department in evaluation of such services and supports.

q. TCAs shall establish agency procedures sufficient to execute transition or diversion coordination according to the provisions of these regulations. Such procedures shall include, but are not limited to:

i. Referral Management ii. Assessment of community needs and preferences iii. Transition or Diversion Planning iv. Risk Mitigation Planning v. Service and support coordination for non-Medicaid transition or diversion-related services and supports vi. Monitoring of the Risk Mitigation and Transition or Diversion Plans vii. Denial and discontinuation of Transition or Diversion Coordination Services viii. Management of interstate TCM-TC transfers ix. Complaint Procedure that includes the requirement to share information, such as points of contact within the agency, to members, families and referring agencies who may wish to file a complaint 8.519.27.D Qualifications of Transition Coordinators 1. TCs must be employed by an approved TCA. TC minimum experience:

a. A bachelor’s degree; or b. Five (5) years of relevant experience in the field of LTSS, which includes Developmental Disabilities; or c. Some combination of education and relevant experience appropriate to the requirements of the position.

d. Relevant experience is defined as:

i. Experience in one of the following areas: long-term care services and supports, gerontology, physical rehabilitation, disability services, children with special health care needs, behavioral science, special education, public health or nonprofit administration, or health/medical services, including working directly with persons with physical, intellectual or developmental disabilities, mental illness, or other vulnerable populations as appropriate to the position being filled; and, ii. Completed coursework and/or experience related to the type of administrative duties performed by case managers may qualify for up to two (2) years of required relevant experience.

iii. For members for whom the TC is providing transition or diversion coordination, TCs may not:

Be related by blood or marriage to the member 2) Be related by blood or marriage to any paid caregiver of the member 3) Be financially responsible for the member 4) Be the member's legal guardian, authorized representative, or be empowered to make decisions on the member's behalf through a power of attorney 8.519.27.E Training 1. TCs must complete and document the following trainings within sixty (60) days from the date of hire and prior to providing transition or diversion coordination services independently, and thereafter on an annual basis:

a. Assessment of community needs/preferences and risk factors b. Transition or Diversion Planning c. Risk Mitigation Plan development, monitoring and revision d. Referral 1 for non-Medicaid services e. Monitoring services f. Case documentation g. Person-centered approaches to planning and practice h. Housing voucher application and housing navigation services 8.519.27.F Functions of Transition Coordinators 1. TCs must perform all the following activities. These activities are the only activities billable under transition coordination:

a. Coordinate (TOT) activities including:

i. Facilitate completion of an assessment which identifies preferences, needs and any risk factors the member may have in a community-based setting within six (6) weeks of first meeting with the member for a Transition Plan and within one (1) week of first meeting with the member for a Diversion Plan.

ii. Facilitate development of a Risk Mitigation Plan to address identified risk factors within eight (8) weeks of accepting a transition referral and two (2) weeks of accepting a diversion referral.

iii. Identify supports and services that will be required to address the member’s needs, preferences, and risk factors.

iv. Complete a transition recommendation from the TOT within six (6)weeks of first meeting with the member but not before the first TOT meeting.

v. Facilitate completion of a Transition or Diversion Plan if the member chooses to proceed with the transition or diversion b. Conduct Pre-Transition or Diversion Coordination including:

i. Facilitate completion of transition or diversion assessment, Risk Mitigation and Transition or Diversion Plans ii. Complete, as needed, housing voucher application, including assistance to obtain necessary documents iii. Collaborate, as needed, with housing navigation services to obtain a voucher and locate housing iv. Assist member to create a transition or diversion budget v. Collaborate with housing navigation services, Division of Housing, voucher administrators and property managers to establish a community-based living arrangement for eligible members.

vi. Coordinate any medication, home modification and/1 or durable medical equipment needs with the nursing facility or HCBS case manager prior to discharge to ensure that all components of the Transition or Diversion Plan are in place prior to discharge vii. Assist member in preparing for discharge, including being present at the nursing facility on the day of discharge to ensure requirements of discharge plan are addressed viii. Meet with the member at their home on the day of discharge to ensure that providers and services needed upon discharge are in place and the household set-up is complete c. Conduct Post-Transition or Diversion Monitoring that meets the member’s need as documented in the risk mitigation plan and occurs at the frequency and type to meet the member’s community risk level Post-Transition or Diversion monitoring includes:

i. Ensuring that members receive services in accordance with their Transition/Diversion Plan and Risk Mitigation Plan ii. Post-Transition or Diversion Monitoring may include as determined by the community risk level:

Face-to-face in the member’s residence 2) Face-to- face in the community.
By telephone, electronic, video or virtual communication d. Post-Transition or Diversion Monitoring includes:

i. Provision of support services to aid in sustaining communitybased living ii. Response to risk incidents and notifying the CMA and Adult Protection Services (APS) as required iii. Revision of Risk Mitigation Plan as needed iv. Assessing the need for independent living skills training v. Problem-solving community integration issues vi. Supporting community integration activities vii. Monitoring service provision, to include contacting guardians, providers, and case management agencies viii. Requesting that member completes a TCM-TC satisfaction survey prior to discharge and at the end of the transition or diversion period to evaluate the member’s experience of the 1) Transition or Diversion Planning 2) Transition or Diversion Plan implementation 3) Transition or Diversion Coordination process 4) Level and adequacy of services provided 5) Overall member satisfaction e. Post-transition or Diversion Monitoring may not duplicate services for Life Skills Training (LST), defined in 10 CCR 2505-10, § 8.553.3; Transition Setup defined in 10 CCR 2505-10, § 8.553.4;

Home Delivered Meals, defined in 10 CCR 2505-10, § 8.553.5; and Peer Mentorship, defined in 10 CCR 2505-10, § 8.553.6. 8.519.27.G Transition Coordination Agencies Approval 1. A TCA shall maintain Department provider approval in accordance with quality assurance standards and requirements set forth in the Department's rules and direction. Department approval is needed for continued receipt of TCM-TC referrals.

a. Approval as a TCA shall be based on an evaluation of the agency's performance in the following areas:

i. The frequency of requests for TCA changes and/or complaints received by the Department pertaining to agency performance;

ii. The agency's compliance with program requirements, including compliance with transition coordination standards adopted by the Department;

iii. The agency's performance of administrative functions, including, timely reporting, program management, on-site visits to individuals, community coordination and outreach and individual monitoring;

iv. Financial accountability;

v. The maintenance of qualified and trained personnel to perform transition coordination duties;

vi. Continual performance and quality assurance activities; and vii. Overall member satisfaction as indicated by member satisfaction surveys.

The Department or its designee shall conduct reviews of the TCA.

a. At least sixty (60) days prior to expiration of the previous approval date the Department shall notify the TCA of the outcome of the review, which may be approval, provisional approval, or denial of approval.

b. The Department shall conduct evaluations as needed based on incidents of member, nursing facility and/or provider complaints regarding TCA performance and/or non-compliance with TCM-TC agency requirements. 8.519.27.H Conflict of Interest for Transition Coordination Agencies 1. If a TCA also provides services under HCBS waivers, a policy must be in place to avoid conflict of interest and provide a free choice of providers to members. The HCBS case management agency shall be responsible for all service brokering for Medicaid HCBS services.

These codes of regulation incorporate by reference (as indicated within) material originally published elsewhere. Such incorporation, however, excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Avenue Denver, CO 80203. The agency shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule. 8.520 Home Health Services 8.520.1. Definitions 8.520.1.A. Activities of Daily Living (ADL) means daily tasks that are required to maintain a []Member’s health, which includes but not limited to eating, bathing, dressing, toileting, grooming, transferring, walking, and continence. When a []Member is unable to perform these activities independently, skilled or unskilled providers may be required for the Member’s needs. [] 8.520.1.B. Acute Medical Condition means a medical condition which has a rapid onset and short duration. A condition is considered acute only until it is resolved or until 60 calendar days after onset, whichever comes first. [] 8.520.1.C. Alternative Care Facility means an Assisted Living Residence licensed by the Colorado Department of Public Health and Environment (CDPHE) and certified by the Department of Health Care Policy and Financing (Department) to provide Assisted Living Care Services and Protective Oversight to []Members. [] 8.520.1.D. Behavioral Intervention means techniques, therapies, and methods used to modify or minimize aggressive (verbal/physical), combative, destructive, disruptive, repetitious, resistive, self-injurious, or other inappropriate behaviors outlined on the CMS-485 Plan of Care, or a form that is of similar format to the CMS-485,(defined below). Behavioral interventions exclude frequent verbal redirection or additional time to transition or complete a task, which are part of the general assessment of the []Member’s needs. 8.520.1.E. Brief Nursing Visit means those Skilled Nursing Services that are provided to a Member who requires multiple visits per day for skilled tasks that can be completed in a shorter or brief visit as compared to a Standard Nursing Visit (excluding the first regular nursing visit of the day). 8.520.1.F[. ] Care Coordination means the deliberate organization of []Member care activities between two or more participants (including the []Member) for the appropriate delivery of health care and health support services, and organization of personnel and resources needed for required []Member activities. 8.520.1.G[. ] Certified Nurse Aide Assignment Form means the form used by the Home Health Agency to list the duties to be performed by the Certified Nurse Aide (CNA) at each visit as per the Department of Public Health and Environment Health Facilities Regulation Division Standards for Hospitals and Health Facilities

Chapter 26, Home Care Agencies 6 CCR 1011-1 Chapter 26 Section 7.15. 8.520.1.H. Chronic Medical Condition means a medical condition that lasts more than one year and requires ongoing medical attention, or limits Activities of Daily Living, or both. 8.520.1.I[. ] Department means the Colorado Department of Health Care Policy and Financing, the Single State Medicaid Agency.[] [] 8.520.1.[]J. Designee means the entity that has been contracted by the Department to review for the Medical Necessity and appropriateness of the requested services, including Home Health prior authorization requests (PARs). Designees may include case management entities such as Single Entry Points or Community Centered Boards who manage waiver eligibility and review. []8.520.1.K[.] Family/In-Home Caregiver means an individual who assumes a portion of the Member’s care in the home in the absence of agency staff. A Family/In-Home Caregiver may either live in the Member’s home or travel to the Member’s home to provide care. []8.520.1.L[. ]Home Health Agency (HHA) means an agency or organization that is certified for participation as a Medicare Home Health Provider []pursuant to 42 U.S.C. § 1395bbb and licensed as a Class A Home Care Agency as required by § 25-27.5-103(1), C.R.S. Title XVIII of the Social Security Act is hereby incorporated by reference.[] 8.520.1.M[. ]Home Health Services means those services listed at Section 8.520.5, Service Types. []8.520.1.N[. ]Intermittent means visits that have a distinct start time and stop time, and are task oriented with the goal of meeting a []Member’s specific needs for that visit. 8.520.1.O[.] Medical Necessity is defined in Program Integrity rules (Section 8.076.1.8). For children 20 and younger, this is further defined to include the requirements outlined in the Early and Periodic Screening, Diagnosis, and Treatment rules (Section 8.280.1.). 8.520.1.P. Member means any person who is eligible for and is enrolled in the Colorado Medical Assistance Program. []8.520.1.Q[] Personal Care Worker means an employee of a licensed Home Care Agency who has completed the required training to provide Personal Care Services, or who has verified experience providing Personal Care Services to Members. A Personal Care Worker shall not perform tasks that are considered skilled Nursing or CNA services. 8.520.1.R.[] Nurse Assessor Vendor means a third-party vendor contracted by the Department to complete the Skilled Care Acuity Assessment for specific skilled care services. 8.520.1.S[.] Physician or Allowed Practitioner means a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) who oversees the delivery of skilled care to a Member within their scope of practice, in accordance with State law, and is actively enrolled with Health First Colorado. 8.520.1.T. []Place of Residence means where the []Member lives. Includes temporary accommodations, homeless shelters or other locations for []Members who are homeless or have no permanent residence. 8.520.1.U[]. Plan of Care (POC) means a completed Centers for Medicare and Medicaid Services (CMS) Form 485, or a form that is of similar format to the CMS-485, also referred to as a care plan developed by the HHA in consultation with the Member, that has been ordered by the Physician or Allowed Practitioner for the provision of services to a Member at his/her residence or community setting, and is periodically reviewed and signed by the Physician or Allowed Practitioner in accordance with Medicare requirements at 42 C.F.R. § 484.18.

Title 42 of the Code of Federal Regulations is hereby incorporated by reference. 8.520.1.V.. ]Pro Re Nata (PRN) means as needed. 8.520.1.W. ] Protective Oversight is supervision of the Member to prevent or mitigate disability, memory, or cognitive functioning-related behaviors or impairment that may result in imminent harm to self, people, or property. 8.520.1.X.[.] Remote Patient Monitoring means the remote monitoring of clinical data transmitted through electronic information processing technologies, from the Member to the home health provider, which meet HIPAA compliance standards. 8.520.1.Y. Skilled Care Acuity Assessment means the assessment that will be used to assess Members for their skilled care needs. The Skilled Care Acuity Assessment will only be accepted as valid documentation when completed by the authorized Nurse Assessor Vendor. The Assessment was finalized on September 25, 2024 and is available at https://hcpf.colorado.gov/nurse-assessor. 8.520.1.Z.[.] Skilled Nursing/Skilled Nursing Service means services provided under the licensure, scope, and standards of the Colorado Nurse and Nurse Aide Practice Act (Title 12 Article 255 of the Colorado Revised Statutes), performed by a registered nurse (RN) under the direction of a Physician or Allowed Practitioner, or a licensed practical nurse (LPN) under the supervision of an RN and the direction of a Physician or Allowed Practitioner, for care that cannot be delegated by the judgment of the nurse. 8.520.1.AA.[.] Standard Nursing Visit means those Skilled Nursing Services that are provided to a Member by a registered nurse (RN) under applicable state and federal laws and professional standards or licensed practical nurse (LPN) under the direction of a RN to the extent allowed under applicable state and federal laws. 8.520.1.BB.[.] Utilization Review Contractor (URC) means a third-party vendor contracted by the Department to perform utilization management functions for specific services. 8.520.2. Criteria for Services [] 8.520.2.A. Home Health Services are available to all ]Members and to all Old Age Pension Program []Members, as defined at Section 8.940, when all program and service requirements in this rule are met. 8.520.3. Provider Eligibility 8.520.3.A. Services must be provided by a Medicare and Medicaid-certified Home Health Agency. 8.520.3.B. All Home Health Agency[] providers shall comply with the rules and regulations set forth by the Colorado Department of Public Health and Environment, the Colorado Department of Health Care Policy and Financing, the Colorado Department of Regulatory Agencies, the Centers for Medicare and Medicaid Services, and the Colorado Department of Labor and Employment. 8.520.3.C. Provider Agency Requirements 1. A Home Health Agency must:

a. Be certified for participation as a Medicare Home Health provider under Title XVIII of the Social Security Act;

b. Be a Colorado Medicaid enrolled provider;

c. Maintain liability insurance for the minimum amount set annually as outlined in 6 CCR 1011-1 Chapter 26[]; and d. []Hold a State of Colorado []Class A Home Care Agency license in good standing.

e. []Comply with applicable regulations promulgated by the Board of Health, Medical Services Board, Medical Board, Nursing Board, Department of Labor and Employment, and the Centers for Medicare and Medicaid Services.

Home Health Agencies which perform procedures in the []Member's home that are considered waivered clinical laboratory procedures under the Clinical Laboratory Improvement Act of 1988 shall possess a certificate of waiver from the Centers for Medicare and Medicaid Services (CMS) or its Designee. The Clinical Laboratory Improvement Act is hereby incorporated by reference.
Home Health Agencies shall regularly review the Medicaid rules, 10 CCR 2505-10. The Home Health Agency shall make access to these rules available to all staff.
A Home Health Agency cannot discontinue or refuse services to a []Member unless documented efforts have been made to resolve the situation that triggers such discontinuation or refusal. The Home Health Agency must provide notice of at least []30 calendar days to the []Member, or the []Member’s designated representative. []
In the event a Home Health Agency is ceasing operations, provider agencies must notify the Department within 30 calendar days. The notification must be submitted through the Provider Portal as a maintenance application for the disenrollment request. The provider must also email the Department the notice to[] the designated Home Health inbox.[]
Colorado Adult Protective Services (CAPS) and Criminal Background Checks a. Home Health Agencies shall conduct criminal background checks and reference checks and compare the employee’s/independent contractor’s name against the list of all currently excluded individuals maintained by the Office of Inspector General prior to employing staff or hiring independent contractors to provide services and supports to Members. All costs related to obtaining a criminal background check shall be borne by the Provider Agency.

Background checks shall be completed every five years for each employee and contractor who provides direct care to Members.

b. Home Health Agencies shall comply with the CAPS check requirements set forth at § 26-3.1- 111(6)(a), C.R.S. and 12 C.C.R. 2518-1, § 30.960.G-J. The Home Health Agency shall maintain accurate records and make records available to the Department upon request.

i) HCPF or its Designee shall act as the oversight agency described at § 26-3.1-111(6)(a)(III), C.R.S. and shall receive CAPS check results for Home Health Agencies requiring Certification, the prospective Agency shall:

Submit to the CDPHE a copy of the CAPS check results as part of their initial application for Certification.

i) Substantiated findings as outlined in Section 8.7409 E.2.b may result in the denial of the Medicaid enrollment application.

ii) Direct Care Workers with any of the following are prohibited from providing direct care to any Member:

An allegation of Mistreatment, Abuse, Neglect and Exploitation (MANE) or harmful act, as defined in

Section 26- 3.1-101, C.R.S., substantiated by Adult Protection Services (APS) within the last 10 years, at a “Severity Level” of “Moderate” or “Severe” as defined in 12 C.C.R. 2518-1; Section 30.100;

Three or more allegations of MANE or harmful act, as defined in Section 26-3.1-101, C.R.S., substantiated by APS within the last five years, at the minor severity level as defined in 12 C.C.R. 2518; Section 30.100; or 3) A criminal conviction of MANE against an at-risk adult defined at § 26-3.1- 101, C.R.S.
Only substantiated allegations for which the state level appeal process as defined as 12 C.C.R. 2518-1;

Section 30.920 has concluded shall be included in the above exclusions list. 8.520.4. Covered Services 8.520.4.A. Home Health Services are covered under Medicaid only when all of the following are met:

Services are Medically Necessary as defined in Section 8.520.1., Definitions;
Services are provided under a Plan of Care as defined at Section 8.520.1., Definitions;
Services are provided on an Intermittent basis, as defined at Section 8.520.1., Definitions;
The []Member meets one of the following:

a. The only alternative to Home Health Services is hospitalization or emergency room care or other institutionalization; or b. []Member medical records indicate that medically necessary services should be provided in the []Member's P[]lace of R[]esidence or community, instead of an outpatient setting, according to one or more of the following guidelines:

i) The []Member, due to illness, injury or disability, is unable to travel to an outpatient setting for the needed service;

ii) Based on the []Member's illness, injury, or disability, travel to an outpatient setting for the needed service would create a medical hardship for the []Member;

iii) Travel to an outpatient setting for the needed service is contraindicated by a documented medical diagnosis;

iv) Travel to an outpatient setting for the needed service would interfere with the effectiveness of the service; or v) The []Member's medical diagnosis requires teaching which is most effectively accomplished in the []Member's P[]lace of R[]esidence on a short-term basis.

The []Member is unable to perform the health care tasks for him or herself, and no []Family/In-Home Caregiver is able or willing to voluntarily perform the tasks; and a. Family/In-Home Caregiver responsibilities should be guided by age-appropriate expectations to distinguish when a Member’s needs require care beyond typical caregiving duties due to the skilled nature of needs and/or intensity of need.
Covered service types are those listed in Service Types, Section 8.520.5. 8.520.4.B. Place of Service 1. Services shall be provided in the []Member’s P[]lace of R[]esidence or one of the following places of service:

a. Assisted Living [] Residence (ALR);

b. Alternative Care Facilities (ACFs);

c. Group Residential Services and Supports (GRSS) including licensed group homes servicing[] four to eight Members []

Services shall not duplicate those that are the contracted responsibility of the GRSS;

d. Individual Residential Services and Supports (IRSS) including host homes, apartments or homes where three or fewer []Members reside. Services shall not duplicate those that are the contracted responsibility of the IRSS; or e. Hotels, or similar temporary accommodations while traveling, will be considered the temporary P[]lace of R[]esidence for purposes of this rule.

f. Nothing in this section should be read to prohibit a []Member from receiving Home Health Services in any setting in which normal life activities take place, other than a hospital, nursing facility; intermediate care facility for individuals with intellectual disabilities; or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board.

g. Telemedicine may be provided in accordance with Section 8.095. 8.520.4.C. Service Categories 1. Acute Home Health Services a. Acute Home Health Services are covered for []Members who experience an acute health care need that requires Home Health b. Acute Home Health Services are provided for 60 or fewer calendar days or until the A[]cute M[]edical C[]ondition is resolved, whichever comes first.

c. Acute Home Health Services are provided for the treatment of the following A[]cute M[]edical C[]onditions/episodes that []include but are not limited to:

i) Infectious disease;

ii) Pneumonia;

iii) New diagnosis of a life-altering disease;

iv) Post-heart attack or stroke;

v) Care related to post-surgical recovery;

vi) Post-hospital care provided as follow-up care for medical conditions that required hospitalization, including neonatal disorders;

vii) Post-nursing home care, when the nursing home care was provided primarily for rehabilitation following hospitalization and the medical condition is likely to resolve or stabilize to the point where the []Member will no longer need Home Health Services within 60 days following initiation of Home Health Services;

viii) Complications of pregnancy or postpartum recovery; or iv) Individuals who experience an acute incident related to a chronic disease may be treated under the acute home health benefit. Specific information on the acute incident shall be documented in the record.

d. A []Member may receive additional periods of acute Home Health Services when at least 10 days have elapsed since the []Member’s discharge from an acute home health episode and one of the following circumstances occurs:

i) The []Member has a change in medical condition that necessitates acute Home Health Services;

ii) New onset of a C[]hronic M[]edical C[]ondition; or iii) Treatment needed for a new A[]cute M[]edical C[]ondition or episode.

e. Nursing visits provided solely for the purpose of assessment or teaching are covered only during the acute period under the following guidelines:

i) An initial assessment visit ordered by a Physician or Allowed Practitioner []is covered for determination of whether ongoing nursing or CNA care is needed. Nursing visits for the sole purpose of assessing a []Member for recertification of Home Health Services shall not be reimbursed if the []Member receives only CNA services;

ii) The visit instructs the []Member or []Member’s [] Family/In- Home Caregiver in providing safe and effective care that would normally be provided by a skilled home health provider; or iii) The visit supervises the []Member or []Member’s [] Family/In- Home Caregiver to verify and document that they are competent in providing the needed task.

f. Acute Home Health Services may be provided to []Members who receive Health Maintenance tasks through In-Home Supports and Services (IHSS) or Consumer Directed Attendant Supports and Services (CDASS).

g. GRSS group home residents may receive acute Home Health h. If the acute home health []Member is hospitalized for planned or unplanned services for 10 or more calendar days, the Home Health Agency may close the []Member’s acute home health episode and start a new acute home health episode when the []Member is discharged.

i. Acute Care Home Health Limitations:

i) A new period of acute Home Health Services shall not be used for continuation of treatment from a prior Acute Home Health episode. New Acute Episodes must be utilized for a new or worsening condition.

ii) A []Member who is receiving either Long-Term Home Health Services or HCBS waiver services may receive acute Home Health Services only if the []Member experiences an event listed in subpart c. as an acute incident, which is separate from the standard needs of the[] Member and makes acute Home Health Services necessary.

iii) If a []Member’s A[]cute M[]edical C[]ondition resolves prior to 60 calendar days from onset, the []Member shall be discharged from acute home health or transitioned to the []Member’s normal Long-Term Home Health S[]ervices 2. Long-Term Home Health Services a. Long-T[]erm Home Health Services are covered for []Members who have long-term chronic needs requiring []Home Health Services.

b. Long-Term Home Health Services may be provided to []Members who receive health maintenance tasks through IHSS. c.[]

C[]. Long-T[]erm Home Health Services are provided:

i) Following the 60th calendar day for acute home health []Members who require additional services to meet treatment goals or to be safely discharged from Home Health Services;

ii) On the first day of Home Health Services for []Members with well documented chronic needs when the []Member does not require an acute home health care transition period; or iii) Continuation of []long-term home health Plan of Care.

d. Long-Term Home Health Limitations:

i) []Members aged 20 and younger may obtain long-term home health physical therapy, occupational therapy, and speech therapy services when Medically Necessary and when:

Therapy services will be more effective if provided in the home setting; or 2) Outpatient therapy would create a hardship for the []Member.

ii) []Members aged 21 and older who continue to require physical therapy, occupational therapy, and speech therapy services after the initial acute home health period may only obtain such long-term services in an outpatient setting.

iv) Long-T[]erm Home Health Services may be provided in GRSS group home settings, when the GRSS provider agency reimburses the Home Health Agency directly for these Home Health Services. Long-term Home Health Service provision in GRSS group homes is not reimbursable through the State Plan.

v) Long-Term Home Health Services may be provided in IRSS settings when the IRSS provider agency reimburses the Home Health Agency directly for these Home Health Services. Long-term Home Health Service provision in IRSS is not a Medicaid reimbursable service..

CNA services are not permitted within IRSS settings, and if such services are required, the IRSS provider agency must contract with the HHA for these services independently. CNA services can be provided under the per diem reimbursement structure.
Standard Nursing Visits are covered as long as they are not duplicative of what is already provided by the IRSS.

Long-Term with Acute Episode Home Health:

a. An episode is considered acute only until it is resolved or until 60 calendar days after onset, whichever comes first.

b. Long-term with acute episode home health is covered if the []Member is receiving long-term H[]ome H[]ealth S[]ervices and requires treatment for an acute episode as defined in Section 8.520.4.C.1. 8.520.5. Service Types 8.520.5.A. Nursing Services 1. Standard Nursing Visit a. Those Skilled Nursing Services that are provided by a registered nurse under applicable state and federal laws, and professional standards;

b. Those Skilled Nursing Services provided by a licensed practical nurse under the direction of a registered nurse, to the extent allowed under applicable state and federal laws and professional standards;

c. Standard Nursing Visits include but are not limited to:

i. 1st medication box fill (medication pre-pouring) of the week;

ii. 1st visit of the day; the remaining visits shall utilize brief nursing units as appropriate;

iii. Insertion or replacement of indwelling urinary catheters;

iv. Colostomy and ileostomy stoma care; excluding care performed by []Members;

v. Treatment of decubitus ulcers (stage 2 or greater);

vi. Treatment of widespread, infected or draining skin disorders;

vii. Wounds that require sterile dressing changes;

viii. Visits for foot care;

ix. Nasopharyngeal, tracheostomy aspiration or suctioning, ventilator care;

x. [] Bolus or continuous nasogastric tube and/or gastrostomy (G-tube) feedings, when formula/feeding needs to be prepared or more than one (1) can of prepared formula is needed per bolus feeding per visit, ONLY when there is not an able or willing caregiver; and xi. Complex Wound care requiring packing, irrigation, and application of an agent prescribed by the Physician or Allowed Practitioner [].

Brief Nursing Visits a. Brief N[]ursing V[]isits are for established long-term home health []Members who require multiple visits per day for uncomplicated skilled tasks that can be completed in a shorter or brief visit. Brief Nursing Visits cannot be[] the first []nursing visit of the day.

b. Brief Nursing Visits include, but are not limited to:

i) Consecutive visits for two or more []Members who reside in the same location and are seen by the same Home Health Agency nurse.

ii) Intramuscular, intradermal and subcutaneous injections[]when required multiple times daily iii) Insulin administration: if the sole reason for a daily visit or multiple visits per day, the first visit of the week is to be treated as a S[]tandard N[]ursing V[]isit and all other visits of the week are to be treated as B[]rief N[]ursing V[]isits.

iv) Additional visits beyond the first visit of the day where simple wound care dressings are the sole reason for the visit;

v) Additional visits beyond the first visit of the day where catheter irrigation is the sole reason for the visit;

vi) Additional visits beyond the first visit of the day where external catheterization, or catheter care is the sole purpose for the visit;

vii) []Bolus or continuous nasogastric tube and/or gastrostomy (G-tube) feedings []of prepared formula []ONLY when there is no willing or able caregiver and it is the sole purpose of the visit;

viii) Medication box refills or changes following the first medication pre-pouring of the week;

ix) Other non-complex nursing tasks as deemed appropriate by the Department or its Designee when documented clinical findings support a brief visit as being appropriate; or x) A combination of uncomplicated tasks when deemed appropriate by the Department or its Designee when documented clinical findings support a brief visit as being appropriate.

c. Ongoing assessment shall be billed as B[]rief N[]ursing V[]isits unless the []Member experiences a change in status requiring a standard visit. If a S[]tandard N[]ursing V[]isit is required for the assessment, the agency shall provide documentation supporting the need on the PAR form and on the Plan of Care for the 3. PRN Nursing Visits a. May be S[]tandard N[]ursing V[]isits or B[]rief N[]ursing V[]isits;

b. Shall include specific criteria and circumstances that warrant a PRN visit along with the specific number of PRN visits requested for the certification period.

Nursing Service Limitations a. Nursing assessment visits are not covered if provided solely to open or recertify the case for CNA services, physical, occupational, or speech therapy.

b. Nursing visits solely for recertifying a []Member for home health services are not covered.

c. Nursing visits that are scheduled solely for CNA supervision are not covered.

d. [] Family/In-Home Caregivers, who meet the requirements to provide nursing services and are nurses credentialed by, and in active status with the Department of Regulatory Agencies, may be employed by the Home Health Agency to provide nursing services to a Member, but may only be reimbursed for services that exceed the usual responsibilities of the Family/In-Home Caregiver.

e. PRN nursing visits may be requested as Standard Nursing Visits or Brief Nursing Visits and shall include a Physician or Allowed Practitioner’s order with specific criteria and circumstances that warrant a PRN visit along with the specific number of PRN visits requested for the certification period.

f. Nursing visits are not reimbursed by Medicaid if solely for the

purpose of psychiatric counseling or Protective Oversight, because that is the responsibility of the Behavioral Health Organization. Nursing visits for Members are reimbursed under Home Health Services for pre-pouring of medications, venipuncture, or other nursing tasks, provided that all other requirements in this section are met.

g. Medicaid does not reimburse for two nurses during one visit except when two nurses are required to perform a procedure. For this exception, the provider may bill for two visits, or for all units for both nurses. Reimbursement for all visits or units will be counted toward the maximum reimbursement limit.

h. Nursing visits provided solely for the purpose of assessing or teaching are reimbursed by the Department only in the following circumstances:

i) Nursing visits solely for the purpose of assessing the Member or teaching the Member or the Member's Family/In- Home Caregiver are not reimbursed unless the care is acute home health or long-term home health with acute episode, per Section 8.520.3, or the care is for extreme instability of a Chronic Medical Condition under long-term home health, per

Section 8.520.3. Long-term home health nursing visits for the sole purpose of assessing or teaching are not covered.

ii) When an initial assessment visit is ordered by a Physician or Allowed Practitioner, and there is a reasonable expectation that ongoing nursing or CNA care may be needed. Initial nursing assessment visits cannot be reimbursed if provided solely to open the case for physical, occupational, or speech therapy.

iii) When a nursing visit involves the nurse performing a nursing task for the purpose of demonstrating to the Member or the Member's Family/In-Home Caregiver how to perform the task, the visit is not considered as being solely for the

purpose of assessing and teaching. A nursing visit during which the nurse does not perform the task, but observes the Member or Family/In-Home Caregiver performing the task to verify that the task is being performed correctly is considered a visit that is solely for the purpose of assessing and teaching and is not covered.

iv) Nursing visits provided solely for the purpose of assessment or teaching cannot exceed the frequency that is justified by the Member's documented medical condition and symptoms.

Assessment visits may continue only as long as there is documented clinical need for assessment, management, and reporting to Physician or Allowed Practitioner of specific medical conditions or symptoms which are not stable or not resolved. Teaching visits may be as frequent as necessary, up to the maximum reimbursement limits, to teach the Member or the Member's Family/In-Home Caregiver, and may continue only as long as needed to demonstrate understanding or to perform care, or until it is determined that the Member or Family/In-Home Caregiver is unable to learn or to perform the skill being taught. The visit in which the nurse determines that there is no longer a need for assessment or teaching shall be reimbursed if it is the last visit provided solely for assessment or teaching.

v) Nursing visits provided solely for the purpose of assessment or teaching are not reimbursed if the Member is capable of self-assessment and of contacting the Physician or Allowed Practitioner as needed, and if the Member's medical records do not justify a need for Member teaching beyond that already provided by the hospital or attending Physician or Allowed Practitioner, as determined and documented on the initial Home Health assessment.

vi) Nursing visits provided solely for the purpose of assessment or teaching cannot be reimbursed if there is an available and willing Family/In-Home Caregiver who is capable of assessing the Member's medical condition and needs and contacting the Physician or Allowed Practitioner as needed; and if the Member's medical records do not justify a need for teaching of the Member's Family/In-Home Caregiver beyond the teaching already provided by the hospital or attending Physician or Allowed Practitioner, as determined and documented on the initial Home Health assessment.

i. Nursing visits provided solely for the purpose of providing foot care are reimbursed by Medicaid only if the Member has a documented and supported diagnosis that supports the need for foot care to be provided by a nurse, and the Member or Family/In-Home Caregiver is not able or willing to provide the foot care.

j. Documentation in the medical record shall specifically, accurately, and clearly show the signs and symptoms of the disease process at each visit. The clinical record shall indicate and describe an assessment of the foot or feet, physical and clinical findings consistent with the diagnosis and the need for foot care to be provided by a nurse. Severe peripheral involvement shall be supported by documentation of more than one of the following:

i) Absent (not palpable) posterior tibial pulse;

ii) Absent (not palpable) dorsalis pedis pulse;

iii) Three of the advanced trophic changes:

Hair growth (decrease or absence), 2) Nail changes (thickening), 3) Pigmentary changes (discoloration), 4) Skin texture (thin, shiny), or 5) Skin color (rubor or redness);

iv) Claudication;

v) Temperature changes (cold feet);

vi) Edema;

vii) Paresthesia ; or viii) Burning.

k. Nursing visits provided solely for the purpose of pre-pouring medications into medication containers such as med-minders or electronic medication dispensers are reimbursed only if:

i) The Member is not living in a licensed Adult Foster Home or Alternative Care Facility, where the facility staff is trained and qualified to pre-pour medications under the medication administration law at Section 25-1.5-301 C.R.S.;

ii) The Member is not physically or mentally capable of prepouring medications or has a medical history of noncompliance with taking medications if they are not prepoured;

iii) The Member has no Family/In-Home Caregiver who is willing or able to pre-pour the medications for the Member;

iv) There is documentation in the Member's chart that the Member's pharmacy was contacted upon admission to the Home Health Agency, and that the pharmacy will not provide this service; or that having the pharmacy provide this service would not be effective for this particular Member.

l. The unit of reimbursement for nursing services is one visit, which is defined as the length of time required to provide the needed care, up to a maximum of two and one-half hours spent in Member care or treatment. 8.520.5.B. Certified Nurse Aide Services 1. CNA services may be provided when a nurse or therapist determines that an eligible Member requires the skilled services of a qualified CNA, as such services are defined in this Section 8.520.5.B.13 2. CNA tasks shall not duplicate waiver services or the Member’s residential agreement (such as an ALR, IRSS, GRSS, or other Medicaid reimbursed Residence, or adult day care setting).

Skilled care shall only be provided by a CNA when a Member is unable to independently complete one or more ADLs. Skilled CNA services shall not be reimbursed for tasks or services that are the contracted responsibilities of an ALR, IRSS, GRSS or other Medicaid reimbursed Residence.
Before providing any services, all CNAs shall be trained and certified according to Federal Medicare regulations, and all CNA services shall be supervised according to Medicare Conditions of Participation for Home Health Agencies found at 42 C.F.R. § 484.36. Title 42 of the Code of Federal Regulations, Part 484.36 as amended effective March 2025 is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. These regulations are available for public inspection at the Department of Health Care Policy and Financing, 303 E. 17th Avenue Denver, CO 80203. The agency shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule.
If the Member receiving CNA services also requires and receives Skilled Nursing care or physical, occupational or speech therapy, the supervising registered nurse or therapist shall make on-site supervisory visits to the Member's home no less frequently than every 14 calendar days.
If the Member receiving CNA services does not require Skilled Nursing care or physical, occupational or speech therapy, the supervising registered nurse shall make on-site supervisory visits to the Member's home no less frequently than every 60 calendar days. Each supervisory visit shall occur while the CNA is providing care. Visits by the registered nurse to supervise and to reassess the care plan are considered costs of providing the CNA services and cannot be billed to Medicaid as nursing visits.
Registered nurses and physical, occupational and speech therapists supervising CNAs shall comply with applicable state laws governing their respective professions.
CNA services can include personal care and homemaking tasks if such tasks are completed during the skilled care visit and are defined below:

a. Personal care or homemaking services which are directly related to and secondary to skilled care are considered part of the skilled care task and are not further reimbursed. For Members who are also eligible for HCBS personal care and homemaker services, the units spent on personal care and homemaker services may not be billed as CNA services.

b. Nurse aide tasks performed by a CNA pursuant to the nurse aide scope of practice defined by the State Board of Nursing but does not include those tasks that are allowed as personal care, at

Section 8.535, Pediatric Personal Care.

c. Personal care means those tasks which are allowed as personal care at Section 8.7538, Home and Community Based Services, Personal Care.

d. Homemaking means those tasks allowed as homemaking tasks at

Section 8.7527, Home and Community Based Services-EBD, Homemaker Services.

CNA services solely for the purpose of behavior management or Protective Oversight are not a benefit under Medicaid Home Health 10. The usual frequency of all tasks is as ordered by the Physician or Allowed Practitioner on the Plan of Care unless otherwise noted.
The Home Health Agency shall document the decline in medical condition or the need for all medically necessary skilled tasks.
Skilled Certified Nurse Aide Tasks a. Ambulation i) Task includes: Walking or moving from place to place with or without assistive device.

ii) Ambulation is a skilled task when:

Member is unable to assist or direct care;
Hands on assistance is required for safe ambulation and Member is unable to maintain balance or to bear weight reliably; or 3) Member has not been deemed independent with assistive devices ordered by a qualified Physician or Allowed Practitioner.

iii) Special Considerations: Ambulation shall not be a sole reason for a CNA visit.

b. Bathing/Showering i) Task includes either:

Preparation for bath or shower, checking water temperature; assisting Member into bath or shower; applying soap and shampoo; rinsing off, towel drying; and all transfers and ambulation related to bathing; all hair care, pericare and skin care provided in conjunction with bathing; or 2) Bed bath or sponge bath.

ii) Bathing/Showering is a skilled task when either:

Open wound(s), stoma(s), broken skin or active chronic skin disorder(s) are present; or 2) Member is unable to maintain balance or to bear weight due to illness, injury, disability, a history of falls, temporary lack of mobility due to surgery or other exacerbation of illness, injury or disability.

iii) Special Considerations:

Additional baths may be warranted for treatment and shall be documented by Physician or Allowed Practitioner order and Plan of Care.
A second person may be staffed when required to safely bathe the Member.
Hand over hand assistance may be utilized for short c. Bladder Care i) Task includes:
Assistance with toilet, commode, bedpan, urinal, or diaper;
Transfers, skin care, ambulation and positioning related to bladder care; and 3) Emptying and rinsing commode or bedpan after each use.

ii) Bladder Care concludes when the Member is returned to a pre-urination state.

iii) Bladder Care is a skilled task when either:

Member is unable to assist or direct care, broken skin or recently healed skin breakdown (less than 60 days); or 2) Member requires skilled skin care associated with bladder care or Member has been assessed as having a high and ongoing risk for skin breakdown.

d. Bowel Care i) Task includes:

Changing and cleaning incontinent Member, or hands on assistance with toileting; and 2) Returning Member to pre-bowel movement status, which includes transfers, skin care, ambulation and positioning related to bowel care.

ii) Bowel care is a skilled task when either:

Member is unable to assist or direct care, broken skin or recently healed skin breakdown (less than 60 days) is present; or 2) Member requires skilled skin care associated with bowel care or Member has been assessed as having a high and ongoing risk for skin breakdown.

e. Bowel Program i) Skilled Task includes:

Administering bowel program as ordered by the Member’s qualified Physician or Allowed Practitioner, including digital stimulation, administering enemas, suppositories, and returning Member to pre-bowel program status; or 2) Care of a colostomy or ileostomy, which includes emptying the ostomy bag, changing the ostomy bag and skin care at the site of the ostomy and returning the Member to pre-procedure status.

ii) Special Considerations 1) To perform the task, the Member must have a relatively stable or predictable bowel program/condition and a qualified Physician or Allowed Practitioner deems that the CNA is competent to provide the Member-specific program.

Use of digital stimulation and over-the-counter suppositories or over-the-counter enema (not to exceed 120ml) only when the CNA demonstrates competence in the Home Health Agency’s Policies & Procedures for the task. (Agencies may choose to delegate this task to the CNA.)

f. Catheter Care i) Task includes:

Care of external, Foley and Suprapubic catheters;
Changing from a leg to a bed bag and cleaning of tubing and bags as well as perineal care;
Emptying catheter bags; and 4) Transfers, skin care, ambulation and positioning related to the catheter care.

ii) Catheter care is a skilled task when either:

Emptying catheter collection bags (indwelling or external) includes a need to record and report the Member’s urinary output to the Member’s nurse; or 2) The indwelling catheter tubing needs to be opened for any reason and the Member is unable to do so independently.

iii) Special Considerations: Catheter care shall not be the sole

purpose of the CNA visit.

g. Dressing i) Task includes:

Dressing and undressing with ordinary clothing, including pantyhose or socks and shoes;
Placement and removal of braces and splints; and 3) All transfers and positioning related to dressing and undressing.

ii) Dressing is a skilled task when:

Member requires assistance with the application of anti-embolic or pressure stockings and placement of braces or splints that can be obtained only with a prescription from a qualified Physician or Allowed Practitioner; or 2) Member is unable to assist or direct care; or 3) Member experiences a temporary lack of mobility due to surgery or other exacerbation of illness, injury or disability.

iii) Special Considerations: Hand-over-hand assistance may be h. Exercise/Range of Motion (ROM)

i) Task includes: ROM and other exercise programs prescribed by a therapist or qualified Physician or Allowed Practitioner, and only when the Member is not receiving exercise/ROM from a therapist or a doctor on the same day.

ii) Exercise/Range of Motion (ROM) is a skilled task when: The exercise/ROM, including passive ROM, is prescribed by a qualified Physician or Allowed Practitioner and the CNA has demonstrated competency.

iii) Special Considerations: The Home Health Agency shall ensure the CNA is trained in the exercise program. The Home Health Agency shall maintain the exercise program documentation in the Member record and it shall be evaluated/renewed by the qualified Physician or Allowed Practitioner or therapist with each Plan of Care.

i. Feeding i) Task includes:

Ensuring food is the proper temperature, cutting food into bite-size pieces, and ensuring the food is proper consistency;
Placing food in Member's mouth; and 3) A Home Health Agency may allow a Certified Nursing Assistant (CNA) to administer feedings via tube, gravity, syringe and/or pump including gastrostomytube and jejunostomy-tube feeding for members with stable health conditions and are not considered high risk if the CNA is deemed competent.

ii) The usual frequency of this task shall not exceed what is ordered by the Physician or Allowed Practitioner.

iii) Feeding is a skilled task when:

Member is unable to communicate verbally, non- 2) Member is unable to be positioned upright;
Member is on a modified texture diet;
Member has a physiological or neurogenic chewing or swallowing problem;
Member is on mechanical ventilation;
Member requires oral suctioning;
A structural issue (such as cleft palate) or other documented swallowing issues are present; or 8) Member has a history of choking or aspirating on food.

iv) Special Considerations:

There shall be a documented decline in medical condition or an ongoing need documented in the Member’s record.
Consistent with Section 12-255-206, C.R.S., a Home Health Agency may allow a competent CNA to perform a syringe feeding, gastrostomy-tube, and jejunostomy-tube feeding for members with stable health conditions and not considered high risk.

j. Hygiene – Hair Care/Grooming i) Task includes: Shampooing, conditioning, drying, and combing.

ii) Task may be completed during skilled bath/shower.

iii) Hygiene – Hair Care/Grooming is a skilled task when:

Member is unable to complete task independently;
Member requires shampoo/conditioner that is prescribed by a qualified Physician or Allowed Practitioner and dispensed by a pharmacy; or 3) Member has open wound(s) or stoma(s) on the head.

iv) Special Considerations:

Hand over hand assistance may be utilized for short 2) Styling of hair is never considered a skilled task.

k. Hygiene – Mouth Care i) Task includes:

Brushing teeth;
Flossing;
Use of mouthwash;
Denture care;
Swabbing (toothette); or 6) Oral suctioning.

ii) Hygiene – Mouth Care is a skilled task when:

Member is unconscious;
Member has difficulty swallowing;
Member is at risk for choking and aspiration;
Member requires oral suctioning;
Member has decreased oral sensitivity or hypersensitivity; or 6) Member is on medications that increase the risk of bleeding of the mouth.

iii) Special Considerations: Hand over hand assistance may be l. Hygiene – Nail Care i) Task includes: Soaking, filing, and nail trimming.

ii) Hygiene – Nail Care is a skilled task when:

The Member has a medical condition that involves peripheral circulatory problems or loss of sensation;
The Member is at risk for bleeding; or 3) The Member is at high risk for injury secondary to the nail care.

iii) Nail Care shall only be completed by a CNA who has been deemed competent in nail care by the Home Health Agency for this population.

iv) Special Considerations: Hand over hand assistance may be m. Hygiene – Shaving i) Task includes: shaving of face, legs and underarms with manual or electric razor.

ii) Task may be completed with bathing/showering.

iii) Hygiene – Shaving is a skilled task when:

The Member has a medical condition involving peripheral circulatory problems;
The Member has a medical condition involving loss of sensation;
The Member has an illness or takes medications that are associated with a high risk for bleeding; or 4) The Member has broken skin at/near shaving site or a chronic active skin condition.

iv) Special Considerations: Hand over hand assistance may be n. Meal Preparation i) Task includes:

Preparation of food, ensuring food is proper consistency based on the Member’s ability to swallow food safely; or 2) Formula preparation.

ii) Meal Preparation is a skilled task when: Member’s diet requires either nurse oversight to administer correctly, or meals requiring a modified consistency.

o. Medication Reminders i) Task includes:

Providing Member reminders that it is time to take medications;
Handing of pre-filled medication box to Member;
Handing of labeled medication bottle to Member; or 4) Opening of prefilled box or labeled medication bottle for Member.

ii) This task may be completed by a CNA during the course of a visit but cannot be the sole purpose of the visit.

iii) Special Considerations: CNAs shall not administer medications without obtaining the CNA-MED certification from the DORA approved course. 3 C.C.R. 716-1 Chapter 19

Section 6. If the CNA has obtained this certification, the CNA may perform pre-pouring and medication administration within the scope of CNA-MED certification at 3 C.C.R. 716-1

Chapter 19 Section 3.

p. Positioning i) Task includes:

Moving the Member from the starting position to a new position while maintaining proper body alignment and support to a Member’s extremities, and avoiding skin breakdown; and 2) Placing any padding required to maintain proper alignment.
Positioning as a stand-alone task excludes positioning that is completed in conjunction with other Activities of Daily Living.
Positioning the Member requires adjusting the Member’s alignment or posture in a bed, wheelchair, other furniture, assistive devices, or Durable Medical Equipment that has been ordered by a qualified Physician or Allowed Practitioner.

ii) Positioning is a skilled task when:

Member is unable to communicate verbally, non- 2) Member is not able to perform this task independently due to illness, injury or disability; or 3) Member has temporary lack of mobility due to surgery or other exacerbation of illness, injury or disability.

iii) Special Considerations:

The Home Health Agency shall coordinate visits to ensure that effective scheduling is utilized for skilled Intermittent visits.
Positioning cannot be the sole reason for a visit.

q. Skin Care i) Task includes:

Applying lotion or other skin care product, when it is not performed in conjunction with bathing or toileting tasks.

ii) Skin care is a skilled task when:

Member requires additional skin care that is prescribed by a qualified Physician or Allowed Practitioner or dispensed by a pharmacy;
Member has broken skin; or 3) Member has a wound(s) or active skin disorder and is unable to apply product independently due to illness, injury or disability.

iii) Special Considerations:

Hand over hand assistance may be utilized for short 2) This task may be included with positioning.

r. Transfers i) Task includes:

Moving the Member from one location to another in a safe manner.

ii) It is not considered a separate task when a transfer is performed in conjunction with bathing, bladder care, bowel care or other CNA task.

iii) Transfers is a skilled task when:

Member is unable to communicate verbally, non- 2) Member is not able to perform this task independently due to fragility of illness, injury or disability;
Member has a temporary lack of mobility due to surgery or other exacerbation of illness, injury or disability;
Member lacks the strength and stability to stand or bear weight reliably;
Member is not deemed independent in the use of assistive devices or Durable Medical Equipment that has been ordered by a qualified Physician or Allowed Practitioner; or 6) Member requires a mechanical lift for safe transfers.

In order to transfer Members via a mechanical lift, the CNA shall be deemed competent in the particular mechanical lift used by the Member.t.

iv) Special Considerations:

A second person may be used when required to safely transfer the Member.
Transfers may be completed with or without mechanical assistance.
Any unskilled task which requires a skilled transfer shall be considered a skilled task.

s. Vital Signs Monitoring i) Task includes:

Taking and reporting the temperature, pulse, blood pressure and respiratory rate of the Member.
Blood glucose testing and pulse oximetry readings only when the CNA has been deemed competent in these measures.

ii) Vital sign monitoring is always a skilled task.

iii) Special Considerations:

Vital signs monitoring cannot be the sole purpose of the CNA visit.
Vital signs shall be taken only as ordered by the Member’s nurse or the Plan of Care and shall be reported to the nurse in a timely manner.
The CNA shall not provide any intervention without the nurse’s direction, and may only perform interventions that are within the CNA practice act and for which the CNA has demonstrated competency.

Certified Nurse Aide Limitations a. In accordance with the Colorado Nurse Aide Practice Act, a CNA shall only provide services that have been ordered on the Home Health Plan of Care as written by the Physician or Allowed Practitioner.

b. CNAs assist with Activities of Daily Living and cannot perform a visit for the purpose of behavior modification. When a Member’s disabilities involve behavioral manifestations, the CNA shall follow all applicable behavioral plans and refrain from actions that will escalate or upset the Member. In such cases the guardian, case manager, behavioral professional or mental health professional shall provide clear direction to the agency for the provision of care. The CNA shall not perform Behavioral Interventions, beyond those listed in c. of this section.

c. If the Member has a behavior plan created by a behavior or mental health professional, the CNA shall follow this plan within their scope and training to the same extent that a family Member or paraprofessional in a school would be expected to follow the plan.

d. When an agency allows a CNA to perform skilled tasks that require competency or delegation, the agency shall have policies and procedures regarding its process for determining the competency of the CNA. All competency testing and documentation related to the CNA shall be retained in the CNA's personnel file.

e. CNA services can only be ordered when the task is outside of the usual responsibilities of the Member’s Family/In-Home Caregiver.

f. Cuing or hand over hand assistance to complete Activities of Daily Living is not considered a skilled task, however, the agency may provide up to 90 days of care to teach a Member Activities of Daily Living when the Member is able to learn to perform the tasks independently. Cuing or hand over hand care that exceeds 90 days or is provided when the Member has not had a change in ability to complete self-care techniques, is not covered. If continued cuing or hand over hand assistance is required after 90 days, this task shall be transferred to a Personal Care Worker or other competent individual who can continue the task.

g. Personal care needs or skilled CNA services that are the contracted responsibility of an ALR, GRSS or IRSS are not reimbursable as a separate Medicaid Home Health Service.

h. Family/In-Home Caregiver who meet all relevant requirements may be employed as a Member’s CNA but may only provide services that are identified in this benefit coverage standard as skilled CNA services and that exceed the usual responsibilities of the Family/In-Home Caregiver. Family/In-Home Caregiver CNAs must meet all CNA requirements.

i. All CNAs who provide Home Health Services shall be subject to all requirements set forth by the policies of the Home Health Agency, and all applicable State and Federal laws.

j. When a CNA holds other licensure(s) or certification(s), but is employed as or functions as a CNA, the services are reimbursed at the CNA rate for services.

k. CNA visits cannot be approved for, nor can extended units be billed for the sole purpose of completing personal care, homemaking tasks or instrumental Activities of Daily Living.

l. Personal care needs for Members ages 20 years and under, not directly related to a skilled care task, shall be addressed through

Section 8.535, Pediatric Personal Care.

m. Homemaker Services provided as directly related tasks secondary to skilled care during a skilled CNA visit shall be limited to the permanent living space of the Member. Such services are limited to tasks that benefit the Member and are not for the primary benefit of other persons living in the home.

n. Nursing or CNA visits, or requests for extended visits, for the sole

purpose of Protective Oversight are not reimbursable by Medicaid.

o. CNA services for the sole purpose of providing personal care or homemaking services are not covered.

p. The Department does not reimburse for services provided by two CNAs to the same Member at the same time, except when two CNAs are required for transfers, there are no other persons available to assist, and the reason why adaptive equipment cannot be used instead is documented in the Plan of Care. For this exception, the provider may bill for two visits, or for all units for both aides. Reimbursement for all visits or units will be counted toward the maximum reimbursement limit.

q. The basic unit of reimbursement for CNA services is up to 60 minutes. A unit of time that is less than 15 minutes cannot be reimbursed as a basic unit.

r. For CNA visits that last longer than one-hour, extended units may be billed in addition to the basic unit. Extended units shall be increments of 15 minutes up to 30 minutes. Any unit of time that is less than15 minutes cannot be reimbursed as an extended unit.

Certified Nurse Aide (CNA) Supervision a. CNA services shall be supervised by a registered nurse, by the physical therapist, or when appropriate, the speech therapist or occupational therapist depending on the specific Home Health Services the Member is receiving.

b. If the Member receiving CNA services is also receiving Skilled Nursing care or physical therapy or occupational therapy, the supervising registered nurse or therapist shall make supervisory visits to the Member's home no less frequently than every 14 days. The CNA does not have to be present for every supervisory visit. However, the registered nurse, or the therapist shall make on-site supervisory visits to observe the CNA in the Member's home at least every 60 days.

c. If the Member is only receiving CNA services, the supervising registered nurse or the physical therapist shall make on-site supervisory visits to observe the CNA in the Member's home at least every 60 days.

d. The Department does not reimburse for any visit made solely for the

purpose of supervising the CNA.

e. For all Members expected to require CNA services for at least a year, during supervisory visits the supervising nurse shall:

i) Obtain input from the Member, or the Member's designated representative into the Certified Nurse Aide Assignment Form, including all CNA tasks to be performed during each scheduled time period.

ii) Document details, duties, and obligations on the Certified Nurse Aide Assignment Form.

iii) Assure the Certified Nurse Aide Assignment Form contains information regarding special functional limitations and needs, safety considerations, special diets, special equipment, and any other information pertinent to the care to be provided by the CNA.

iv) Obtain the Member’s, or the Member's authorized representative’s signature on the Certified Nurse Aide Assignment Form , and provide a copy to the Member at the beginning of services, and at least once per year thereafter. A new copy of the Written Notice of Home Care Consumer Rights form, per Section 8.520.7.E.1, shall also be provided at these times.

v) Explain the rights listed in the patient’s rights form whenever the Certified Nurse Aide Assignment Form is renegotiated and rewritten.

vi) For purposes of complying with this requirement, once per year means a date within one year of the prior certification.

If a Member does not meet the factors that make a task skilled, as outlined in Section 8.520.5.B.12., the Member may be eligible to receive those services as unskilled personal care through Section 8.7538, Home and Community Based Services, Personal Care. 8.520.5.C. Therapy Services 1. Therapies are only covered:

a. In acute home health care; or b. Members 20 years of age or younger may receive long-term home health therapy when services are medically necessary.

c. When the Member’s Physician or Allowed Practitioner prescribes therapy services, and the therapist is responsible for evaluating the Member and creating a treatment plan with exercises in accordance with practice guidelines.

The therapist shall teach the Member, the Member’s Family/In-Home Caregiver and other Members of the Home Health care team to perform the exercises as necessary for an optimal outcome.
When the therapy Plan of Care includes devices and equipment, the therapist shall assist the Member in initiating or writing the request for equipment and train the Member on the use of the equipment.
Home Health Agencies shall only provide physical, occupational, or speech therapy services when:

a. Improvement of functioning is expected or continuing;

b. The therapy assists in overcoming developmental problems;

c. Therapy visits are necessary to prevent deterioration;

d. Therapy visits are indicated to evaluate and change ongoing treatment plans for the purpose of preventing deterioration, and to teach CNAs or others to carry out such plans, when the ongoing treatment does not require the skill level of a therapist; or e. Therapy visits are indicated to assess the safety or optimal functioning of the Member in the home, or to train in the use of equipment used in implementation of the therapy Plan of Care.

Physical Therapy a. Physical therapy includes any evaluations and treatments allowed under state law at C.R.S. § 12- 41-101 through 130, which are applicable to the home setting.

b. When devices and equipment are indicated by the therapy Plan of Care, the therapist shall assist in initiating or writing the request in accordance with Sections 8.590 through 8.590.7.P., Durable Medical Equipment, and shall assist in training on the use of the c. Treatment must be provided by or under the supervision of a licensed physical therapist who meets the qualifications prescribed by federal regulation for participation in Medicare and who meets all requirements under state law.

i) Physical therapy assistants (PTA) can render Home Health therapy but shall practice under the supervision of a registered physical therapist.

d. For Members who do not require Skilled Nursing care, the physical therapist may open the case and establish the Plan of Care.

e. Physical therapists are responsible for completing Member assessments related to various physical skills and functional abilities.

f. Physical therapy includes evaluations and treatments allowed under state law and is available to all acute home health Members and pediatric long-term Home Health Members. Therapy plans and assessments shall contain the therapy services requested; the specific procedures and modalities to be used, including amount, duration, and frequency; and specific goals of therapy service provision.

g. Limitations i) Physical therapy for Members ages 21 or older is not covered for acute care needs when treatment becomes focused on maintenance, and no further functional progress is apparent or expected to occur.

ii) Physical therapy is not a benefit for adult long-term home health Members. Members 20 years of age or younger may receive Long-Term Home Health therapy services when services are medically necessary.

iii) Members ages 21 and older who continue to require therapy after the acute home health period may obtain long-term therapy services in an outpatient setting. Members shall not be moved to acute home health for the sole purpose of continuing therapy services from a previous acute home health care episode.

iv) Members 20 years of age or younger may obtain therapy services for maintenance care through acute home health and through long-term home health.

v) Physical therapy visits for the sole purpose of providing massage or ultrasound are not covered.

vi) Medicaid does not reimburse for two physical therapists vii) The unit of reimbursement for physical therapy is one visit, which is defined as the length of time required to provide the needed care, up to a maximum of two and one-half hours spent in Member care or treatment.

Occupational Therapy a. Occupational therapy includes evaluations and treatments allowed under the standards of practice authorized by the American Occupational Therapy Association, which are applicable to the home setting.

b. When devices and equipment are indicated by the therapy Plan of Care, the therapist shall assist in initiating or writing the request and shall assist in training the Member on the use of the c. Treatment shall be provided by or under the supervision of a registered occupational therapist who meets the qualifications prescribed by federal regulations for participation under applicable federal and state laws, including Medicare requirements at 42 C.F.R. § 484.4. Title 42 of the Code of Federal Regulations is hereby incorporated by reference.

i) Occupational therapy assistants (OTA) can render Home Health therapy but shall practice under the supervision of a registered occupational therapist.

d. For Members who do not require Skilled Nursing care, the occupational therapist may open the case and establish the Plan of Care.

e. Occupational therapy includes only evaluations and treatments that are allowed under state law for occupational therapists.

f. Occupational therapists shall create a plan and perform assessments which state the specific therapy services requested, the specific procedures and modalities to be used, the amount, duration, frequency, and the goals of the therapy service provision.

g. Limitations i) Occupational therapy for Members ages 21 or older is not a benefit under acute Home Health Services when treatment becomes maintenance, and no further functional progress is apparent or expected to occur.

ii) Occupational therapy is not a benefit for adult long-term home health Members.

iii) Members ages 21 and older who continue to require therapy after the acute home health period may only obtain longterm therapy services in an outpatient setting.

iv) Members shall not be moved to acute home health for the sole purpose of continuing therapy services from a previous acute home health care episode.

v) Members 20 years of age or younger may continue to obtain therapy services for maintenance care in acute home health and in long-term home health.

vi) Medicaid does not reimburse for two occupational therapists vii) The unit of reimbursement for occupational therapy is one visit, which is defined as the length of time required to provide the needed care, up to a maximum of two and onehalf hours spent in Member care or treatment.

Speech Therapy a. Speech therapy services include any evaluations and treatments allowed under the American Speech-Language-Hearing Association (ASHA) authorized scope of practice statement, which are applicable to the home setting.

b. When devices and equipment are indicated by the therapy Plan of Care, the therapist shall assist in initiating or writing the request in accordance with Sections 8.590 through 8.590.7.P., Durable Medical Equipment, and shall assist in training on the use of the c. Treatment must be provided by a speech/language pathologist who meets the qualifications prescribed by federal regulations for participation under Medicare at 42 C.F.R. § 484.4. Title 42 of the Code of Federal Regulations is hereby incorporated by reference.

d. For Members who do not require Skilled Nursing care, the speech therapist may open the case and establish the Medicaid Plan of Care.

e. The speech/language pathologist shall state the specific therapy services requested, the specific procedures and modalities to be used, as well as the amount, duration, frequency and specific goals of therapy services on the Plan of Care.

f. Limitations i) Speech therapy for Members ages 21 or older is not a benefit under acute Home Health Services when treatment becomes maintenance, and no further functional progress is apparent or expected to occur.

ii) Members cannot be moved to acute home health for the sole

purpose of continuing therapy services from a previous acute home health care episode.

iii) Speech therapy is not a benefit for adult long-term home health Members.

iv) Treatment of speech and language delays is only covered when associated with a Chronic Medical Condition, neurological disorder, acute illness, injury, or congenital issue.

v) Members 20 years of age or younger may continue to obtain therapy services for maintenance care in acute home health and in long-term home health.

vi) Medicaid does not reimburse for two speech therapists vii) The unit of reimbursement for speech therapy is one visit, which is defined as the length of time required to provide the needed care, up to a maximum of two and one-half hours spent in Member care or treatment. 8.520.5.D. Remote Patient Monitoring 1. The Home Health Agency shall create policies and procedures for the use and maintenance of the monitoring equipment and the process of Remote Patient Monitoring. This service shall be used to monitor the Member and manage the Member’s care, and shall include all of the following elements:

a. The Member’s designated registered nurse or licensed practical nurse, consistent with state law, shall review all data collected within 24 hours of receipt of the ordered transmission, or in cases where the data is received after business hours, on the first business day following receipt of the data;

b. The Member’s designated nurse shall oversee all planned interventions;

c. Member-specific parameters and protocols defined by the agency staff and the Member’s Physician or Allowed Practitioner ; and d. Documentation of the clinical data in the Member’s chart and a summary of response activities, if needed.

i) The nurse assessing the clinical data shall sign and date all documentation; and ii) Documentation shall include the health care data that was transmitted and the services or activities that are recommended based on the data.

The Home Health Agency shall provide monitoring equipment that possesses the capability to measure any changes in the monitored diagnoses, and meets all of the following requirements:

a. Food and Drug Administration (FDA) certified or Underwriters Laboratory (UL) listed, and used according to the manufacturer’s instructions;

b. Maintained in good repair and free from safety hazards; and c. Sanitized before installation in a Member’s home.

Remote Patient Monitoring services are covered for Members receiving Home Health Services, when all of the following requirements are met:

a. Member receives services from a home health provider for at least one of the following diagnoses:

i) Congestive Heart Failure;

ii) Chronic Obstructive Pulmonary Disease;

iii) Asthma;

iv) Diabetes;

v) Pneumonia; or vi) Other diagnosis or medical condition deemed eligible by the b. Member requires ongoing and frequent monitoring, minimum of five times weekly, to manage their qualifying diagnosis as defined and ordered by a Physician or Allowed Practitioner or podiatrist;

c. Member has demonstrated a need for ongoing monitoring as evidenced by:

i) Having been hospitalized or admitted to an emergency room two or more times in the last 12 months for medical conditions related to the qualifying diagnosis;

ii) If the Member has received Home Health Services for less than six months, the Member was hospitalized at least once in the last three months;

iii) An acute exacerbation of a qualifying diagnosis that requires Remote Patient Monitoringor iv) New onset of a qualifying disease that requires ongoing monitoring to manage the Member in their residence.

d. Member or caregiver misses no more than five transmissions of the provider and agency prescribed monitoring events in a 30-day period; and e. Member’s home environment has the necessary connections to transmit the Remote Patient Monitoring data to the agency and has space to set up and use the equipment as prescribed.

The Home Health Agency shall make at least one home health nursing visit every 14 days to a Member using Remote Patient Monitoring.
The Home Health Agency shall develop agency-specific criteria for assessment of the need for Remote Patient Monitoring, to include patient selection criteria, home environment compatibility, and patient competency. The agency shall complete these assessment forms prior to the submission of the enrollment application and they shall be kept on file at the agency.
The Member and/or caregiver shall comply with the Remote Patient Monitoring as ordered by the qualifying Physician or Allowed Practitioner.
Limitations:

a. Members who are unable to comply with the ordered Remote Patient Monitoring shall be disenrolled from the services.

b. Services billed prior to obtaining approval to enroll a Member into Remote Patient Monitoring by the Department or its Designee are not a covered benefit.

c. The unit of reimbursement for Remote Patient Monitoring is one calendar day.

i) The Home Health Agency may bill one initial installation unit per Member lifetime when the monitoring equipment is installed in the home.

ii) The Home Health Agency may bill the daily rate for each day the Remote Patient Monitoring equipment is used to monitor and manage the Member’s care.

d. Once per lifetime per Member, a Home Health Agency may bill for the installation of the Remote Patient Monitoring equipment. 8.520.6 Supplies 8.520.6.A. Reimbursement for routine supplies is included in the reimbursement for nursing, CNA, physical therapy, occupational therapy, and speech therapy services. Routine supplies are supplies that are customarily used during the course of home care visits. These are standard supplies utilized by the Home Health Agency staff and not designated for a specific Member. 8.520.6.B. Non-routine supplies may be a covered benefit when approved by the 8.520.6.C. Limitations 1. A Home Health Agency cannot require a Member to purchase or provide supplies that are necessary to carry out the Member’s Plan of Care.

A Member may opt to provide his or her own supplies. 8.520.7. Documentation 8.520.7.A. Home Health Agencies shall have written policies regarding delegation of tasks by nurses. 8.520.7.B. Home Health Agencies shall have written policies regarding maintenance of Members’ durable medical equipment and make full disclosure of these policies to all Members with durable medical equipment in the home. The Home Health Agency shall provide such disclosure to the Member at the time of intake. 8.520.7.C. Home Health Agencies shall have written policies regarding procedures for communicating with case managers of Members who are also enrolled in HCBS programs. Such policies shall include, at a minimum:
How agencies will inform case managers that services are being provided or are being changed; and 2. Procedures for sending copies of Plans of Care if requested by case managers. These policies shall be developed with input from case managers. 8.520.7.D. Plan of Care Requirements 1. The Member’s Physician or Allowed Practitioner shall order Home Health Services in writing, as part of a written Plan of Care. The written Plan of Care shall be reviewed and updated every 60 calendar days but need not be provided to the Department or its Designee unless the Member’s status has changed significantly, a new PAR is needed, or if requested by the 2. The initial assessment or continuation of care assessments shall be completed by a registered nurse, or by a physical therapist, occupational therapist or speech therapist when no Skilled Nursing needs are required.

The assessment shall be utilized to develop the Plan of Care with provider input and oversight. The written Plan of Care and associated documentation shall be used to complete the CMS-485 Plan of Care, or a form that is of similar format to the CMS-485 and shall include:

a. Identification of the Physician or Allowed Practitioner;

b. Physician or Allowed Practitioner orders;

c. Identification of the specific diagnoses, including the primary diagnosis, for which Medicaid Home Health Services are requested.

d. The specific circumstances, Member medical condition(s) or situation(s) that require services to be provided in the Member’s residence rather than in a Physician or Allowed Practitioner’s office, clinic or other outpatient setting including the availability of natural supports and the Member’s living situation;

e. A complete list of supplements, and medications, both prescription and over the counter, along with the dose, the frequency, and the means by which the medication is taken;

f. A complete list of the Member’s allergies;

g. A list of all non-routine durable medical equipment used by the Member;

h. A list of precautions or safety measures in place for the Member, as well as functional limitations or activities permitted by the Member’s Physician or Allowed Practitioner ;

i. A behavioral plan when applicable. Physical Behavioral Interventions, such as restraints, shall not be included in the home health Plan of Care;

j. A notation regarding the Member’s Physician or Allowed Practitioner-ordered dietary (nutritional) requirements and restrictions, any special considerations, other restrictions or nutritional supplements;

k. The Home Health Agency shall indicate a comprehensive list of the amount, frequency, and expected duration of provider visits for each discipline ordered by the Member’s Physician or Allowed Practitioner, including:

i) The specific duties, treatments and tasks to be performed during each visit;

ii) All services and treatments to be provided on the Plan of Care;

Treatment plans for physical therapy, occupational therapy and speech therapy may be completed on a form designed specifically for therapy Plans of Care;

iii) Specific situations and circumstances that require a PRN visit, if applicable.

l. Current clinical summary of the Member’s health status, including mental status, and a brief statement regarding homebound status of the Member;

m. The Member’s prognosis, goals, rehabilitation potential and where applicable, the Member’s specific discharge plan;

i) If the Member’s illness, injury or disability is not expected to improve, or discharge is not anticipated, the agency is not required to document a discharge plan;

ii) The Member’s medical record shall include the reason that no discharge plan is present;

n. The Physician or Allowed Practitioner shall approve the Plan of Care with a dated signature. If an electronic signature is used, the agency shall document that an electronic signature was used and shall keep a copy of the Physician or Allowed Practitioner’s physical signature on file;

o. Brief statement regarding the Member’s support network including the availability of the Member’s Family/In-Home Caregiver and if applicable, information on why the Member’s Family/In-Home Caregiver is unable or unwilling to provide the care the Member requires; and p. Other relevant information related to the Member’s need for Home Health care.

A new Plan of Care shall be completed every 60 calendar days while the Member is receiving Home Health Services. The Plan of Care shall include a statement of review by the Physician or Allowed Practitioner every 60 days.
Home Health Agencies shall send new Plans of Care and other documentation as requested by the Department or its Designee. 8.520.7.E. Additional Required Member Chart Documentation 1. A signed copy of the Written Notice of Home Care Consumer Rights as required by the Department and at 42 C.F.R. § 484.10. Title 42 of the Code of Federal Regulations is hereby incorporated by reference.;
Evidence of a face-to-face visit with the Member’s referring provider, or other appropriate provider, as required at 42 C.F.R. § 440.70. Title 42 of the Code of Federal Regulations is hereby incorporated by reference. ;
A signed and dated copy of the Agency Disclosure Form as required by the Department, with requirements at 42 C.F.R. § 484.12. Title 42 of the Code of Federal Regulations is hereby incorporated by reference.;
Dates of the most recent hospitalization or nursing facility stay. If the most recent stay was within the last 90 days, reason for the stay (diagnoses), length of stay, summary of treatment, date and place discharged to shall be included in the clinical summary or update;
The expected health outcomes, which may include functional outcomes;
An emergency plan including the safety measures that will be implemented to protect against injury;
A specific order from the Member’s Physician or Allowed Practitioner for all PRN visits utilized;
Clear documentation of skilled and non-skilled services to be provided to the Member with documentation that the Member or Member’s Family/In- Home Caregiver agrees with the Plan of Care;
Accurate and clear clinical notes or visit summaries from each discipline for each visit that include the Member’s response to treatments and services completed during the visit. Summaries shall be signed and dated by the person who provided the service. If an electronic signature is used, the agency shall document that an electronic signature was used and keep a copy of the physical signature on file;
Documented evidence of Care Coordination with the Member’s other providers;
When the Member is receiving additional services (skilled or unskilled) evidence of Care Coordination between the other services shall be documented and include an explanation of how the requested Home Health Services do not overlap with these additional services;
A plan for how the agency will cover Member services (via Family/In- Home Caregiver or other agency staff) if inclement weather or other unforeseen incident prevents agency staff from delivering the Home Health care ordered by thePhysician or Allowed Practitioner; and; and 13. If foot or wound care is ordered for the Member, the Home Health Agency shall ensure the signs and symptoms of the disease process/medical condition that requires foot or wound care by a nurse are clearly and specifically documented in the clinical record. The Home Health Agency shall ensure the clinical record includes an assessment of the foot or feet, or wound, and physical and clinical findings consistent with the diagnosis, and the need for foot or wound care to be provided by a nurse. 8.520.8 Prior Authorization 8.520.8.A. General Requirements 1. Approval of the PAR does not guarantee payment by Medicaid.
The Member and the HHA shall meet all applicable eligibility requirements at the time services are rendered and services shall be delivered in accordance with all applicable service limitations.
Medicaid is always the payer of last resort and the presence of an approved or partially approved PAR does not release the agency from the requirement to only bill for Medicaid approved services to Medicare or other third-party insurance prior to billing Medicaid.

a. Exceptions to this include Early Intervention Services documented on a child’s Individualized Family Service Plan (IFSP) and the following services that are not a skilled Medicare benefit (CNA services only, OT services only, Med-box pre-pouring and routine lab draws).

In the event a Member changes provider agencies, the receiving HHA shall submit a Change of Provider Form and POC to the URC within 10 business days of starting LTHH services. 8.520.8.B. Acute Home Health 1. Acute Home Health Services do not require prior authorization. This includes episodes of acute home health for Long-Term Home Health Members. A condition is considered acute only until it is resolved or until 60 calendar days after onset, whichever comes first.
If a Member receiving Long-Term Home Health Services experiences an acute care event that necessitates moving the Member to an acute home health episode, the agency shall notify the Department or its Designee that the Member is moving from long-term home health to acute Home Health Services.
If the Member’s acute home health needs resolve prior to 60 calendar days, the Home Health Agency shall discharge the Member, or submit a PAR for Long-Term Home Health Services if the Member is eligible.

a. If an acute home health Member experiences a change in status (e.g. an inpatient admission), that totals nine calendar days or less, the Home Health Agency shall resume the Member’s care under the current acute home health Plan of Care.

b. If an acute home health Member experiences a change in status (e.g. an inpatient admission), that totals 10 calendar days or more, the Home Health Agency may start a new Acute Home Health episode when the Member returns to the Home Health Agency.

c. The Home Health Agency shall inform the SEP case manager or the Medicaid fiscal agent within 10 working days of the beginning and within 10 working days of the end of the acute care episode. 8.520.8.C. Long-Term Home Health 1. Long-Term Home Health Services require prior authorization.

When an agency accepts an HCBS waiver Member to Long-Term Home Health Services, the Home Health Agency shall contact the Member’s case management agency to inform the case manager of the Member's need for Home Health Services.
Long-Term Home Health Services require the completion of the Skilled Care Acuity Assessment to reliably provide consistent information, and is to be completed by the designated Nurse Assessor Vendor. The assessment results are a part of a body of evidence used to determine Medical Necessity but does not independently determine the outcomes of service eligibility.
The complete formal written PAR shall include:

a. A completed Department-prescribed Prior Authorization Request Form, see Section 8.058;

b. A home health Plan of Care, which includes all clinical assessments and current clinical summaries or updates of the Member. The Plan of Care shall be on the CMS-485 form, or a form that is of similar format to the CMS-485, and all sections of the form shall be completed. For Members 20 years of age or younger, all therapy services requested shall be included in the Plan of Care or addendum, which lists the specific procedures and modalities to be used and the amount, duration, frequency and goals. If extended aide units, as described in Section 8.520.5.B.13.r. are requested, there shall be sufficient information about services on each visit to justify the extended units. Documentation to support any PRN visits shall also be provided. If there are no nursing needs, the Plan of Care and assessments may be completed by a therapist if the Member is 20 years of age or younger and is receiving home health therapy services;

c. For Members under 21 years of age, written documentation of the results of the EPSDT medical screening, or other equivalent examination results provided by the Member's third-party insurance;

d. Any other medical information which will document the Medical Necessity for the Home Health Services. Support for Medical Necessity must be documented in the PAR submission to be considered in the PAR review and any subsequent appeal; e If applicable, written instructions from the therapist or other medical professional to support a current need when range of motion or other therapeutic exercise is the only skilled service performed on a CNA visit;

f. When the PAR includes a request for nursing visits solely for the

purpose of pre-pouring medications, evidence that the Member's pharmacy was contacted, and advised the Home Health Agency that the pharmacy will not provide medication set-ups, shall be documented; and g. When a PAR includes a request for reimbursement for two aides at the same time to perform two-person transfers, documentation supporting the current need for two-person transfers, and the reason adaptive equipment cannot be used instead, shall be provided.

h. Long-Term Home Health Services for Members 20 years of age or younger require prior authorization by the Department or its Designee using the approved utilization management tool.

Authorization time frames:

a. PARs shall be submitted for and may be approved for up to a oneyear period. b The Department or its Designee may initiate PAR revisions if the Plans of Care indicate significantly decreased services.

c. PAR revisions for increases initiated by Home Health Agencies shall be submitted and processed according to the same requirements as for new PARs, except that current written assessment information pertaining to the increase in care may be submitted in lieu of the CMS-485 Plan of Care, or a form that is of similar format to the CMS-485.

The PAR shall not be backdated to a date prior to the 'from' date of the CMS-485 Plan of Care, or a form that is of similar format to the CMS-485.
The Department or its Designee shall approve or deny according to the following guidelines for safeguarding Members:

a. PAR Approval: If services requested are in compliance with Medicaid rules and are medically necessary and appropriate for the diagnosis and treatment plan, the services are approved retroactively to the start date on the PAR form. Services may be approved retroactively for no more than 10 days prior to the PAR submission date.

b. PAR Denial:

i) The Department or its Designee shall notify Home Health Agencies in writing of denials that result from noncompliance with Medicaid rules or failure to establish Medical Necessity (e.g., the PAR is not consistent with the Member's documented medical needs and functional capacity). Denials based on Medical Necessity shall be determined by a registered nurse, Physician or Allowed Practitioner.

ii) When denied or reduced, services shall be approved in accordance with Section 8.057.5.

c. Interim Services: Services provided during the period between the provider’s submission of the PAR form to the Department or its Designee, to the final approval or denial by the Department may be approved for payment. Payment may be made retroactive to the start date on the PAR form, or up to 30 working days, whichever is shorter.

i) If the PAR is denied and the Member appeals that denial, the Department will not be the proponent of an order regarding that denial solely by virtue of having provided interim services. The Member will maintain the burden of proof to establish eligibility for services requested in the PAR. 8.520.8.D. EPSDT Services 1. Home Health Services beyond those allowed in Section 8.520.5, for Members under the age of 21, shall be reviewed for Medical Necessity under the EPSDT requirement, as defined at Section 8.280.1.

Home Health Services beyond those in Section 8.520.5, which are provided under the Home Health benefit due to Medical Necessity, cannot include services that are available under other Colorado Medicaid benefits for which the Member is eligible, including, but not limited to, Private Duty Nursing, Section 8.540; Home and Community-Based Services (HCBS),

Section 8.7000; Pediatric Personal Care, Section 8.535; School Health and Related Services, Section 8.290, or Outpatient Therapies, Section 8.200.3.A.6, Section 8.200.5.B., and Section 8.200.3.D.2. Exceptions may be made if EPSDT Home Health Services will be more cost-effective, provided that Member safety is assured. Such exceptions shall, in no way, be construed as mandating the delegation of nursing tasks.

PARs for EPSDT home health shall be submitted and reviewed as outlined in Section 8.520.8, including all documentation outlined in Section 8.520.8, and any other medical information which will document the Medical Necessity for the EPSDT Home Health Services. The Plan of Care shall include the place of service for each home health visit. 8.520.8.E. Remote Patient Monitoring 1. Remote Patient Monitoring requires prior authorization.
The Remote Patient Monitoring PARs shall include all of the following:

a. A completed enrollment form;

b. An order for Remote Patient Monitoring signed and dated by the Physician or Allowed Practitioner or podiatrist;

c. A Plan of Care, which includes nursing and therapy assessments for Members. Remote Patient Monitoring shall be included on the CMS-485 Plan of Care, or a form that is of similar format to the CMS-485 and all applicable forms shall be complete; and d. For ongoing Remote Patient Monitoring, the agency shall include documentation on how Remote Patient Monitoring data has been used to manage the Member’s care, if the Member has been using Remote Patient Monitoring. 8.520.9 Reimbursement 8.520.9.A. Payment for Home Health Services is the lower of the billed charges or the maximum unit rate of reimbursement.

The maximum reimbursement for any 24-hour period, as measured from midnight to midnight, shall not exceed the daily maximum as designated by the Department and in alignment with the Legislative Budget.
The maximum daily reimbursement includes reimbursement for nursing visits, home health CNA visits, physical therapy visits, occupational therapy visits, speech/language pathology visits, and any combinations thereof.
Each individual Nurse (RN/LPN) and Certified Nursing Assistant (CNA) must adhere to the Weekly Caregiver Limit and Per Day Hourly Limit defined in Section 8.7419. 8.520.9.B. Special Reimbursement Conditions 1. Total reimbursement by the Department combined with third party liability and Medicare crossover claims shall not exceed Medicaid rates.
When Home Health Agencies provide Home Health Services in accordance with these regulations to Members who receive Home and Community-based Services for the Developmentally Disabled (HCBS-DD), the Home Health Agency is reimbursed:

a. Under normal procedures for home health reimbursement if the Member resides in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID); or b. By the group home provider, if the Member resides in a GRSS, because the provider has already received Medicaid funding for the Home Health Services and is responsible for payment to the Home Health Agency.

Acute Home Health Services for Medicaid HMO Members are the responsibility of the Medicaid HMO, including Members who are also HCBS recipients.
Services for a dual eligible Member shall be submitted first to Medicare for reimbursement. All Medicare requirements shall be met and administrative processes exhausted prior to any dual eligible Member’s claims being billed to Medicaid, as demonstrated by a Medicare denial of benefits, except for the specific services listed in Section 8.520.0.E.4.a below for Members which meet the criteria listed in Section 8.520.9.E.4.b below.

a. A Home Health Agency may bill only Medicaid without first billing Medicare if both of the following are true:

i) The services below are the only services on the claim:

Pre-pouring of medications;
CNA services;
Occupational therapy services when provided as the sole skilled service; or 4) Routine laboratory draw services.

ii) The following conditions apply:

The Member is stable;
The Member is not experiencing an acute episode;
The Member routinely leaves the home without taxing effort and unassisted for social, recreational, educational, or employment purposes.

b. The Home Health Agency shall maintain clear documentation in the Member’s record of the conditions and services that are billed to Medicaid without first billing Medicare.

c. A Home Health Change of Care Notice or Advance Beneficiary Notice of Non-Coverage shall be filled out as prescribed by Medicare.

Services for a dually eligible long-term home health Member who has an acute episode shall be submitted first to Medicare for reimbursement.

Medicaid may be billed if payment is denied by Medicare as a noncovered benefit and the service is a Medicaid benefit, or when the service meets the criteria listed in Section 8.520.9.E.4 above.

If both Medicare and Medicaid reimburse for the same visit or service provided to a Member in the same episode, the reimbursement is considered a duplication of payment and the Medicaid reimbursement shall be returned to the Department.

a. Home Health Agencies shall return any payment made by Medicaid for such visit or service to the Department within 60 calendar days of receipt of the duplicate payment. 8.520.9.C. Reimbursement for Supplies 1. A Home Health Agency shall not ask a Member to provide any supplies. A request for supplies from a Member may constitute a violation of Section 8.012, providers prohibited from collecting payment from recipients.

Supplies other than those required for practice of universal precautions which are used by the Home Health Agency staff to provide Home Health Services are not the financial responsibility of the Home Health Agency.

Such supplies may be requested by the Physician or Allowed Practitioner as a benefit to the Member under Section 8.590, Durable Medical Equipment and disposable medical supplies.

Supplies used for the practice of universal precautions by the Member's Family/In-Home Caregiver are not the financial responsibility of the Home Health Agency. Such supplies may be requested by the Physician or Allowed Practitioner as a benefit to the Member under Section 8.590, Durable Medical Equipment and disposable medical supplies. 8.520.9.D. Restrictions 1. When the Member has Medicare or other third-party insurance, Home Health claims to Medicaid will be reimbursed only if the Member's care does not meet the Home Health coverage guidelines for Medicare or other insurance.
When an agency provides more than one employee to render a service, in which one employee is supervising or instructing another in that service, the Home Health Agency shall only bill and be reimbursed for one employee's visit or units.
Any visit made by a nurse or therapist to simultaneously serve two or more Members residing in the same household shall be billed by the Home Health Agency as one visit only, unless services to each Member are separate and distinct. If two or more Members residing in the same household receive Medicaid CNA services, the services for each Member shall be documented and billed separately for each Member.
In the event of limited resources for a Home Health Agency, two agencies may coordinate care and provide services to the same Member as long as there is no duplication of services on the same date(s) of service and the Home Health Agencies comply with the following:

a. The Home Health Agencies shall document the need and reason for two Home Health Agencies to render services to a Member.

b. The Home Health Agencies shall coordinate the Member’s Plan of Care and maintain the Plan of Care and documentation on all services rendered by each provider in the member’s records.

c. Each Home Health Agency shall obtain prior authorization, identify to the URC the coordinated Plan of Care and revise the PAR as needed to ensure coverage.

Improper Billing Practices: Examples of improper billing include, but are not limited to:

a. Billing for visits without documentation to support the claims billed.

Documentation for each visit billed shall include the nature and extent of services, the care provider's signature, the month, day, year, and the exact time in and time out of the Member's home.

Providers shall submit or produce requested documentation in accordance with rules at Section 8.076.2;

b. Billing for unnecessary visits, or visits that are unreasonable in number, frequency or duration;

c. Billing for CNA visits in which no skilled tasks were performed and documented;

d. Billing for skilled tasks that were not medically necessary;

e. Billing for Home Health Services provided at locations other than an eligible place of service, except EPSDT services provided with prior authorization; and f. Billing of personal care or homemaker services as Home Health 6. A Home Health Agency that is also certified as a personal care/homemaker provider shall ensure that neither duplicate billing nor unbundling of services occurs in billing for Home Health Services and HCBS personal care services. Examples of duplicate billing and unbundling of services include:

a. One employee makes one visit, and the agency bills Medicaid for a CNA visit, and also bills all of the hours as HCBS personal care or homemaker.

b. One employee makes one visit, and the agency bills for one CNA visit, and bills some of the hours as HCBS personal care or homemaker, when the total time spent on the visit does not equal at least 1 hour plus the number of hours billed for HCBS personal care and homemaker.

c. Any other practices that circumvent these rules and result in excess Medicaid payment through unbundling of CNA and personal care or homemaker services.

The Department may take action against the offending Home Health Agency, including termination from participation in Colorado Medicaid in accordance with Section 8.076. 8.520.10 Compliance Monitoring Reviews 8.520.10.A. General Requirements 1. Compliance monitoring of Home Health Services may be conducted by state and federal agencies, their contractors and law enforcement agencies in accordance with Section 8.076.
Home Health Agencies shall submit or produce all requested documentation in accordance with Section 8.076.
Physician or Allowed Practitioner -signed Plans of Care shall include nursing or therapy assessments, current clinical summaries and updates for the Member. The Plan of Care shall be on the CMS-485 Plan of Care, or a form that is of similar format to the CMS-485. All sections of the form shall be completed. All therapy services provided shall be included in the Plan of Care, which shall list the specific procedures and modalities to be used and the amount, duration and frequency.
Provider records shall document the nature and extent of the care actually provided.
Unannounced site visits may be conducted in accordance with Section 25.5-4-301(14)(b) C.R.S.
Home Health Services which are duplicative of any other services that the Member has received funded by another source or that the Member received funds to purchase shall not be reimbursed.
Services which total more than 24 hours per day of care, regardless of funding source shall not be reimbursed.
Billing for visits or contiguous units which are longer than the length of time required to perform all the tasks prescribed on the care plan shall not be reimbursed.
Home Health Agencies shall not bill Members or families of Member for any services for which Medicaid reimbursement is recovered due to administrative, civil or criminal actions by the state or federal government. 8.520.11 Denial, Termination, or Reduction in Services by the Home Health Agency 8.520.11.A. When services are denied, terminated, or reduced by action of the Home Health Agency, the Home Health Agency shall notify the Member. 8.520.11.B. Termination of services to Members still medically eligible for Coverage of Medicaid Home Health Services:
When a Home Health Agency decides to terminate services to a Member who needs and wants continued Home Health Services, and who remains eligible for coverage of services under the Medicaid Home Health rules, the Home Health Agency shall give the Member, or the Member's designated representative/legal guardian, written advance notice of at least 30 business days. The Physician or Allowed Practitioner and the Department’s Home Health Policy Specialist shall also be notified.
Written notice to the Member, or Member’s designated representative/legal guardian shall be provided in person or by certified mail and shall be considered given when it is documented that the recipient has received the notice. The notice shall provide the reason for the change in services 3. The agency shall make a good faith effort to assist the Member in securing the services of another agency.
If there is indication that ongoing services from another source cannot be arranged by the end of the advance notice period, the terminating agency shall ensure Member safety by making referrals to appropriate case management agencies or County Departments of Social Services; and the attending Physician or Allowed Practitioner shall be informed.
Exceptions will be made to the requirement for 30 days advance notice when the provider has documented that there is immediate danger to the Member, Home Health Agency, staff, or when the Member has begun to receive Home Health Services through a Medicaid HMO.

8.535 PEDIATRIC PERSONAL CARE SERVICES 8.535.1 Pediatric Personal Care Services are provided in accordance with the provisions of Appendix A, which sets forth the coverage standards for the benefit. 8.535.2 Pediatric Personal Care providers are required to comply with all Base Wage requirements established in Section 8.511.

8.540 PRIVATE DUTY NURSING SERVICES

8.540.1 DEFINITIONS

A. Designated Representative means a person appointed by the member to act on their behalf for healthcare and treatment decisions as documented in the member’s advanced healthcare directive or other comparable documentation.

B. Family/In-Home Caregiver means an individual who assumes a portion of the member’s care in the home in the absence of agency staff. A Family/In-Home Caregiver may either live in the member’s home or travel to the member’s home to provide care.

C. Group Nursing means the provision of Private Duty Nursing services by a Registered Nurse or Licensed Practical Nurse to more than one member at the same time in the same home or community-based setting.

D. Home Health Agency (HHA) means an agency or organization that is certified for participation as a Medicare Home Health provider pursuant to 42 U.S.C. § 1395bbb and licensed as a Class A provider as required by § 25-27.5-103(1), C.R.S.

E. Medical Necessity is as defined in Program Integrity rules at Section 8.076.1.8.

For children and youth under the age of 21, this is further defined to include the requirements set forth in the Early and Periodic Screening, Diagnosis, and Treatment rules at Section 8.280.1.

F. [Nurse Assessor Vendor means a third-party vendor contracted by the Department to complete the Skilled Care Acuity Assessment for specific skilled care services.]

G. [PDN Nursing Assessment means an individualized comprehensive assessment of a member that is completed by the HHA RN case coordinator. This assessment documents a member's health status by gathering subjective and objective data to understand a member’s needs and develop a plan of care/CMS Form 485. Additionally, for members receiving ongoing care, the responses to treatment and skilled interventions are included in the assessment documentation. PDN nursing assessments are done at admission and at 60-day intervals while under HHA care or at the change in member’s condition.} H. Physician or Allowed Practitioners means an enrolled physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) who oversees the delivery of skilled care to a member within their scope of practice as set forth at Colorado Revised Statutes, Title 25, Articles 240 or 255, as applicable.

I. Plan of Care (POC) means a completed Centers for Medicare and Medicaid Services (CMS) Form 485, also referred to as a care plan, developed by the HHA in consultation with the member, that has been ordered by the physician or allowed practitioner for the provision of services to a member at his/her residence or community setting, and is periodically reviewed and signed by the physician or allowed practitioner in accordance with Medicare requirements at 42 CFR § 484.60. The Department incorporates by reference 42 C.F.R. 438.60. [No amendments or later additions of this regulation are incorporated. Copies are available for inspection from the following person at the following address:

Custodian of Records, Colorado Department of Health Care Policy and Financing, 303 E. 17th Ave, Suite 1100, Denver, CO 80203.]

J. Private Duty Nursing (PDN) means medically necessary nursing services that are more individual and continuous care than is available under the Home Health benefit or routinely provided by the nursing staff of a hospital or skilled nursing facility, that allow a member to remain in their home or community-based setting.

K. Re-Hospitalization means any hospital admission that occurs after the initial hospitalization for the same condition.

L. [Skilled Care Acuity Assessment means the assessment that will be used to assess members for their skilled care needs. The Skilled Care Acuity Assessment will only be accepted as valid documentation when completed by the authorized Nurse Assessor Vendor. The Assessment was finalized on September 25, 2024 and is available at https://hcpf.colorado.gov/nurseassessor.]

M.. Skilled Nursing/Skilled Nursing Service means services provided under the licensure, scope, and standards of the Colorado Nurse and Nurse Aide Practice Act, § 12-255-101, C.R.S., performed by a registered nurse (RN) under the direction of a physician or allowed practitioner, or a licensed practical nurse (LPN) under the supervision of a RN and the direction of a physician or allowed practitioner, for care that cannot be delegated by the judgment of the RN or LPN.

N.. Technology Dependent means the daily use of medical devices or procedures to maintain a bodily function without which adverse health consequences creating further disability, hospitalization or death could likely follow.

O.. Utilization Review Contractor (URC) means a third-party vendor contracted by the Department to perform utilization management functions for specific services.

8.540.2 CRITERIA FOR SERVICES 8.540.2.A To receive PDN services, a member must receive an approved PAR as set forth in Section 8.540.6 and satisfy the following criteria:

The member is able to be safely served in their home or community setting by a HHA under the agency requirements and limitations of the PDN benefit and with the staff services available.
The member is not residing in a nursing facility or hospital at the time PDN services are delivered.
The member has previously been determined to be eligible for the medical assistance program pursuant to Section 8.100.
The member meets one of the following criteria:

a. Members aged 21 years or older who demonstrate medical necessity for Skilled Nursing Services in accordance with Section 8.076.1.8, are technology dependent, and for whom a delay in skilled nurse-level interventions would result in deterioration of a chronic condition, loss of function, imminent risk to health status due to medical fragility or risk of death.

b. Members under the age of 21 who demonstrate medical necessity in accordance with Early and Periodic Screening, Diagnostic, and Treatment benefits requirements at Section 8.280.4.E.

i. Members under the age of 21 shall require skilled nursing assessment, intervention, and evaluation of both equipment (if applicable) and member.

ii. The services provided shall be medical in nature, safe, effective, generally recognized as an accepted method of treatment, not experimental/investigational, cost-effective, necessary for care of a member's condition, and within accepted standards of nursing practice.

8.540.3 BENEFITS 8.540.3.A All PDN services require prior authorization as set forth in Section 8.540.6- 7.

The ongoing need for PDN care shall be re-evaluated annually, at a minimum, or when necessary due to a change in the member’s condition.

The Department, in coordination with the URC, determines the number of PDN hours based on documented medical necessity. PDN hours may be increased or reduced when necessitated by a change in the member’s condition as documented in the member’s medical record.

Authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Reimbursement for PDN claims requires that the member have active coverage on the date of service. Submitted claims shall comply with current billing policies effective on the date of service as set forth in the Home Health Billing Information Manual.
A member’s need for skilled nursing care is determined based solely on their unique condition and individual needs at the time the services were ordered and what was, at that time, expected to be appropriate treatment throughout the certification period, whether the illness or injury is acute, chronic, terminal, stable, or expected to extend over a long period.
Authorized PDN hours shall be used only to meet the medically necessary needs as described in the POC and approved prior authorization request (PAR). 8.540.3.B Pediatric members under the age of 21 may be approved for up to 24 hours per day of PDN services if the member meets the URC medical necessity criteria defined at Section 8.540.1.E. 8.540.3.C Adult members aged 21 or older may be approved up to 23 hours per day of PDN services if the member meets medical necessity criteria defined at

Section 8.540.1.E. 8.540.3.D A member may be eligible for a short-term increase in PDN services for a change of condition. The HHA shall apply for additional hours through a revision to the original PAR. 8.540.3.E A member who is eligible and authorized to receive PDN services in the home may receive care outside the home during those hours when the member’s activities of daily living take him or her away from the home. The total hours authorized shall not exceed those that would have been authorized if the member received all care in the home.

8.540.4 BENEFIT LIMITATIONS 8.540.4.A A member who meets both the eligibility requirements for PDN and home health shall be allowed to choose whether to receive care as either a PDN or Home Health benefit. The member may choose a combination of the two benefits if the care is not duplicative and the resulting combined care does not exceed the medical needs of the member. 8.540.4.B Total hours of PDN services shall not exceed what has been determined medically necessary by the URC and ordered by the physician or allowed practitioner. 8.540.4.C PDN services shall not be authorized under the following circumstances:

The services consist of assistance with activities of daily living or other non-skilled services.
The physician’s or allowed practitioner’s treatment plan does not identify the need for skilled nursing.
The services consist of observation or monitoring for medical conditions not requiring skilled nursing assessment and intervention, as documented in the physician’s or allowed practitioner’s treatment plan and/or nursing notes.
The PDN services are used solely for the convenience of the member or other caregiver.
The services are custodial or stand-by care to ensure compliance with treatment.
The services are intended for other members of the household who are not receiving approved, group PDN services.
The services are duplicative of care covered by another benefit or funding source.

8.540.4.D HOSPITAL DISCHARGE PROCEDURES

The hospital discharge planner shall plan for the member’s hospital discharge by coordinating with the HHA to:

a. Arrange services with the HHA, medical equipment suppliers, counselors and other healthcare service providers as needed.

b. Coordinate a safe home care plan in conjunction with the physician or allowed practitioner and the HHA that meets program requirements.

c. Advise the HHA of any changes in medical condition and care needs.

d. Ensure that the member, family and caregivers are educated about the member’s medical condition and trained to perform the home care in the absence of HHA staff.

8.540.5 PROVIDER AND FAMILY REQUIREMENTS 8.540.5.A. Provider Eligibility 1. HHA services shall be provided by an HHA certified for participation pursuant to 42 U.S.C. § 1395bbb and licensed as a Class A provider pursuant to § 25-27.5-103(1), C.R.S.

All Home Health Agency providers shall comply with applicable regulations promulgated by the Board of Health, Medical Services Board, Medical Board, Nursing Board, Department of Labor and Employment, and the Centers for Medicare and Medicaid Services. 8.540.5.B Provider Agency Requirements 1. An HHA shall:

a. Be certified for participation as a Medicare Home Health provider pursuant to 42 U.S.C. § 1395bbb and licensed as a Class A provider as required by § 25-27.5-103(1), C.R.S.;

b. Be a Colorado Medicaid enrolled provider;

c. Maintain liability insurance for the minimum amount set annually as set forth at 6 CCR 1011-1, Chapter 26, Section 4.2. [The Department incorporates by reference 6 CCR 1011-1, Chapter 26,

Section 4.2. No amendments or later additions of this regulation are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 303 E. 17th Ave, Suite 1100, Denver, CO 80203;] and d. Hold a State of Colorado Class A Home Care Agency license in good standing.

Home Health Agencies that perform tests in the member's home that are identified as eligible for a Clinical Laboratory Improvement Amendments (CLIA) waiver pursuant to 42 C.F.R. § 493.15 shall possess a certificate of waiver from CMS or its Designee. [The Department incorporates by reference 42 C.F.R. 493.15. No amendments or later additions of this

regulation are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 303 E. 17th Ave, Suite 1100, Denver, CO 80203.]

A HHA shall not discontinue or refuse services to a member unless documented efforts have been made per agency policies to resolve the situation that triggers the discontinuation or refusal. The HHA shall provide at least 30 calendar days advance notice to the member or the member’s designated representative.
In the event an HHA ceases operations, it shall notify the Department within 30 calendar days. The notification shall be submitted through the Provider Portal as a maintenance application for the disenrollment request. The provider shall also email the notice to the Department at the designated Home Health email inbox. 8.540.5.C. Provider Responsibilities 1. A certified HHA that provides PDN services shall meet all of the following:

a. Employ nursing staff nursing staff licensed to practice in Colorado pursuant to the Nurse and Nurse Aide Practice Act, § 12-255-101, C.R.S. that possess education and experience in providing care to individuals who require skilled nursing care in a home or community-based setting in accordance with HHA policy, state practice acts, and professional standards of practice b. Employ nursing personnel with documented skills, training and/or experience appropriate for the member’s individualized needs and care requirements, including cultural and disability competency.

c. Provide appropriate nursing skills orientation and ongoing inservice education to nursing staff to meet the member’s specific nursing care needs.

d. Require nursing staff to complete cardiopulmonary resuscitation (CPR) instruction and certification at least every two years.

e. Provide adequate supervision and training for all nursing staff as required by the agencies listed in Section 8.540.5.A.2. To be reimbursed for time billed, nursing staff shall be engaged in an activity that directly benefits the member receiving services. Staff shall be physically able and mentally alert to carry out the duties of the job.

f. Coordinate services with a supplemental certified HHA, if necessary, to meet the staffing needs of the member.

g. Designate a case coordinator who is responsible for the management of private duty nursing services, h.[ Ensure that members have a current Skilled Care Acuity Assessment or, if there is not a current assessment, make timely referral to the Nurse Assessor for an assessment.]

i. Develop the individualized care plan by completing the PDN [N]{}ursing [A]{}ssessment and obtaining information from the attending physician or allowed practitioner and the primary caregiver.

j. For members discharging from a hospital, include information from the discharge planner in the care planning process.

k. Assess the home prior to the initial start of services or hospital discharge and on an ongoing basis for safety compliance.

l. Involve the member and Family/In-Home Caregiver in the plan for home care and the provision of home care.

m. Assist the member to reach maximum independence.

n. Communicate changes in the member’s status with the physician or allowed practitioner and the URC on a timely basis, including changes in medical conditions and/or psychological/social situations that may affect safety and home care needs, and revise the PAR if a change in services is required to meet the member’s changed needs.

o. Assist with communication and coordination between the service providers supplementing the primary HHA, the primary care physician or allowed practitioner, specialist(s) and the primary HHA as needed.

p. Make regular on-site visits according to HHA policies and procedures and professional standards of practice to monitor the safety and quality of home care and make appropriate referrals to other agencies for care as necessary.

q. Ensure that a complete and current care plan prepared within the prior 60 days and nursing chart are in the member’s home at all times. The nursing chart shall include interim physician or allowed practitioner orders, current medication orders and nursing notes.

Records of treatments and interventions shall clearly show compliance with the care plan.

r. Communicate with the Case Management Agency and/or Regional Accountability Entity as needed regarding service planning and coordination.

s. Make and document the efforts made to resolve any situation that triggers a discontinuation of or refusal to provide services prior to 8.540.5.D. Family/In-Home Caregiver Responsibilities 1. The HHA shall inform the member and their Family/In-Home Caregiver of the following responsibilities for PDN services and ensure that the caregiver:

a. Is able to assume some portion of the member’s care when agency staff is not available.

b. Has the specific skills necessary to care for the member.

c. Has completed CPR instruction or certification and/or training specific to the member’s emergency needs prior to providing PDN d. Is able to maintain a home environment that allows for safe home care, including a plan for emergency situations.

e. Participates in the planning, implementation, and evaluation of PDN f. Communicates changes in care needs and any problems to health care providers and physicians or allowed practitioners as needed.

g. Works toward the member’s maximum independence, including finding and using alternative resources as appropriate.

h. Has notified power companies, fire departments and other pertinent agencies of the presence of a person relying on skilled nursing in the household. 8.540.5.E. Environmental Requirements 1. Prior to providing PDN services, the HHA shall perform an in-home assessment and document that the home meets the following safety requirements:

a. Adequate electrical power, including a backup power system.

b. Adequate space and ventilation for equipment and supplies.

c. Adequate fire safety and adequate exits for medical and other emergencies.

d. A clean environment to the extent that the member’s life or health is not at risk.

e. A working phone available 24 hours a day. 8.540.5.F. Physician or Allowed Practitioner Role 1. The HHA shall coordinate with the member’s attending physician or allowed practitioner to:

a. Determine that the member is medically stable, except for acute episodes that may be managed by PDN services, and that the member may be safely served within the requirements and limitations of the PDN benefit.

b. Cooperate with the URC in establishing medical eligibility.

c. Prescribe a POC at least every 60 days.

d. Coordinate with any other physician(s) or allowed practitioner(s) treating the member.

e. Communicate changes in the member’s medical condition and care, including discharge from the hospital.

f. Empower the member and the Family/In-Home Caregiver by working with them to maximize the member’s independence.

8.540.6 PRIOR AUTHORIZATION PROCEDURES 8.540.6.A A PAR is required for all PDN services. Prior authorization is a request for medically necessary services, based on the needs of the member. The presence of additional members in the home shall not impact the individual member’s medical necessity determination. 8.540.6.B The PAR may be approved for up to six months for a new member and up to one year for ongoing care. 8.540.6.C The PAR shall include the following:

[A current Skilled Care Acuity Assessment completed by the Nurse Assessor. The assessment results are one component to be used to determine medical necessity but do not independently determine whether the requested services are medically necessary.]
A current POC on CMS Form 485, or form of similar format, that summarizes health conditions, specific care needs, and current treatments, signed by the physician or allowed practitioner or a documented verbal order. The POC shall include:

a. A signed PDN Nursing Assessment, a current clinical summary or 60-day summary of care, orders for all disciplines and treatments signed by the physician or allowed practitioner, and goals of care/rehabilitation potential, if applicable.

b. A current diagnosis list and medication list including PRN medications.

c. A documented process by which the member receiving services and support may continue to receive necessary care, which may include backup care, if the member’s Family or In-Home Caregiver is unavailable due to an emergency situation or unforeseen circumstances. The Family or In-Home Caregiver shall be informed of the alternative care provisions at the time the individual plan is initiated.

d. A hospital discharge summary if there has been a hospitalization since last PAR.

Identification of professional disciplines supporting the medical needs of the member in the home and responsible for the delivery of care. If care overlaps, documentation shall identify overlapping care and the rationale for the overlap.
For new members approved for PDN directly upon discharge from the hospital, a copy of the transcribed verbal physician or allowed practitioner orders may be substituted for the POC.
Documentation submitted shall include sufficient information to demonstrate the medical necessity of Skilled Nursing Services. The number of hours authorized may differ from the number of hours requested based on the clinical review of the request and supporting documentation. The HHA shall not misrepresent or omit facts in a treatment plan.
If a member’s condition necessitates a change in PDN hours, the HHA shall submit a PAR revision request within 10 business days of a change.

The revision may be an increase or a decrease in hours. Discharge notification is also required within 10 business days via a PAR revision request.

In the event a member changes provider agencies, the receiving HHA shall submit a Change of Provider Form and POC to the URC within 10 business days of starting PDN services.
In the event of limited nursing resources for a HHA, two HHAs may coordinate care and provide services to the same member as long as there is no duplication of services on the same date(s) of service and the HHAs comply with the following:

a. The HHAs shall document the need and reason for two HHAs to render services to a member.

b. The two HHAs shall coordinate the member’s POC and maintain the POC and documentation on all services rendered by each PDN Provider in the member’s records.

c. Each HHA shall obtain prior authorization, identify to the URC the coordinated POC and revise the PAR as needed to ensure coverage.

8.540.7 UTILIZATION REVIEW 8.540.7.A Providers shall submit requests for prior authorization of PDN services directly to the URC within 10 business days of starting PDN services. Incomplete requests shall be held in pending status for up to 10 business days for the provider to submit additional, required information. 8.540.7.B The criteria for approval of PDN services are based upon the submission of records that demonstrate the skilled nature of the nursing care needed, including physician and/or allowed practitioner records, specialty notes, and nursing notes. The URC shall review requests for prior authorization according to the information submitted and the application of the medical criteria as described herein.:

The URC shall consider combinations of technologies and co-morbidities when making medical determinations that would qualify the member for care pursuant to EPSDT exceptions to benefit limits and coverage standards. The medical judgment of the attending physician or allowed practitioner and the URC shall be used for an individual determination whenever the medical criteria are not defined by specific measurements.
Within 10 business days of receipt of the complete PAR, the URC shall approve or deny the PAR or refer the PAR to the URC physician reviewer.
The URC shall process the physician review referrals and approve, partially approve, or deny the PAR within 10 business days of referral to the physician reviewer. 8.540.7.C The URC shall issue written notification of all PAR denials, including a member’s appeal rights, to the member or member’s designated representative and the submitting provider within one business day of the determination.
The HHA may request reconsideration by the URC if the PAR is only partially approved or is denied. The HHA also may request a Peer-to-Peer review if the ordering physician or allowed practitioner agrees.
Services provided during the period between the provider’s submission of the PAR to the URC through the final approval or denial by HCPF may be approved for payment. Payment may be made retroactive to the start date on the PAR form or for up to 30 calendar days prior to PAR approval, whichever is shorter.
When a PAR determination results in the reduction or termination of services, services shall be approved for 30 additional calendar days after the date on the member’s notice of denial letter. If the termination or reduction of PDN services is appealed by the member in accordance with

Section 8.057.5, services shall be maintained at the previously approved level for the duration of the appeal until the final agency action is rendered.

For appeals of an initial PAR denial, continuation of benefits is not applicable. 8.540.7.D Expedited PAR reviews may be requested in situations where adhering to the time frames above would seriously jeopardize the member’s life or health.

8.540.8 REIMBURSEMENT 8.540.8.A No skilled services shall be authorized or reimbursed if the skilled hours of service, regardless of funding source, total more than 24 hours per day for members under the age of 21 and no more than 23 hours per day for members aged 21 or older. 8.540.8.B No services shall be reimbursed if the care is duplicative of care that is being reimbursed under another benefit or funding source, including but not limited to home health or other insurance. 8.540.8.C Approval of the PAR by the URC shall authorize the HHA to submit claims to the Medicaid fiscal agent for authorized PDN services provided during the authorized period. Payment of claims is conditioned upon the member’s benefit eligibility on the date of service and the provider's use of correct billing 8.540.8.D No services shall be reimbursed for dates of service prior to the PAR start date as authorized by the URC, except as provided in Section 8.540.7.C.2. 8.540.8.E Skilled Nursing services provided as a PDN benefit shall be reimbursed in units of one hour at the lesser of the provider’s usual and customary charge or the maximum Medicaid allowable rates established by HCPF.

Units of one hour may be billed for RN or LPN.
The RN group rate shall be utilized when a registered nurse is providing PDN services to more than one member at the same time in the same setting.
The LPN group rate shall be utilized when a licensed practical nurse is providing PDN services to more than one member at the same time in the same setting.
The blended RN/LPN rate shall be requested by the HHA when utilizing an RN or LPN as the assigned staff for more than one member at the same time in the same setting.
PDN services may be provided by a single nurse to an individual or to multiple individuals in a non-institutional group setting as described above.

The nurse-member ratio shall not exceed what is required for one licensed nurse to safely care for each member simultaneously, based on member acuity and the availability of additional support in the home. 8.540.8.F Reimbursement shall not be allowed at any time when nursing staff is sleeping during the provision of PDN services. 8.540.8.G No individual nurse shall be reimbursed for over 16 hours of care per day, except in a documented emergency situation. 8.545 Health-Related Social Needs Health-Related Social Needs (HRSN) are covered under a Section 1115 demonstration waiver approved by the federal Centers for Medicare and Medicaid Services (CMS).

HRSN benefits are covered when CMS approves or continues the waiver. HRSN benefits are not covered if the waiver is not approved or continued. 8.545.1.A Definitions 1. Behavioral Health Need means a diagnosed behavioral health disorder, according to the criteria of the current editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases and Related Health Problems where there is a need for improvement, stabilization, or prevention of deterioration of functioning (including ability to live independently without support) resulting from the presence of a behavioral health condition.

Billing Manual, for the purposes of Section 8.545, means a reference document that assists providers with appropriately billing claims for Health-Related Social Needs.
Chronic Health Condition means one or more chronic conditions including but not limited to those identified in Social Security Act section 1945(h)(2).
Home Delivered Meals means receipt of prepared hot foods, meal kits, or restaurant meals to members who require additional food support. This service may be provided in place of pantry stocking for members who do not have a place to store or prepare groceries.
Medically Tailored Meals means meals to support improved health outcomes are available to eligible members not receiving pantry stocking or home-delivered meals in accordance with section 8.545.4.G. Medically Tailored Meal services include: Preparation, provision, and delivery of prescribed meals, consistent with a nutrition care plan. Limited to three (3) meals per day for a maximum of six (6) months.
Nutrition Counseling means any combination of educational strategies designed to motivate and facilitate voluntary adoption of food choices and other food and nutrition-related behaviors conducive to health and wellbeing.
One-Time Transition and Moving Costs means move-in costs as well as furnishings and other items necessary to make new housing habitable and comfortable.
Pantry Stocking means services which allow a member to purchase an assortment of foods aimed at promoting improved nutrition for the member. For members who do not have the means to prepare or store groceries, members may pick up food from a food retailer or have food delivered to the member’s home or private residence, if delivery service is available 9. Pre-Tenancy Supports and Housing Transition Navigation Services means assisting members to locate, move into, and maintain housing.
Rent and Temporary Housing means rent payments for apartments, single room occupancy (SRO) units, single-family homes, multi-family homes, mobile home communities, accessory dwelling units (ADUs), co-housing communities, middle housing types, trailers, manufactured homes, manufactured home lots, motel or hotel when it is serving as the member’s primary residence, transitional and recovery housing, including bridge, site-based, population-specific, and community living programs that may or may not offer supportive services and programming.
Targeted Case Management means services are limited to service planning, advocacy, and linkage to other appropriate medical services related to identified member needs, monitoring, and care coordination 12. Tenancy-Sustaining Services means assisting members with maintaining housing. 8.545.2 Member Eligibility 8.545.2.A. A Health First Colorado (Colorado Medicaid) member is eligible for Health- Related Social Needs (HRSN) services if they meet one of the social risk factors in section 8.545.2.A.1.a-.b and the clinical criteria for one of the populations in sections 8.545.2.A.2.a-.c.
Social risk factors:

a. “Homeless” or “At Risk of Homelessness” as defined at 24 C.F.R. § 91.5 (2020) which is hereby incorporated by reference. The incorporation of 24 C.F.R. § 91.5 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at (address), Denver, CO, 80203.

Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at ecfr.gov.

b. “Nutrition Insecurity”, which qualifies as either low or very low food security, as defined at 24 C.F.R. § 91.5 (2020) which is hereby incorporated by reference. The incorporation of 24 C.F.R. § 91.5 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at (address), Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at ecfr.gov.

Clinical criteria:

a. Permanent Supportive Housing (PSH) population must meet one of the following clinical criteria:

i. Behavioral Health Need as defined in section 8.545.1.A.1.

ii. Chronic Health Condition as defined in section 8.545.1.A.3.

Clinical criteria are initially determined through selfdisclosure of a behavioral health need or chronic health condition through the HMIS Coordinated Entry referral process. Supportive Housing Providers must establish policies and procedures regarding the confirmation of an eligible diagnosis to be kept on file by the agency.

b. Colorado Fostering Success (CFS) Housing population must meet the following clinical criteria:

i. Clinical criteria are determined through self-disclosure of a Behavioral Health Need or Chronic Health Condition during the initial screening.

ii. While not a requirement of the CFS program, individuals who qualify for CFS may be screened for Health-Related Social Needs (HRSN) criteria, including assessment for clinical care, and if HRSN criteria are met and clinical need is determined by a clinician, the member would be eligible to enroll as an HRSN services recipient.

c. Community access team vouchers (CAT) population must meet the following clinical criteria:

i. Eligible for and receiving targeted case management for transition coordination services (TCM-TC) as defined at 8.519.27.A.13. 8.545.2.B. Service Eligibility Requirements:

Members eligible for Pre-Tenancy Supports and Housing Transition Navigation Services must have been matched to a permanent supportive housing voucher within the last twelve (12) months (PSHa), or be eligible for permanent supporting housing but not matched to a voucher (PSHb), or in the CFS voucher program. Eligibility for Pre-Tenancy Supports and Housing Transition Navigation Services must not be dependent on the receipt of other HRSN services.
Members eligible for One-Time Transition and Moving Costs must have been matched to a permanent supporting housing voucher within the last twelve (12) months (PSHa) or be in the Colorado Fostering Success Housing (CFS) voucher program. Eligibility for One-Time Transition and Moving Costs must not be dependent on the receipt of other HRSN 3. Members eligible for housing deposits and fees to secure housing must have been matched to a permanent supporting housing voucher within the last twelve (12) months (PSHa) or be in the Colorado Fostering Success Housing (CFS) voucher program. Eligibility for Housing Deposits and Fees to Secure Housing must not be dependent on the receipt of other HRSN 4. Members eligible for Tenancy-Sustaining Services must have been residing in a permanent supporting housing for more than one (1) year (PSHc) or be eligible for a community access team voucher (CAT).

Eligibility for Tenancy-Sustaining Services must not be dependent on the receipt of other HRSN services.

Members eligible for Nutrition Counseling must have been matched to a permanent supporting housing voucher within the last twelve (12) months (PSHa), must have been residing in a permanent supporting housing for more than one (1) year (PSHc), be eligible for a community access team voucher (CAT), or be in the Colorado Fostering Success Housing (CFS) voucher program. Eligibility for Nutrition Counseling must not be dependent on the receipt of other HRSN services.
Members eligible for Medically Tailored Meals must have been matched to a permanent supporting housing voucher within the last twelve (12) months (PSHa), have lived in permanent supporting housing for more than a year (PSHc), or be in the Colorado Fostering Success Housing (CFS) voucher program. Eligibility for Medically Tailored Meals must not be dependent on the receipt of other HRSN services.
Members eligible for Home-Delivered Meals or Pantry Stocking must have been matched to a permanent supporting housing voucher within the last twelve (12) months (PSHa), be eligible for a community access team voucher (CAT), or be in the Colorado Fostering Success Housing (CFS) voucher program. Eligibility for Home-Delivered Meals or Pantry Stocking must not be dependent on the receipt of other HRSN services.
Members eligible for Targeted Case Management must have been determined eligible for HRSN services. 8.545.3 Provider Eligibility 8.545.3.A. The following providers enrolled with Health First Colorado are eligible to provide Health-Related Social Needs services. Provider eligibility requirements listed below must be documented by the provider and available upon request:
Voucher Administrator and Housing Program providers rendering Rent and Temporary Housing services must:

a. Have the ability to provide housing services benefit;

b. Be knowledgeable of covered housing services;

c. Have experience with homeless services, community based mental health services, and, or, other housing sectors;

d. Have knowledge of safety tactics for individuals at risk of victimization or violence;

e. Have knowledge and understanding of housing best practices (Housing First, Trauma Informed Care, and Harm Reduction); and, f. Be a current Department of Housing (DOH) contracted Voucher Administrator agency or have a letter of commitment from a current DOH contracted Voucher Administrator agency.

Housing Program Providers rendering Pre-Tenancy Supports, Housing Transition Navigation Services and Tenancy-Sustaining Services must:

a. Be able to address the demand for services in their geographic area;

b. Have project planning skills, community engagement experience, involvement with peers, persons with , lived experience and experience providing high quality supports to persons experiencing homelessness;

c. Have knowledge of Tenancy-Sustaining Services (TSS), or comparable services meant to support individuals in obtaining and maintaining stable housing;

d. Must provide quality services as evidenced by deficient free audit or compliance with a plan of action; and, e. Must employ or contract with a licensed clinician to serve as the rendering provider overseeing the delivery of services by unlicensed professionals.

Nutrition Program Providers rendering Nutrition Counseling, medically tailored meals, and home-delivered meals or pantry stocking must:

a. Have knowledge of principles, methods, and procedures of covered nutrition services;

b. Have evidence-based guidelines; and, c. Have knowledge of food safety standards and experience with person-centered culturally appropriate dietary preferences.

Case Managers rendering targeted case management for HRSN services must:

a. Have a bachelor’s degree, or at least three (3) years of relevant experience appropriate to the requirements of the position; and, b. Have the following training:

i. Training in social, cultural, educational, economic and health-related factors which affect an individual;

ii. Training on person-centered planning;

iii. Training in interpersonal communication skills;

iv. Training in crisis intervention strategies;

v. Training on relevant agency policies and procedures; and, vi. Training on relevant state and federal laws. 8.545.4 Covered Services 8.545.4.A. Rent and Temporary Housing for up to six (6) months 1. Rent and Temporary Housing includes the following services:

a. Reimbursement for room (without board) for a short-term period, not to exceed six (6) total months within a five (5) year period.

b. Allowable units for housing must provide access to a clean and healthy environment with a private, semi-private, or shared room; a personal bed for the entire day; and no more than three roommates.

c. Allowable payments and fees include rent payment (past due and, or, forward rent), storage fees, renter’s insurance, and utilities.

Payments must only be provided in connection with dwellings that meet maintenance regulation code within the local jurisdiction for safety, sanitation, and habitability.
Rent and Temporary Housing is not eligible for:

a. Dormitories.

b. Congregate sleeping space.

c. Facilities that have been temporarily converted to shelters. For example, gymnasiums or convention centers.

d. Facilities in which sleeping spaces are not available to residents twenty-four (24) hours a day.

e. Facilities without private sleeping space. 8.545.4.B. Pre-Tenancy Supports and Housing Transition Navigation Services 1. Pre-Tenancy Support and Housing Transition Navigation services may include the following services:

a. Coordinating transportation to ensure access to housing options, which includes but is not limited to looking for housing, transportation to sign the lease, and obtaining required documents like identification and voucher paperwork.

b. Functional needs assessment.

c. Assistance with social services connection.

d. Individualized community integration plan.

c. Person-centered care planning with supports and interventions.

d. Housing search, which includes:

i. Identifying housing needs and preferences.

ii. Addressing any existing housing barriers.

iii. Applying for income supports, including completing an assessment in vocational rehabilitation and other employment opportunities.

iv. Information and referral to resources that can help address housing barriers (including legal barriers).

v. Connection to supports and services aiding the member in maintaining housing.

e. Application assistance, which includes:

i. Helping fill out applications and collecting accompanying documents (including funding to obtain documents, if needed).

ii. Helping submit housing applications (including associated fees) and applications for resources that help stabilize housing. 8.545.4.C. One-Time Transition and Moving Costs 1. One-Time Transition and Moving Costs include:

a. Unresolved arrearages (up to 6 months of combined arrears and prospective payments), if necessary, to set up services in new residence.

b. Relocation expenses.

c. Basic household goods and furniture, which may include appliances necessary for food consumption, bedding, furnishings, cribs, bathroom supplies, and cleaning supplies.

d. Security deposits.

e. First month’s rent is a one time moving cost, which counts towards the six month limitation on rent payments.

f. Movers.

g. Furnishings, and other items necessary to make new housing habitable and comfortable.

i. Transitional housing goods must not exceed the limits listed in the Billing Manual. 8.545.4.D. Tenancy-Sustaining Services 1. Tenancy-Sustaining Services include:

a. Providers assist members with maintaining housing including:

i. Landlord relationships ii. Community relationships iii. Lease renewals and payments 1. Assist enrollees to access benefits, negotiate with landlords, seek legal assistance, apply for new housing (if needed), or take other actions to help stabilize an enrollee’s housing situation.

Review, update, and modify preferences with the member to reflect current needs and preferences, and address existing or recurring housing retention barriers 3. Apply for income supports and housing that are aligned with the enrollee’s identified needs and preferences, including completing an assessment in vocational rehabilitation or other employment opportunities 4. Provide information and referrals to resources in the community to address identified housing issues, such as referrals to: Legal assistance organizations, Local housing quality enforcement agencies and funding sources for home improvements iv. Housing stabilization, including life skills needed to adjust to community-based housing.
Ensure the enrollee makes timely rent payments (e.g., connect the enrollee to money management services)
Provide coaching on life skills needed to adjust to community-based housing 3. Provide education and training on appropriate tenant behaviors 4. Provide referrals to community-based organizations, as needed, for ongoing housing stabilization services 5. Mediation and negotiations to sustain a tenancy such as those below:

a. Mediating with the landlord (or landlord’s designee)

b. Assisting in submitting a request for a reasonable accommodation c. Establishing a payment plan with the landlord (or landlord's designee) or bank 8.545.4.E. Targeted Case Management 1. Targeted case management refers to coordination and planning services provided with, or on behalf of, a member.

a. The member does not need to be physically present for this service to be performed if it is done on the member’s behalf.

Targeted case management services are limited to service planning, advocacy, and linkage to other appropriate medical services related to identified member needs, monitoring, and care coordination 3. A unit of service equals one 15-minute increment of targeted case management and consists of at least one documented contact with a member or person acting on behalf of a member, identified during the case planning process. 8.545.4.F. Nutrition Counseling 1. Nutrition Counseling Services include any combination of educational strategies designed to motivate and facilitate voluntary adoption of food choices and other food and nutrition-related behaviors conducive to health and well-being. 8.545.4.G. Pantry Stocking and Home Delivered Meals 1. Pantry stocking services allow a member to purchase an assortment of foods aimed at promoting improved nutrition for the member. For members who do not have the means to prepare or store groceries, members may pick up food from a food retailer or have food delivered to the member’s home or private residence, if delivery service is available.

a. Must be consistent with the nutrition care plan developed by the member’s Nutrition Program Provider.

Pantry stocking is limited to up to 30 days of food.

b. Limited to three (3) meals per day for a maximum of six (6) months.

Home-delivered meals include receipt of prepared hot foods, meal kits, or restaurant meals for members who require additional food support. This service may be provided in place of pantry stocking for members who do not have a place to store or prepare groceries.

a. Must be consistent with the nutrition care plan.

b. Limited to three (3) meals per day for a maximum of six (6) months. 8.545.4.H. Medically Tailored Meals 1. Medically tailored meals to support improved health outcomes are available to eligible members not receiving pantry stocking or homedelivered meals in accordance with section 8.545.4.G. Medically Tailored Meal services include:

a. Preparation, provision, and delivery of prescribed meals, consistent with a nutrition care plan.

b. Limited to three (3) meals per day for a maximum of six (6) months. 8.545.5 Reimbursement 8.545.5.A. Health First Colorado Providers 1. Eligible Health First Colorado (Colorado Medicaid) providers shall be reimbursed according to the number of units billed pursuant to the corresponding Billing Manual.

8.550 HOSPICE BENEFIT

8.550.1 DEFINITIONS

A. Alternative Care Facility (ACF) means an assisted living residence that is enrolled as a Medicaid provider.

B. Assisted Living Residence means an assisted living residence as defined in 6 CCR 1011-1 Chapter 7.

C. Benefit Period means a period during which the Client has made an Election to receive hospice care defined as one or more of the following:

An initial 90-day period.
A subsequent 90-day period.
An unlimited number of subsequent 60-day periods.

The periods of care are available in the order listed and may be Elected separately at different times.

D. Certification means that the Client’s attending physician and/or the Hospice Provider’s medical director have affirmed that the Client is Terminally Ill.

E. Client Record means a medical file containing the Client’s Election of Hospice, eligibility documentation, and other medical records.

F. Department means the Colorado Department of Health Care Policy and Financing. The Department is designated as the single state Medicaid agency for Colorado, or any divisions or sub-units within that agency.

G. Election/Elect means the Client’s written expression to choose Hospice care for Palliative and Supportive Medical Services. Home Care Services means Hospice Services that are provided primarily in the Client’s home but may be provided in a residential facility and/or licensed or certified health care facility.

H. Hospice means a centrally administered program of palliative, supportive, and Interdisciplinary Team services providing physical, psychological, sociological, and spiritual care to Terminally Ill Clients and their families.

I. Hospice Provider means a Medicaid and Medicare-certified Hospice provider.

J. Hospice Services means counseling, certified nurse aide, personal care worker, homemaker, nursing, physician, social services, physical therapy, occupational therapy, speech therapy, and trained volunteer services.

K. Interdisciplinary Team means a group of qualified individuals, consisting of at least a physician, registered nurse, clergy, counselors, volunteer director or trained volunteers, and appropriate staff who collectively have expertise in meeting the special needs of Hospice Clients and their families.

L. Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) means a care facility which is designed, and functions, to meet the needs of four or more individuals with developmental disabilities, or related conditions, who require twenty-four-hour active treatment services.

M. Medical Necessity or Medically Necessary is defined in Section 8.076.1.8.

N. Palliative and Supportive Medical Services means those services and/or interventions which are not curative, but which produce the greatest degree of relief from the symptoms of the Terminal Illness.

O. Room and Board includes a place to live and the amenities that come with that place to live, including but not limited to provision of:

Meals and additional nutritional requirements, as prescribed;
Performance of personal care services, including assistance with activities of daily living;
Provision of social activities;
Equipment necessary to safely care for the Client and to transport the Client, as necessary;
Administration of medication;
Maintenance of the cleanliness of a Client’s room; and 7. Supervision and assistance in the use of durable medical equipment and prescribed therapies.

P. Terminally Ill/Terminal Illness means a medical prognosis of life expectancy of nine months or less, should the illness run its normal course.

8.550.2 INITIATION OF HOSPICE 8.550.2.A. Certification The Hospice Provider must obtain Certification that a Client is Terminally Ill in accordance with the following procedures:

For the first Benefit Period of Hospice coverage or re-Election following revocation or discharge from the Hospice benefit, the Hospice Provider must obtain:

a. A written Certification signed by either the Hospice Provider’s medical director or the physician member of the Interdisciplinary Team and the Client's attending physician. The written Certification must be obtained and placed in the Client Record within two calendar days after Hospice Services are initiated. The written Certification must include:

i) A statement of the Client’s life expectancy including diagnosis of the terminal condition, other health conditions whether related or unrelated to the terminal condition, and current clinically relevant information supporting the diagnoses and prognosis for life expectancy and Terminal Illness;

ii) The approval of the Client’s physician(s) for Hospice Services; and iii) The approval of the Hospice Provider of Hospice Services for the Client.

b. A verbal Certification statement from either Hospice Provider’s medical director or the physician member of the Interdisciplinary Team and the Client's attending physician, if written certification cannot be obtained within two calendar days after Hospice Services are initiated. The verbal Certification must be documented, filed in the Client Record, and include the information described at Section 8.550.2.A.1.a.i, ii, and iii. Written Certification documentation must follow and be filed in the Client Record prior to submitting a claim for payment.

At the beginning of each subsequent Benefit Period, the Hospice Provider must obtain a written re-Certification prepared by either the attending physician, the Hospice Provider’s medical director or the physician member of the Interdisciplinary Team. 8.550.2.B. Election Procedures 1. An Election of Hospice Services continues as long as there is no break in care and the Client remains with the Elected Hospice Provider.
If a Client Elects to receive Hospice Services, the Client or Client representative must file an Election statement with the Hospice Provider that must be maintained in the Client’s Record and must include:

a. Designation of the Hospice Provider. A Client must choose only one Hospice Provider as the designated Hospice Provider;

b. Acknowledgment that the Client or Client representative has a full understanding of the palliative rather than curative nature of Hospice Services;

c. Designation by the Client or Client representative of the effective date for the Election period. The first day of Hospice Services must be the same or a later date;

d. An acknowledgement that for the duration of the Hospice Services, the Client waives all rights to Medicaid payments for the following services:

i) Hospice Services provided by a Hospice Provider other than the provider designated by the Client (unless provided under arrangements made by the designated Hospice Provider);

ii) Any Medicaid services that are related to the treatment of the terminal condition for which Hospice Services were Elected, or a related condition, or that are equivalent to Hospice Services, except for services that are:

Provided by the designated Hospice Provider;
Provided by another Hospice Provider under arrangements made by the designated Hospice Provider;
Provided by the individual’s attending physician if that physician is not an employee of the designated Hospice Provider or receiving compensation from the Hospice Provider for those services; and, 4) Services provided to Clients ages 20 and under.

e. A signature, physical or digital, of either the Client or Client representative, as allowed by Colorado law.

A Client or client representative may revoke the Election of Hospice Services by filing a signed statement of revocation with the Hospice Provider. The statement must include the effective date of the revocation.

The Client must not designate an effective date earlier than the date that the revocation is made. Revocation of the Election of Hospice Services ends the current Hospice Benefit Period.

a. Clients who are dually eligible for Medicare and Medicaid must revoke the Election of Hospice Services under both programs.

The Client may resume coverage of the waived benefits as described at 8.550.2.B.2.d. upon revoking the Election of Hospice Services.
The Client may re-Elect to receive Hospice Services at any time after the services are discontinued due to discharge, revocation, or loss of Medicaid eligibility, should the Client thereafter become eligible.
The Client may change the designation of the Hospice Provider once each Benefit Period. A change in designation of Hospice Provider is not a revocation of the Client’s Hospice Election. To change the designation of the Hospice Provider, the Client must file a statement with the current and new provider which includes:

a. The name of the Hospice Provider from which the Client is receiving care and the name of the Hospice Provider from which he or she plans to receive care;

b. The date the change is to be effective; and c. The signature, physical or digital, of the Client or Client representative, as allowed by Colorado law.

8.550.3 HOSPICE RELATED TO HCBS WAIVERS 8.550.3.A. Provision of Services 1. Hospice Services may be provided to a client who is enrolled in one of the Colorado Medicaid home and community-based services (HCBS) waivers, including the Children with Complex Health Needs Waiver.

HCBS waiver services may be provided for conditions unrelated to the client’s terminal diagnosis. For children ages 20 and under, HCBS waivers services may be provided for conditions related or unrelated to the client’s terminal diagnosis.
HCBS waiver services may also be provided to the client when these services are not duplicative of the services that are the responsibility of the Hospice Provider. HCBS waivers are those waivers as defined at Sections 8.500 through 8.599. 8.550.3.B. Waiver Coordination 1. The Hospice Provider must notify the HCBS waiver case manager or support coordinator of the client’s Election of Hospice Services and the anticipated start date.
The Hospice Provider must coordinate Hospice Services and HCBS waiver services with the HCBS waiver case manager or support coordinator and must document coordination of these services in the Client Record. Documentation must include:

a. Identification of the Hospice Services that will be provided;

b. Identification of the HCBS waiver services that will be provided under the waiver; and c. Integration of Hospice Services and HCBS waiver services in the Hospice plan of care.

The Hospice Provider must invite the HCBS waiver case manager or support coordinator to participate in the Interdisciplinary Team meetings for the client when possible.

8.550.4 BENEFITS 8.550.4.A. Hospice Standard of Care 1. Hospice Services must be reasonable and Medically Necessary for the palliation or management of the Terminal Illness as well as any related condition, but not for the prolongation of life.

Clients ages 20 and under are exempt from the restriction on care for the prolongation of life. 8.550.4.B. Covered Services Covered Hospice Services include, but are not limited to:
Nursing care provided by or under the supervision of a registered nurse.
Medical social services provided by a qualified social worker or counselor under the direction of a physician.
Counseling services, including dietary and spiritual counseling, provided to the Terminally Ill client and his or her family members or other persons caring for the client.
Bereavement counseling delivered through an organized program under the supervision of a qualified professional. The plan of care for these services should reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery (up to one year following the death of the client).
Short-term general inpatient care necessary for pain control and/or symptom management up to 20 percent of total Hospice Service days.
Short-term inpatient care of up to five consecutive days per Benefit Period to provide respite for the client's family or other home caregiver.
Medical appliances and supplies, including pharmaceuticals and biologicals which are used primarily for symptom control and relief of pain related to the Terminal Illness.
Intermittent certified nurse aide services available and adequate in frequency to meet the needs of the client. Certified nurse aides practice under the general supervision of a registered nurse. Certified nurse aide services may include unskilled personal care and homemaker services that are directly related to a visit.
Occupational therapy, physical therapy, and speech-language pathology appropriate to the terminal condition, provided for the purposes of symptom control or to enable the terminal client to maintain activities of daily living and basic functional skills.
Trained volunteer services.
Any other service that is specified in the client’s plan of care as reasonable and Medically Necessary for the palliation and management of the client’s Terminal Illness and related conditions and for which payment may otherwise be made under Medicaid. 8.550.4.C. [Expired 05/15/2014 per House Bill 14-1123] 8.550.4.D. Non-Covered Services Services not covered as part of the Hospice Benefit include, but are not limited to:
Services provided before or after the Hospice Election period.
Services of the client's attending or consulting physician that are unrelated to the terminal condition which are not waived under the Hospice Benefit.
Services or medications received for the treatment of an illness or injury not related to the client's terminal condition.
Services which are not otherwise included in the Hospice benefit, such as electronic monitoring, non-medical transportation, and home modification under a Home and Community-Based Services (HCBS) program.
Personal care and homemaker services beyond the scope provided under Hospice Services which are contiguous with a certified nurse aide visit.
Hospice Services covered by other health insurance, such as Medicare or private insurance.
Hospice Services provided by family members. 8.550.4.E. Prior Authorization Prior authorization is not required for Hospice Services. 8.550.4.F. Intermittent Home Health Certified Nurse Aide Services Intermittent home health certified nurse aide services may be utilized with Hospice Services coordination for treatment of conditions that are not related to the terminal diagnosis and are not meant to cure the client’s terminal condition.

Children under 20 are exempt from this requirement. 8.550.4.G. Included Activities Medicaid does not separately reimburse for activities that are the responsibility of the Hospice Provider, including coordination of care for the client and bereavement counseling.

8.550.5 ELIGIBLE PLACE OF SERVICE 8.550.5.A. Place of Service 1. Hospice Services are provided in a Client’s place of residence, which includes:

a. A residence such as, but not limited to, a house, apartment or other living space that the Client resides within;

b. An assisted living residence including an Alternative Care Facility;

c. A temporary place of residence such as, but not limited to, a relative’s home or a hotel. Temporary accommodations may include homeless shelters or other locations provided for a Client who has no permanent residence to receive Hospice Services;

d. Other residential settings such as a group home or foster home;

e. A licensed Hospice Facility or Nursing Facility (NF);

f. An Intermediate Care Facility for Individuals with Intellectual and Developmental Disabilities (ICF/IID), or Nursing Facility (NF), unless the Client is in a waiver program which does not allow residency in an ICF/IID or NF; or g. An Individual Residential Services & Supports (IRSS) or a Group Residential Services & Supports (GRSS) host home setting.

For Hospice Clients residing in a NF, ICF/IID, IRSS or GRSS, the Client must meet both the Hospice requirements and the requirements for receipt of those Medicaid-covered services.
Colorado Medicaid does not reimburse Hospice Services provided in hospitals except when the Client has been admitted for respite services. 8.550.5.B. Hospice Setting Requirements 1. Nursing Facilities:

a. Hospice Services may be provided to a Client who resides in a Medicaid participating NF.

b. When a Client residing in a NF Elects Hospice Services, the Client is considered a Hospice Client and is no longer a NF Client with the exception of the facility’s responsibility to provide Room and Board to the Client.

c. In order for a Client to receive Hospice Services while residing in a NF, the Hospice Provider must:

i) Notify the NF that the Client has Elected Hospice and the expected date that Hospice Services will commence;

ii) Ensure the NF concurs with the Hospice plan of care;

iii) Ensure the NF is Medicaid certified; and iv) Execute a written agreement with the NF, which must include the following:

The means through which the NF and the Hospice Provider will communicate with each other and document these communications to ensure that the needs of Clients are addressed and met 24 hours a day;
An agreement on the Client’s Hospice Service plan of care by the NF staff;
A means through which changes in Client status are reported to the Hospice Provider and NF;
A provision stating that the Hospice Provider is considered the primary provider and is responsible for any Medically Necessary routine care or continuous care related to the Terminal Illness and related conditions;
A provision stating that the Hospice Provider assumes responsibility for determining the appropriate course of Hospice Services, including the determination to change the level of services provided;
An agreement that it is the NF provider’s responsibility to continue to furnish 24 hour Room and Board care, meeting the personal care, durable medical equipment and nursing needs that would have been provided by the NF at the same level of care provided prior to Hospice Services being Elected;
An agreement that it is the Hospice Provider’s responsibility to provide services at the same level and to the same extent that those services would be provided if the Client were residing in his or her own residence;
A provision that the Hospice Provider may use NF personnel, where permitted by State law and as specified by the agreement, to assist in the administration of prescribed therapies included in the plan of care only to the extent that the Hospice Provider would routinely use the services of a Client’s family in implementing the plan of care;
The NF remains responsible for compliance with mandatory reporting of such violations to the State’s protective services agency. As such, the Hospice Provider and its staff or subcontractors must report all alleged violations of a Client’s person involving mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of Client property to the NF administrator within 24 hours of the Hospice Provider becoming aware of the alleged violation;
Bereavement services that the Hospice Provider will provide to the NF staff;
The amount to be paid to the NF or ICF/IID by the Hospice Provider; and 12) An agreement describing whether the Hospice Provider or the NF will be responsible for collecting the Client’s patient payment for his or her care.

Intermediate Care Facilities for Individuals with Intellectual Disabilities, Independent Residential Support Services, and Group Residential Support Services settings:

a. Hospice Services may be provided to a Client who resides in a Medicaid participating ICF/IID, IRSS or GRSS residential settings.

When a Client resides in one of the settings, the Client remains a resident of the ICF/IID, IRSS or GRSS residence. The Hospice Provider must provide services as if treating a Client in his or her place of residence.

b. The Hospice Provider is not responsible for reimbursing the IRSS or GRSS for the Client’s Room and Board.

c. In order for a Client to receive Hospice Services while residing in these settings, the Hospice Provider must work with the ICF/IID, IRSS or GRSS to:

i) Notify the ICF/IID, IRSS or GRSS that the Client has Elected Hospice and the expected date that Hospice Services will commence;

ii) Ensure the ICF/IID, IRSS or GRSS concurs with the Hospice plan of care;

iii) Determine the responsibilities covered under the ICF/IID, IRSS or GRSS so that the Hospice Provider does not duplicate service (to include medication and supplies), including:

An agreement that the Hospice Provider will be responsible to provide services at the same level and to the same extent as those services would be provided if the Client were residing in his or her private residence; and 2) An agreement of the services the ICF/IID, IRSS or GRSS personnel will perform, where permitted by State law, to assist in the administration of prescribed therapies included in the plan of care only to the extent that the Hospice Provider would routinely use the services of a Client’s family in implementing the plan of care;

iv) Develop a coordinated plan of care to ensure that the Client’s needs are met;

v) Develop a communication plan through which the Hospice Provider and the ICF/IID, IRSS or GRSS will communicate changes in the Client’s condition or changes in the Client’s care plan to ensure that the Client’s needs are met; and vi) Ensure bereavement services are available to the staff and caregivers of the Client.

In settings other than nursing facilities and ICF/IIDs, the Hospice Provider and assisted living residence or foster home must develop an agreement related to the provision of care to the Client, including;

a. Hospice Provider staff access to and communication with staff or caregivers in these facilities or homes;

b. Developing an integrated plan of care;

c. Documenting both respective entities’ records, or other means to ensure continuity of communication and easy access to ongoing information;

d. Role of any Hospice vendor in delivering and administering any supplies and medications;

e. Ordering, renewing, delivering and administering medications;

f. Role of the attending physician and process for obtaining and implementing orders;

g. Communicating Client change of condition; and h. Changes in the Client’s needs that necessitate a change in setting or level of care.

8.550.6 ELIGIBLE CLIENTS 8.550.6.A. Requirements To be eligible to Elect Hospice Services, all of the following requirements must be met:

Clients must be Medicaid eligible on the dates of service for which Medicaid-covered Hospice Services are billed. The services must be Medically Necessary, including certification of the Client’s Terminal Illness, and appropriate to the Client’s needs for Hospice Services to be covered by Medicaid.
The Client has been certified as being Terminally Ill by an attending physician or the Hospice Provider’s medical director.
Before services are provided, an initial plan of care must be established by the Hospice Provider in collaboration with the Client and anyone else that the Client wishes to have present for care planning. When the Client is unable to direct his or her own care, care planning must involve the Client’s family or caregiver.
The Client has agreed to cease any and all curative treatment. Clients ages 20 and younger are exempt from this requirement.
Hospice Clients residing in an ICF/IID or NF must meet the Hospice eligibility criteria pursuant to Section 8.550 et. seq., together with functional eligibility, medical eligibility criteria, and the financial eligibility criteria for institutional care as required by Sections 8.400, 8.401, and 8.482.
Clients who do not meet eligibility requirements for State Plan Medicaid may be eligible for Medicaid through the long-term care eligibility criteria, which may require the Client to pass a level of care assessment through a designated case management agency. 8.550.6.B. Special Requirements 1. Eligibility for, and access to, Hospice Services does not fall within the purview of the long-term care Single Entry Point system for prior authorization.
Nursing facility placement for a Client who has Medicaid and has Elected Hospice Services in a nursing facility does not require a LOC Screen. The nursing facility must complete a Pre Admission Screening and Resident Review (PASRR).

8.550.7 DISCHARGE 8.550.7.A. A Hospice Provider may discharge a client when:

The client moves out of the Hospice Provider’s service area or transfers to another Hospice Provider;
The Hospice Provider determines that the client is no longer Terminally Ill; or 3. The Hospice Provider determines, under a policy set by the Hospice Provider for the purpose of addressing discharge for cause that meets the requirements of 42 C.F.R. Section 418.26(a)(3) (2018), that the client’s (or other person in the client’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care or the Hospice Provider’s ability to operate effectively is seriously impaired. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1818.

a. The Hospice Provider must:

i) Advise the client that a discharge for cause is being considered;

ii) Make a serious effort to resolve the problem presented by the situation;

iii) Ascertain that the proposed discharge is not due to the client’s use of necessary Hospice Services;

iv) Document the problem and the effort made to resolve the problem; and v) Enter this documentation into the client’s medical record.

The Hospice Provider must obtain a written discharge order from the Hospice Provider’s medical director prior to discharging a client for any of the reasons in this section.
The Hospice Provider medical director must document that the attending physician involved in the client’s care has been consulted about the discharge and include the attending physician’s review and decision in the discharge note.
The Hospice Provider must have in place a discharge planning process that takes into account the prospect that a client’s condition might stabilize or otherwise change such that the client cannot continue to be certified as Terminally Ill. The discharge planning process must include planning for any necessary family counseling, patient education, or other services before the client is discharged because he or she is no longer Terminally Ill.
The Hospice Provider must implement the discharge planning process to ensure to the maximum extent feasible, that the client’s needs for health care and related services upon termination of Hospice Services will be met.
The Hospice Provider must document whether the client or client’s authorized representative was involved in the discharge planning.
The Hospice Provider must document the transition plan for the client.

8.550.8 PROVIDER REQUIREMENTS 8.550.8.A. Licensure The Hospice Provider must be licensed by the Colorado Department of Public Health and Environment, have a valid provider agreement with the Department and be Medicare certified as being in compliance with the conditions of participation for a Hospice Provider as set forth at 42 C.F.R. §§ 418.52 through 418.116 (2018). No amendments or later editions are incorporated. Copies are available for inspection from the Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203- 8.550.8.B. Qualified Personnel Hospice Services must be performed by appropriately qualified personnel:

Physicians who are a doctor of medicine or osteopathy licensed in accordance with the Colorado Medical Practice Act (C.R.S. § 12-36-101, et seq.);
Advanced Practice Nurses and Physician Assistants licensed in accordance with the Colorado Nurse Practice Act and the Colorado Medical Practice Act;
Registered Nurses (RN) and Licensed Practical Nurses (LPN), licensed in accordance with the Colorado Nurse Practice Act (C.R.S. § 12-38-101,et seq.);
Physical therapists who are licensed in accordance with the Colorado Physical Therapy Practice Act (C.R.S. § 12-41-101et seq.);
Occupational therapists who are licensed in accordance with the Colorado Occupational Therapy Practice Act (C.R.S. § 12-40.5-101, et seq.);
Speech language pathologists who are certified by the American Speech- Language-Hearing Association (ASHA);
Licensed clinical social workers who have a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education, or a baccalaureate degree in psychology, sociology, or other field related to social work and who are supervised by a social worker with a Master’s Degree in Social Work and who have one year of social work experience in a health care setting;
Certified nurse aides who are certified in accordance with the Colorado Nurse Aide Practice Act (C.R.S. § 12-38-101, et seq.) and who have appropriate training. At the option of the Hospice Provider, homemakers with appropriate training may provide homemaking services, which is included as a component of Hospice Services;
Hospice volunteers who have received volunteer orientation and training that is consistent with Hospice industry standards;
Members of the clergy or religious support services; and 11. Members of the Hospice Interdisciplinary Team acting within the scope of his or her license, as determined by the Hospice Provider. 8.550.8.C. Laboratory Services 1. Laboratory services provided by Hospice Providers are subject to the requirements of 42 U.S.C. § 263a (2012) entitled the Clinical Laboratory Improvement Act of 1967 (CLIA). No amendments or later editions are incorporated. Copies are available for inspection from the Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1818.
Hospice Providers must obtain a CLIA waiver from the Department of Public Health and Environment to perform laboratory tests. A Hospice Provider that collects specimens, including drawing blood, but does not perform testing of specimens is not subject to CLIA requirements. 8.550.8.D. Provider Responsibilities 1. A Hospice Provider must routinely provide all core services by staff employed by the Hospice Provider. These services must be provided in a manner consistent with acceptable standards of practice. Core services include nursing services, certified nursing aide services, medical social services, and counseling.
The Hospice Provider may contract for physician services. The contracted provider(s) will function under the direction of the Hospice Provider’s medical director.
A Hospice Provider may use contracted staff, if necessary, to supplement Hospice Provider employees in order to meet the needs of the Client. A Hospice Provider may also enter into a written arrangement with another Colorado Medicaid and Medicare certified Hospice program for the provision of core services to supplement Hospice Provider employees/staff to meet the needs of Clients. Circumstances under which a Hospice Provider may enter into a written arrangement for the provision of core services include:

a. Unanticipated periods of high Client loads, staffing shortages due to illness or other short-term, temporary situations that interrupt Client care;

b. Temporary travel of a Client outside of the Hospice Provider’s service area; and c. When a Client resides in a NF, ICF/IID, IRSS or GRSS.

The Hospice Provider must ensure, prior to the provision of Medicaid Hospice Services, that Clients are evaluated to determine whether or not they are Medicare eligible. Hospice Services are not covered by Medicaid during the period when a Client is Medicare eligible, except for Clients residing in a NF in which case Medicaid pays to the Hospice Provider an amount for Room and Board.
The Hospice Provider must ensure a Client, or his or her legally authorized representative, completes the Hospice Election form prior to or at the time Medicaid Hospice Services are provided.
Medicare Hospice Election may not occur retroactively. Therefore, Clients with retroactive Medicare eligibility may receive Medicaid covered services during the retroactive coverage period. The Hospice Provider must make reasonable efforts to determine a Client’s status concerning Medicare eligibility or a Client’s application for Medicare and must maintain documentation of these efforts. These efforts must include routine and regular inquiry to determine Medicare eligibility for Clients who reach the age of sixty-five and regular inquiry for Clients who indicate they receive Social Security Disability Income (SSDI) and are approaching the 24th month of receipt of SSDI. See also Section 8.550.3.
Clients who are eligible for Medicare and Medicaid must Elect Hospice Services under both programs.
If a Client becomes eligible for Medicaid while receiving Medicare Hospice benefits, Medicare Hospice coverage continues under its current Election period and Medicaid Hospice coverage begins at Medicaid’s first Election 9. An individual Client Record must be maintained by the designated Hospice Provider and must include:

a. Documentation of the Client’s eligibility for and Election of Hospice Services including the physician certification and recertification of Terminal Illness;

b. The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes;

c. The amount, frequency, and duration of services delivered to the Client based on the Client’s plan of care;

d. Documentation to support the care level for which the Hospice Provider has claimed reimbursement; and e. Medicaid provider orders.

Incomplete documentation in the Client Record shall be a basis for recovery of overpayment.
Notice of the Client's Election and Benefit Periods must be provided to the Medicaid fiscal agent in such form and manner as prescribed by the 12. The Hospice Provider must provide reports and keep records as the Department determines necessary including records that document the cost of providing care.
The Hospice Provider must perform case management for the Client.

Medicaid will not reimburse the Hospice Provider separately for this responsibility.

The Hospice Provider must designate an Interdisciplinary Team composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the Clients and his or her family facing Terminal Illness and bereavement. Interdisciplinary Team members must provide the care and services offered by the Hospice Provider. The Interdisciplinary Team, in its entirety, must supervise the care and services.
The Interdisciplinary Team includes, but is not limited to:

a. A Doctor of Medicine or Osteopathy, advanced practice nurse, or physician assistant (who is an employee or under contract with the Hospice Provider);

b. A registered nurse or licensed practical nurse;

c. A social worker;

d. A pastoral or other counselor; and e. The volunteer coordinator or designee.

The Hospice Provider must designate a member of the Interdisciplinary Team to provide coordination of care and to ensure continuous assessment of each Client’s and family’s needs and implementation of the interdisciplinary plan of care. The designated member must oversee coordination of care with other medical providers and agencies providing care to the Client.
All Hospice Services and services furnished to Clients and their families must follow an individualized written plan of care established by the Hospice Interdisciplinary Team in collaboration with the Client’s primary provider (if any), the Client or his or her representative, and the primary caregiver in accordance with the Client’s needs and desires.
The plan of care must be established prior to providing Hospice Services and must be based on a medical evaluation and the written assessment of the Client’s needs and the needs of the Client’s primary caregiver(s).
The plan of care must be maintained in the Client’s record and must specify:

a. The Client’s medical diagnosis and prognosis;

b. The medical and health related needs of the Client;

c. The specific services to be provided to the Client through Hospice and when necessary the NF, ICF/IID, IRSS or GRSS;

d. The amount, frequency and duration of these services; and e. The plan of care review date.

The plan of care must be reviewed as needed, but no less frequently than every 15 days. The Interdisciplinary Team leader must document each review. The Interdisciplinary Team members, including the Medicaid provider who is managing the Client’s care, must sign the plan of care.
The Hospice Provider must ensure that each Client and his or her primary care giver(s) receive education and training provided by the Hospice Provider as appropriate based on the Client’s and primary care giver(s)’ responsibilities for the care and services identified in the plan of care.
The Hospice Provider is responsible for paying for medications, durable medical equipment, and medical supplies needed for the palliation and management of the Client’s Terminal Illness.

8.550.9 REIMBURSEMENT 8.550.9.A. Reimbursement Determination Reimbursement follows the method prescribed in 42 C.F.R. §§ 418.301 through 418.309 (2018). No amendments or later editions are incorporated. Copies are available for inspection from the Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203- 1. Reimbursement rates are determined by the following:

a. Rates are published by the Department annually in compliance with the Centers for Medicare and Medicaid Services (CMS) state Medicaid Hospice reimbursement.

b. Each care-level per-diem rate is subject to a wage index multiplier, to compensate for regional differences in wage costs, plus a fixed non-wage component.

c. The Hospice wage indices are published annually by October 1 in the Federal Register.

d. Rates are adjusted for cost-of-living increases and other factors as published by the Centers for Medicare and Medicaid Services.

e. Continuous home care is reimbursed at the applicable hourly rate, the per-diem rate divided by 24 hours, multiplied by the number of hourly units billed from eight up to 24 hours per day of continuous care (from midnight to midnight).

f. Reimbursement for routine home care and continuous home care must be based upon the geographic location at which the service is furnished and not on the business address of the Hospice Provider.

Reimbursement for Hospice Services must be made at one of four predetermined care level rates, including the routine home care rate, continuous home care rate, inpatient respite care rate, and general inpatient care rate. If no other level of care is indicated on a given day, it is presumed that routine home care is the applicable rate.

a. Care levels and reimbursement guidelines:

i) The routine home care rate is reimbursed for each day the Client is at home and not receiving continuous home care.

This rate is paid without regard to the volume or intensity of Home Care Services provided. This is the service type that must be utilized when a Client resides in a NF, ICF/IID, IRSS or GRSS unless the Client is in a period of crisis.

ii) The continuous home care rate is reimbursed when continuous home care is provided and only during a period of medical crisis to maintain a Client at home. A period of crisis is a period in which a Client requires continuous care, which is primarily nursing care, to achieve palliation or for the management of acute medical symptoms. Either a registered nurse or a licensed practical nurse must provide more than half of the billed continuous homecare hours.

Homemaker and certified nurse aide services may also be provided to supplement nursing care. The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate. A minimum of eight hours must be provided. For every hour or part of an hour of continuous care furnished, the hourly rate shall be reimbursed up to 24 hours a day.

Continuous home care must not be utilized when a Client resides in a NF, ICF/IID, IRSS or GRSS unless the Client is in a period of crisis.

iii) The inpatient respite care rate is paid for each day on which the Client is in an approved inpatient facility for respite care.

Payment for respite care may be made for a maximum of five days at a time including the date of admission but not counting the date of discharge. Payment for the sixth and any subsequent days is to be made at the routine home care rate. Payment for inpatient respite care is subject to the Hospice provider's 20 percent aggregate inpatient days cap as outlined in 8.550.9.B.

iv) The general inpatient rate must be paid only during a period of medical crisis in which a Client requires 24-hour continuous care, which is primarily nursing care, to achieve palliation or for the management of acute medical symptoms. Payment for general inpatient care is subject to the Hospice provider's 20 percent aggregate inpatient days cap as outlined in 8.550.9.B.

The Hospice Provider is paid a Room and Board fee in addition to the Hospice per diem for each routine home care day and continuous care day provided to Clients residing in an ICF/IID or NF.

a. The payment for Room and Board is billed by and reimbursed to the Hospice provider on behalf of the Client residing in the facility.

The Department reimburses 95 percent of the facility per diem amount less any patient payments.

b. Payments for Room and Board are exempt from the computation of the Hospice payment cap.

c. The Hospice Provider must forward the Room and Board payment to the NF or ICF/IID.

d. Clients who are eligible for Post Eligibility Treatment of Income (PETI) shall be eligible for PETI payments while receiving services from a Hospice Provider. The Hospice Provider must submit claims on behalf of the Client and nursing facility or ICF/IID.

e. Patient payments for Room and Board charges must be collected for Hospice Clients residing in a NF or ICF/IID as required by

Section 8.482. While the Medicaid NF and ICF/IID Room and Board payments must be made directly to the Hospice Provider, the patient payment must be collected by the nursing facility or ICF/IID.

f. Nursing facilities, ICF/IIDs, and Hospice Providers are responsible for coordinating care of the Hospice Client and payment amounts.

The Hospice Provider is reimbursed for routine home care or continuous home care provided to Clients residing in a NF or ICF/IID. If a Client is eligible for Medicare and Medicaid and the Client resides in a NF or ICF/IID, Medicare reimburses the Hospice Services, and Medicaid reimburses for Room and Board.
Reimbursement for date of discharge:

a. Reimbursement for date of discharge must be made at the appropriate home care rate for the day of discharge from general or respite inpatient care, unless the Client dies at an inpatient level of care. When the Client dies at an inpatient level of care, the applicable general or respite inpatient rate is paid for the discharge date.

b. Reimbursement for nursing facility and ICF/IID residents is made for services delivered up to the date of discharge when the Client is discharged, alive or deceased, including applicable per diem payment for the date of discharge. 8.550.9.B. Reimbursement Limitations 1. Aggregate payment to the Hospice Provider is subject to an annual indexed aggregate cost cap. The method for determining and reporting the cost cap must be identical to the Medicare Hospice Benefit requirements as contained in 42 C.F.R. Sections 418.308 and 418.309 (2018). No amendments or later editions are incorporated. Copies are available for inspection from the Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203- 2. Aggregate days of care provided by the Hospice Provider are subject to an annual limitation of no more than 20 percent general and respite inpatient care days. The method for determining and reporting the inpatient days percentage shall be identical to the Medicare Hospice Benefit requirements as contained in 42 C.F.R. Section 418.302 (2018).

No amendments or later editions are incorporated. Copies are available for inspection from the Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1818. Inpatient days in excess of the 20 percent limitation must be reimbursed at the routine home care rate.

The Hospice Provider must not collect co-payments, deductibles, cost sharing or similar charges from the client for Hospice Services including biological and respite care.
The Hospice Provider must submit all billing to the Medicaid fiscal agent within such timeframes and in such form as prescribed by the Department.
Specific billing instructions for submission and processing of claims is provided in the Department’s Hospice billing manual. 8.550.9.C. State-Only Hospice Room and Board Reimbursement 1. As used in this section, unless context otherwise requires:

a. “Eligible Patient” means a person who is enrolled in Colorado Medicaid at the time the service is provided and who:

i) Is eligible under Colorado Medicaid for care in a nursing facility at the time the service is provided;

ii) Has a hospice diagnosis; and iii) Despite attempts to secure a bed, is unable to secure a Medicaid bed in a nursing facility due to COVID-19 impacts, complexity of medical care, behavioral health issues, or other issues as determined by the Department.

b. “Qualified Hospice Provider” means a hospice provider that:

i) Has been continuously enrolled with the Department since at least January 1, 2021;

ii) Provided hospice services to the eligible patient in a licensed hospice facility during the period beginning in the last quarter of the 2020-2021 state fiscal year through the 2021-2022 state fiscal year; and iii) Complies with any billing or administrative requests of the Department for purposes of determining eligibility for and administering the state payment.

Qualified Hospice Providers who provide hospice care in a licensed hospice facility to an Eligible Patient may receive a room and board payment equal to one-half (1/2) of the statewide average per diem rate, as defined in C.R.S. § 25.5-6-201. The payment is subject to the following limitations:

a. Payment is limited to not more than twenty-eight (28) days per Eligible Patient.

b. No payments will be made after June 30, 2022 or after appropriations are exhausted, whichever occurs first, in accordance with C.R.S. § 25.5-4-424. 8.552 IN-HOME SUPPORT SERVICES [Repealed eff. 11/30/2025]

8.553 LIFE SKILLS TRAINING, HOME DELIVERED MEALS, PEER MENTORSHIP,

TRANSITION SETUP SERVICES, & HOME DELIVERED MEALS POST-HOSPITAL

DISCHARGE [Repealed eff. 11/30/2025] 8.555 Money Follows the Person (MFP) Demonstration 8.555.1 Program Overview 8.555.1.A Program Definition, Authority, and Scope 1. Program Definition a. Money Follows the Person is a federal grant that supports state strategies to rebalance their long-term services and supports (LTSS) systems from institutional to community-based care. MFP plays a key role in LTSS rebalancing efforts under the Medicaid program. The program provides flexible funding opportunities to help states develop and test the necessary processes, tools, and infrastructure to advance LTSS system reform and to support successful transitions from institutional to community-based settings for individuals eligible for Medicaid LTSS. The model demonstrates the likely impact of new methods of service delivery, coverage of new types of service, and new payment approaches to promote the objective of the Medicaid program.

Legal Authority a. The federal authority for the MFP demonstration is section 6071 of the Deficit Reduction Act of 2005 (DRA). Section 6071 of the DRA has been amended by: section 2403 of Patient Protection and Affordable Care Act; section 2 of the Medicaid Extenders Act of 2019; section 5 of the Medicaid Services Investment and Accountability Act of 2019; section 4 of the Sustaining Excellence in Medicaid Act of 2019; section 205 of the Further Consolidated Appropriations Act, 2020 (CAA); section 3811 of the Coronavirus Aid, Relief, and Economic Security Act, 2020; section 2301 of the Continuing Appropriations Act, 2021 and Other Extensions Act;

section 1107 of the Further Continuing Appropriations Act, 2021, and Other Extensions Act; and section 204 of the Consolidated Appropriations Act, 2021 (CAA).

b. MFP is designed to complement the services offered through the Home and Community-Based Services (HCBS) waivers authorized through Section 1915(c) of the Social Security Act (42 U.S.C. § 1396n).

c. The State Authority for the Rule is in C.R.S. § 25.5-6-1501(6).

Scope and Purpose a. The MFP program assists members residing in qualified institutions with exploring their community-based options for long term supports and services; facilitates the transition of members to a community setting so long as the right services and supports can be arranged in the community to ensure the health, welfare, and safety of the member; and provides enhanced services and supports through willing and qualified providers.

b. The MFP program strengthens the transition process for members of qualified institutions and provides additional support and services for a successful transition. These additional supports and services fall into the categories of demonstration services or supplemental services.

c. Demonstration Assurances:

i. Services will be made available throughout the entirety of the demonstration and last for 365 calendar days, 366 days during a leap year if applicable, following discharge to a qualified residence.

ii. Services offered under the demonstration will not duplicate any existing benefits, and adequate services definitions will create role clarity for those involved in the processes.

iii. Outreach and training will be provided to build awareness of the services offered under the demonstration to include program goals, documentation, and quality oversight.

iv. Successful completion of the demonstration will include authorization of HCBS services needed for continuity of care following the demonstration period. 8.555.1.B Definitions 1. Case Management means the Assessment of an individual seeking or receiving Long-Term Services and Supports’ needs, the development and implementation of a Person-Centered Support Plan for such individual, Referral and related activities, the coordination and monitoring of longterm service delivery, the evaluation of service effectiveness, and the periodic Reassessment of such individual’s needs and collaboration with other entities impacting the Members’ HCBS, health and welfare.

Demonstration Services for the purposes of the MFP demonstration means Targeted Case Management - Transition Coordination (TCM-TC) where support will be available to members upon confirmation of member eligibility and for 365 calendar days following discharge from the qualified institution. Need for demonstration services will be identified by the TCM- TC Community Needs and Preference Assessment and Risk Mitigation Plan.
Division of Housing (DOH) is the State entity within the Department of Local Affairs (DOLA) that represents the housing authority for MFP programs through an Interagency Agreement (IA) with the Department of Health Care Policy and Financing (HCPF).
Qualified institution means a nursing facility; intermediate care facilities for individuals with intellectual disabilities (ICF-IID); Regional Center (RC) or institutions for mental diseases (IMD), which include Psychiatric Hospitals only to the extent medical assistance is available under the State Medicaid plan for services provided by such institutions.
Qualified residence means a home owned or leased by the member or the member's family member; a residence, in a community-based residential setting, in which no more than 4 unrelated individuals reside; or an apartment with an individual lease, eating, sleeping, cooking, and bathing areas, lockable access and egress, and not associated with the provision or delivery of services.
Qualified services mean services that are provided through an existing HCBS waiver and may continue if needed by the member and if the member continues to meet eligibility for HCBS at the end of his or her enrollment in MFP.
MFP Supplemental Services mean services not otherwise available under Medicaid but that directly support a member through one-time or shortterm expenses. Supplemental Services are reimbursable for up to six months while the member resides in a qualified institution and for a period of up to six months following discharge to a qualified residence. Need for Supplemental Services will be identified by the TCM-TC Community Needs and Preference Assessment and Risk Mitigation Plan.
Targeted Case Management – Transition Coordination (TCM-TC) services means transition coordination assistance provided to a member who is transitioning from a skilled nursing facility, extended SNF LOC hospital stay, intermediate care facility for individuals with intellectual disabilities, or regional center and includes the following activities: comprehensive assessment for transition, community risk assessment, development of a transition plan, referral and related activities, and monitoring and follow up activities as they relate to the transition 9. Transition Assessment/Plan means an assessment of member needs completed by a transition coordinator prior to a transition and the corresponding plan developed by the coordinator to meet the needs of the member in a community-setting post-transition.
Transition Coordinator (TC) means a person who provides Transition Coordination Services and meets all regulatory requirements for a TC at

Section 8.519.27.

Transition Coordination Agency (TCA) means a public or private not-forprofit or for-profit agency that meets state and federal requirements at

Section 8.519.27 and 8.763 and is certified by the Department to provide Targeted Case Management – Transition Coordination (TCM-TC) services pursuant to a provider participation agreement with the Department.

Transition Options Team (TOT) means a group of individuals who have a personal or professional relationship with the member who is exploring their options for community living. This group is responsible wholly or in

part for the transition assessment, transition plan, determining whether the transition is recommended, completing the service plan, and brokering 8.555.2 Eligibility 8.555.2.A. Eligible Persons 1. MFP services shall be offered only to persons who meet all of the following eligibility requirements:

a. Members shall be aged 18 years or older.

b. Members shall have resided in a qualified institution for a period of 60 days or more. Days in a nursing facility for a rehabilitation stay will count towards the 60 days.

Members shall be Medicaid eligible 3. Members shall reside in a qualified residence post-transition.
MFP members admitted to a nursing facility or hospital for 30 consecutive days or longer, post-transition, shall be discontinued from the MFP program but may have the option to re-enroll once they meet all eligibility requirements. The Department has the right to exempt the 30-day exclusion on a case-by-case basis where failure to do so would result in health and safety concerns, loss of housing, loss of caregivers, or loss of benefits.

a. MFP members entering a nursing facility for Respite Care as a qualified HCBS waiver service shall not be discontinued from the MFP program.

Members who reside in a residence that is not a Qualified Residence as defined in Section 8.555.1 are not eligible for MFP services. 8.555.2.B Financial Eligibility 1. Members shall meet the eligibility criteria as specified in the Income Maintenance Staff Manual of the Colorado Department of Health Care Policy and Financing regulations at Section 8.100, Medical Assistance Eligibility. 8.555.2.C Level of Care Criteria 1. Members shall require long-term support services at a level comparable to services typically provided in a hospital, nursing facility, or ICF-IID in accordance with the waiver to which they will enroll upon transition. 8.555.2.D. Need for MFP Services 1. Members will be eligible for the MFP program when all eligibility criteria listed in Section 8.555.2. have been met.

a. The desire or need for any Medicaid services other than MFP demonstration services, as listed at Section 8.555.1, or qualified services offered through one of the waiver programs listed in

Section 8.555.2 shall not satisfy this eligibility requirement.

Eligible services include but are not limited to Transition Coordination, Peer Mentorship, Pre-tenancy Support, and Environmental Adaptations.
Once enrolled, members who have not received demonstration or qualified services for a period greater than 30 consecutive days shall be discontinued from the program.
MFP members will be eligible to receive all MFP Supplemental Services identified as a need during MFP enrollment. 8.555.3 MFP Demonstration Program 8.555.3.A Program Duration 1. MFP members may be enrolled in the demonstration and receive TCM-TC Services for a period of 365 days, 366 days during a leap year if applicable, following discharge from a qualified institution. After discharge the member may be enrolled in the appropriate long-term care program.
Following discharge from a qualified institution, MFP members will be concurrently enrolled in the MFP program and one of the following waivers:

a. Home and Community Based Services for the Elderly, Blind and Disabled (HCBS-EBD) (Section 8.7101.);

b. Home and Community Based Services Complementary and Integrative Health (HCBS-CIH) (Section 8.7101.);

c. Home and Community Based Services for People with Brain Injury (HCBS-BI) (Section 8.7101.);

d. Home and Community Based Services for Community Mental Health Supports (HCBS-CMHS) (Section 8.7101.);

e. Home and Community Based Services for the Developmentally Disabled (HCBS-DD) (Section 8.7101.; or f. Home and Community Based Services for Supported Living Services (HCBS-SLS) (Section 8.7101.).

At the end of the 365-day enrollment period for the MFP program, HCBS case managers will disenroll members from the program.

a. TCM-TC Demonstration services will terminate at the end of the 365 days of MFP enrollment period.

b. Supplemental services will end 6 months after discharge.

c. After MFP concludes, if members continue to meet eligibility requirements at the time of the Continued Stay Review (CSR) for one of the waivers listed in Section, 8.555.3, case managers will arrange for the continuation of qualified HCBS services through the appropriate waiver. For members that do not meet eligibility requirements for one of the waivers listed in Section 8.555.4, case managers will provide referrals to alternate resources that may include Medicaid state plan benefits. 8.555.3.B MFP Demonstration Service 1. Targeted Case Management - Transition Coordination (TCM-TC)

a. Transition Coordination will be provided in accordance with requirements defined in Transition Coordination Services Section 8.519.27.

b. Eligibility i. Members will be eligible for MFP Transition Coordination services when all eligibility criteria described in Targeted Case Management - Transition Coordination (TCM-TC)

Section 8.519.27, 8.763 and 8.555.2 are met.

c. Inclusions i. Transition Coordination will ensure that members meet all eligibility requirements identified in Section 8.555.2 prior to enrollment.

ii. Transition Coordination shall facilitate the completion of the Department approved Transition Assessment/Plan for each member with the support of the Transitions Options Team members. The need for MFP supplemental services will be determined through this assessment process.

d. Exclusions i. Reimbursement for mileage, travel, or transportation.

e. Provider Requirements i. Transition Coordination Agencies will follow all policies and procedures defined in Section 8.519.27 and made available through training and other guidance.

f. Provider Reimbursement i. TCM-TC services will be reimbursed according to requirements outlined in Section 8763 and the Targeted Case Management - Transition Coordination (TCM-TC)

Billing Manual.

ii. Reimbursement shall be claimed only by a qualified provider 2. MFP Housing Assistance a. MFP Supplemental service that provides funding for MFP members while long-term solutions are established. Colorado administers State-funded housing resources that provide members with housing vouchers. MFP Housing Assistance supports members in urgent situations while long-term State-funded options are pending or unavailable.

b. Eligibility i. Members who have identified housing payments as a need during MFP enrollment will be eligible for six months of total rental payments through MFP Housing Assistance. MFP Housing Assistance recognizes rental arrears and monthly rental payments as eligible expenses where the combination of the two types of payments cannot exceed six months of total MFP Housing Assistance payments.

ii. Will be documented by the TCA and reported to the Division of Housing (DOH) who will be responsible for authorizing the start date and amount of monthly MFP Housing Assistance payments and subsequent State-funded housing assistance.

c. Inclusions i. Activities reimbursable as short-term rental assistance.

Monthly rental payments:
Will be calculated based on State-funded housing standards.
Will be administered and tracked by the DOH who will be responsible for implementing State-funded housing assistance for members to avoid any interruption of payment following the member’s eligibility period for MFP Housing Assistance.

ii. Rental arrears:

Rental arrears payments are eligible expenses under MFP Housing Assistance and will offset funding available for rental assistance following transition.
Rental arrears payments will not exceed six months of calculated MFP Housing Assistance.

iii. Activities reimbursable for payment prior to transitioning.

Security Deposit d. Exclusions i. Any MFP Housing Assistance to exceed a combination of six months of rental payments.

ii. Expenses for home furnishings or grocery items.

iii. Payment for modifications or accessibility adaptations to the home associated rental and utility fees identified during transition planning.

e. Provider Requirements i. MFP Housing Assistance will be administered by the Division of Housing (DOH) as a State entity within the Department of Local Affairs (DOLA) through an Interagency Agreement (IA) with the Department of Health Care Policy and Financing (HCPF) and/or HCPF Department staff or contracts.

f. Provider Reimbursement i. MFP Housing Assistance payments will be made by the State’s designated entity to landlords and/or property management groups.

ii. Reimbursement shall be claimed only by a qualified provider 3. MFP Food Assistance a. MFP Supplemental Service that provides short-term funding for food pantry items, community meal programs, and food boxes.

This service will ensure that a member has access to food while adjusting to community-living. Funding will be available for MFP Food Assistance for 30 days following transition to the community.

b. Eligibility i. Members who have identified food as a need during MFP enrollment will be eligible for MFP Food Assistance for a period of 30 days following transition to the community.

c. Inclusions:

i. Food pantry stocking items may include:

Perishable food items.
Non-perishable food items.
Nutritional vitamins and other meal supplements.
Nutritional items associated with dietary restrictions.
Food preparation items.

ii. Community meal delivery fees for non-Medicaid resources prior to authorization of HCBS Home Delivered Meals (HDM) or other long-term alternatives. Membership fees for community programs such as Meals on Wheels or food boxes would be an example of appropriate costs under this category.

d. Exclusions i. The combination of costs associated with Short-term Food Assistance will not exceed $500 per member for the 30-day ii. HCBS Home Delivered Meals.

iii. Any costs that exceeds the member’s MFP Food Assistance eligibility period.

e. Provider Requirements i. MFP Food Assistance providers will be subject to the standards outlined in Section 8.7549.

f. Provider Reimbursement i. MFP Food Assistance must not exceed $500 per eligible member for a period of 30 days following discharge from a qualified institution.

ii. Funding provided will not duplicate any other food expenses covered by Medicaid.

iii. The total amount will be prior authorized in the State’s MMIS system and will be reimbursable upon delivery of service.

iv. Reimbursement for MFP services shall reflect the lower of billed charges or the maximum rate of reimbursement set by 1) The statewide fee schedule for these services is 2) Reimbursement for MFP services is also conditional a) The member's eligibility for MFP services;

b) The provider’s certification status; and c) The submission of claims in accordance with v. Payments will be made by agencies designated by contract with the State to provide this service.

vi. Reimbursement shall be claimed only by a qualified provider 4. MFP Pre-Tenancy Support a. MFP Supplemental Service that teaches members how to satisfy the requirements of community-based tenancy through education and direct support. The service teaches members how to successfully secure and maintain community housing and avoid unnecessary returns to higher levels of care.

b. Eligibility:

i. Members who have identified housing as a need during MFP enrollment will be eligible for MFP Pre-Tenancy Support for a period up to six months prior to transitioning.

c. Inclusions i. Teaching members how to satisfy the requirements of tenancy.

ii. Teaching members their rights as tenants.

iii. Teaching members compliance requirements for lease agreements.

iv. Teaching members about tenancy sustaining practices.

v. Completing lease applications and requesting rental accommodations.

vi. Coordinating required documentation.

vii. Teaching members how to make payments to landlords.

viii. Teaching members how to schedule tours for prospective units.

ix. Accessing other resources related to Pre-tenancy Support and household management.

d. Exclusions i. Pre-tenancy Support shall not be available to members following transition to the community.

ii. Pre-Tenancy Support services will be limited to 52 units where 1 unit equals 15 minutes.

Reimbursement for mileage, travel, or transportation.

iii. Provider Requirements 1) Providers of MFP services must:

a) Abide by all the terms of their provider agreement with the Department; and b) Not discontinue or refuse services to a member resolve the situation that triggers such c) Comply with all applicable federal and state statutes, regulations, and guidance.

e. Provider Reimbursement i. Pre-Tenancy Support will be reimbursed up to 52 units where 1 unit equals 15 minutes.

ii. The total amount will be prior authorized in the State’s MMIS system and will be reimbursable upon delivery of service.

iii. Requests for units above the authorized amount will be reviewed by designated State staff.

b) The provider’s certification status; and c) The submission of claims in accordance with 3) Payments will be made by agencies designated by contract with the State to provide this service 4) Reimbursement shall be claimed only by a qualified provider who delivers services in accordance with the service definition and policy guidance established by 5. MFP Peer Mentorship a. MFP Supplemental Service that offers support from providers with lived experience to better understand the transition process, how to navigate Colorado’s Medicaid System and other community resources prior to transition. The goal of MFP Peer Mentorship is to connect members with other people who have transitioned to the community to build independence and reduce impacts of social isolation after leaving a long-term care facility.

b. Eligibility i. MFP Peer Mentorship will be available to members for a period up to six months prior to transitioning who meet the following eligibility criteria:

c. Inclusions i. MFP Peer Mentorship means support provided by peers of the member on matters of community living and may include:

Problem-solving issues drawing from shared experience 2) Goal setting, self-advocacy, community acclimation and techniques 3) Assisting with interviewing potential providers, understanding complicated health and safety issues, and participating on private and public boards, advisory groups, and commissions 4) Activities that promote interaction with friends and companions of choice 5) Teaching and modeling of social skills, communication, group interaction, collaboration 6) Developing community relationships with the intent of building social capital that results in the expansion of opportunities to explore personal interests 7) Assisting the person in acquiring, retaining, and improving self-help, socialization, self-advocacy, and adaptive skills necessary for community living.
Support for integrated and meaningful engagement and awareness of opportunities for community involvement including volunteering, self- advocacy, education options, and other opportunities identified by the individual 9) Assisting members to be aware of and engage in community resources.

ii. Exclusions 1) MFP Peer Mentorship will not be available to members following transition to the community 2) Reimbursement for mileage, travel, or transportation.

iii. Provider Requirements 1) MFP Peer Mentorship providers must meet requirements at Section 8.7537.

Providers of MFP services must:

a) Conform to all state established standards for the specific services they provide under this program.

b) Not discontinue or refuse services to a member resolve the situation that triggers such c) Abide by all the terms of their provider agreement with the Department; and 3) Comply with all applicable federal and state statutes, regulations, and guidance.

iv. Provider Reimbursement 1) MFP Peer Mentorship will be reimbursed up to 26 units where 1 unit equals 15 minutes.

Requests for units above the authorized amount will be reviewed by designated State staff.
The total amount will be prior authorized in the Department’s MMIS system and will be reimbursable upon delivery of service.
Reimbursement for MFP services shall reflect the lower of billed charges or the maximum rate of reimbursement set by the Department.
The statewide fee schedule for these services is 6) Reimbursement for MFP services is also conditional a) The member's eligibility for MFP services.

b) The provider’s certification status.

c) The submission of claims in accordance with 7) Payments will be made by agencies designated by contract with the State to provide this service.

Reimbursement shall be claimed only by a qualified provider who delivers services in accordance with the service definition and policy guidance established by 6. Environmental Adaptations a. MFP Supplemental Service that allows for modifications to a member’s residence to be completed prior to transitioning where the modification represents a barrier that would otherwise prevent a member from discharging safely to the community. This support is differentiated from the existing home modification waiver benefit through the ability to initiate modifications to a member’s home while they reside in a skilled setting. The TCA will work directly with the member to make referrals to Environmental Adaptation providers while the member resides in the facility planning for transition. The TCA will communicate with the HCBS case manager to ensure continuity with further home modifications under the HCBS Waiver following transition as warranted.

b. Eligibility i. Members who have identified home accessibility as a need during MFP enrollment will be eligible for MFP Environmental Adaptations for a period up to six months prior to transitioning.

c. Inclusions i. Inclusions for Environmental Adaptations are outlined in

Section 8.7524.

d. Exclusions i. Exclusions for Environmental Adaptations are outlined in

Section 8.7524.

e. Environmental Adaptations Oversight Responsibilities ii. The EA Contractor may approve Environmental Adaptation projects estimated at less than $2,500 without Department approval, contingent on member MFP eligibility and confirmation of Environmental Adaptation fund availability.. iii EA projects shall not exceed $14,000 unless:

(1) there are extenuating circumstances prior to the EA work commencing and a request for reimbursement over $14,000 is submitted to and approved by the Department prior to the EA work commencing; or (2) there are unanticipated complications after EA work commenced that require an increase to the original bid amount and a request for reimbursement over $14,000 is submitted to and approved by the Department prior to the EA work being completed.

The EA Contractor must submit the request and all supporting documentation according to Department prescribed processes and procedures. EA Requests submitted with improper documentation cannot be authorized.
The EA Contractor is responsible for retaining and tracking all documentation related to a member's Environmental Adaptation benefit and communicating that information to the member and EA Providers. The EA Contractor may request confirmation of a member’s Environmental Adaptation history from the Department, its fiscal agent, or DOH.

iv. Environmental Adaptations estimated to cost $2,500 or more shall be evaluated according to the following procedures:

An occupational or physical therapist (OT/PT) shall assess the member’s needs and the therapeutic value of the requested Environmental Adaptation. When an OT/PT with experience in Environmental Adaptation is not available, a Department-approved qualified individual may be substituted. An evaluation specifying how the Environmental Adaptation would contribute to a member’s ability to remain in or return to their home, and how the Environmental Adaptation would increase the individual's independence and decrease the need for other services, shall be completed before bids are solicited. This evaluation shall be submitted with the EA Request.
The evaluation services may be provided by a home health agency or other qualified and approved OT/PT through Medicaid Home Health consistent with Home Health rules set forth in Section 8.520, including physician orders and plans of care.

b) A Transition Coordinator (TC) may initiate the OT/PT evaluation process before the member physically resides in the home to be modified, as long as the current property owner agrees to the evaluation.

The EA Contractor and the OT/PT shall consider less expensive alternative methods of addressing the member’s needs.
The EA Contractor shall solicit bids according to the following procedures: a)

ii) The bids must be submitted according to Department prescribed processes and procedures b) The bids shall include a breakdown of the costs of the project including:

i) Description of the work to be completed.

ii) Description and estimate of the materials and labor needed to complete the project. Material costs should include price per square foot for materials purchased by the square foot.

Labor costs should include price per hour.

iii) Estimate for building permits, if needed.

iv) Estimated timeline for completing the project.

v) Name, address and telephone number of the Environmental Adaptation Subcontractor.

vi) Signature, including option for digital signature, of the Environmental Adaptation Subcontractor.

vii) Signature, including option for digital signature, of the member or guardian or other indication of approval.

viii) Signature, including option for digital signature, of the homeowner or property manager if applicable. c)

d) The EA Contractor shall upload copies of the bid(s) and the OT/PT evaluation into the Department approved system.

e) A revised bid and Change Order request shall be submitted according to the procedures outlined in this section for any changes from the original EA Request according to Department prescribed processes and v. If the member does not own a property to be modified, the EA Contractor shall obtain signatures from the homeowner or property manager on the submitted bids authorizing the specific modifications described therein. Signatures may be completed using a digital signature based on preference of the individual signing the form.

Written consent of the homeowner or property manager, as evidenced by the above-mentioned signatures, is required for all projects that involve permanent installation within the member’s residence or installation or modification of any equipment in a common or exterior area.
If the member vacates the property, these signatures can be used as evidence that the homeowner or property manager agrees to allow the member to leave the modification in place or remove the modification as the member chooses. If the member chooses to remove the modification, the property must be left equivalent or better to its pre-modified condition. The homeowner or property manager may not hold any party responsible for removing all or part of an Environmental Adaptation project.

vi. If the EA Contractor does not comply with the process described above resulting in increased cost for an Environmental Adaptation, the Department may hold the EA Contractor financially liable for the increased cost.

vii. The Department or its agent may conduct on-site visits, or any other investigations deemed necessary.

f. Environmental Adaptations Provider Requirements i. ii.

iii. Providers of MFP services must 1) Conform to all state established standards for the specific services they provide under this program 2) Not discontinue or refuse services to a member resolve the situation that triggers such discontinuation or refusal to provide services 3) Abide by all the terms outlined in the contract requirements with the Department; and 4) Comply with all applicable federal and state statutes, regulations, and guidance iv. Provider Reimbursement 1) Environmental Adaptations will be reimbursable up to a maximum cost of $14,000 unless:

a) there are extenuating circumstances prior to the EA work commencing and a request for reimbursement over $14,000 is submitted to and approved by the Department prior to the EA work commencing; or b) there are unanticipated complications after EA work commenced that require an increase to the original bid amount and a request for reimbursement over $14,000 is submitted to and approved by the Department prior to the EA work being completed. 2)

The total reimbursement will not exceed the total amount identified in the bid 4) Reimbursement for MFP services shall reflect the lower of billed charges or the maximum rate of reimbursement set by the Department.

a) The statewide fee schedule for these services is reviewed annually and published in the provider billing manual.

b) Reimbursement for MFP services is also conditional upon:

i) The member's eligibility for MFP services;

ii) The provider’s certification status; and iii) The submission of invoices in accordance with proper billing v. Payments will be made by agencies designated by contract with the State to provide this service 1) Payment for Environmental Adaptations does not offset the funding available to members under HCBS Home Modification benefits vi. Reimbursement shall be invoiced only by a qualified provider definition and policy guidance established by the Department 8.555.4. MFP Case Management Functions 8.555.4.A Case Management Responsibilities 1. The case manager shall provide support in accordance with the functions outlined in Section 8.7206 8.555.4.B. Case Management Responsibilities – MFP Disenrollment 1. The case manager shall begin preparing members for dis-enrollment from the MFP program 90 days prior to the end of the member’s MFP enrollment period and arrange for the continuation of HCBS services if the member continues to meet the eligibility requirements for a waiver listed at

Section 8.7100 8.555.4.C. MFP Service Plan 1. The MFP Service Plan will be developed with input from the transition coordinator, staff from the discharging facility, the resident wanting to transition and others at the invitation of the member or guardian.

The transition assessment/plan, the member’s level of functioning, service needs, available resources and potential funding resources will inform the development of the service plan.
The MFP Service Plan shall document that the member has been offered a choice:

a. Between community-based services or institutional care;

b. Between the MFP Program or a traditional HCBS Waiver;

c. Among qualified and demonstration services; and d. Among qualified providers.

A new MFP Service Plan will be developed each time a member is reinstitutionalized and plans to return to a community setting. The MFP Service Plan shall address the reasons for the member’s reinstitutionalization.

8.555.5 MFP SERVICE AUTHORIZATION

Determination for MFP services shall occur when all requirements defined in 8.555.2 have been met. Members will be identified in the State’s prescribed case management system during the MFP referral screening.

Once identified in the system, all services prior authorized for the member’s care will be mapped to MFP funds in the State’s MMIS system.

Transition Coordination services may be offered prior to the member’s transition in preparation of the transition to a community setting.

8.560 CLINIC SERVICES – CERTIFIED HEALTH AGENCIES

Clinic Services rendered by certified health agencies shall be a benefit of the Colorado Medical Assistance Program for categorically eligible individuals.

8.560.1 DEFINITIONS

For the purposes of this Section 8.560, the following definitions shall apply:

A. Certified health agency: a county/district health department, regional health department or local board of health established pursuant to part 5, 6, or 7 of

article 1 of title 25, C.R.S., that is certified by the Colorado State Department of Health.

B. Nurse/Nurse practitioner: a registered professional nurse who is currently licensed to practice in the State of Colorado and who meets the qualifications established by the Nurse Practice Act.

C. Nurse-midwife: a registered professional nurse currently licensed to practice in the State of Colorado who meets the following requirements: is certified as a nurse-midwife by the American College of Nurse-Midwives; is authorized under state statute to practice as a nurse-midwife; and whose services are rendered pursuant to the Colorado Medical Practice Act.

D. Physician assistant/child health associate: a certified individual who performs under the supervision of a physician and meets the qualifications of the Colorado State Board of Medical Examiners.

E. Physician: a doctor of medicine, osteopathy, legally authorized to provide medicine or surgery in Colorado.

F. Medicaid primary care physician: a physician enrolled in the Primary Care Physician Program under the Colorado Medical Assistance Program.

G. Visit: a face-to-face encounter between a clinic patient and nurse/nurse practitioner/nurse-midwife, physician assistant/child health associate, or physician providing services reimburseable under the Medicaid Program. If a patient sees more than one health professional, or meets more than once with the same health professional, on the same day and at a single location, this shall be counted as one visit.

8.561 REQUIREMENTS FOR CERTIFICATION

A. Participating health agencies must be certified by the Colorado State Department of Health in accord with federal regulations 42 CFR 431.610, October 1991 edition. No amendments or later editions are incorporated. Copies are available for inspection and available at cost at the following address: Manager, Health and Medical Services, Colorado Department of Social Services, 1575 Sherman Street, Denver, Colorado 80203-1714. Certified health agencies performing laboratory services must be certified as a clinical laboratory in accordance with regulations cited at 8.660 through 8.666. Certified health agencies must obtain a certificate of waiver from the Health Care Financing Administration or its designated agency if the health agency only performs waivered tests as defined by Clinical Laboratory Improvement Amendments of 1988 (CLIA).

B. All certified health agencies and staff shall comply with all applicable federal, state and local regulations concerning the operation of such clinic services.

These include but are not limited to the following: certification, organization, staffing, licensure of personnel, service provision responsibilities, maintenance of health records and program evaluation.

C. Termination of certification or non-renewal of certification will be determined by the Colorado State Department of Health.

8.562 REQUIREMENTS FOR PARTICIPATION

Health agencies providing clinic services must be certified by the Colorado State Department of Health, must enroll in the Medical Assistance Program and provide proof of their certification status in order to participate under Medicaid. The certification document must be attached to the Medical Assistance enrollment form. Medical Assistance enrollment and/or reimbursement cannot be accomplished without proof of certification on file with the State's fiscal agent for the effective date of enrollment and date of service for which reimbursement is claimed.

8.563 BENEFITS AND LIMITATIONS

Clinic Services are a benefit of the Medical Assistance Act in Colorado when:

A. The services are benefits of the Colorado Medicaid Program as determined by the Colorado State Department of Social Services;

B. The services which are performed are medically necessary;

C. The services are provided by certified health agencies;

D. The services which are performed are within the scope of the providers' Medical and/or Nurse Practice Acts;

E. The services are provided by a registered nurse, qualified nurse practitioner, or certified nurse-midwife or by a physician or physician's assistant (including child health associates) certified by the Colorado State Board of Medical Examiners;

F. The services provided are obstetrical services which are benefits of the Medicaid program; or G. The services provided are EPSDT medical screening services which meet the requirements set forth in sections 8.285.02 through 8.287.01.

8.564 BILLING PROCEDURES

A. Certified health agencies providing clinic services must bill the Medical Assistance Program directly using the designated billing method and the prescribed procedure codes recognized by the Colorado State Department of Social Services. The amount of the provider's usual and customary charges to the general public will be billed if applicable.

B. Obstetrical services and adjunctive services, except for EPSDT medical screenings, must be billed directly as described in 10 C.C.R. 2505-10, Section 8.040.2.

C. EPSDT medical screening services must be billed directly on the EPSDT Screening/Claim Form.

8.565 REIMBURSEMENT

Reimbursement shall be made according to the following:

A. Payment for benefit services shall be in accord with the physician reimbursement policies as cited in Section 8.200 et seq.

B. Each certified health agency will be reimbursed for only those services performed for which it is certified and for only one visit per recipient per day.

C. Reimbursement for injectable vaccines obtained through the Infant Immunization Program is limited to the maximum allowed administrative fee.

D. A health agency must be certified on any date for which reimbursement is being claimed. If reimbursement is claimed for a date of service on which the health agency is not certified, reimbursement shall be denied.

8.566 APPEALS

Provider grievances and appeals, resulting from State actions under this section of regulations, shall be handled in accordance with existing appeals regulations delineated in Sections 8.049 through 8.051.44.

8.567 CERTIFIED HEALTH AGENCY/PHYSICIAN RELATIONSHIP

A. Obstetrical services require referral from the Medicaid Primary Care (PCP) or “Lock-In” physician. The certified agency will contact the PCP to obtain the appropriate referral for obstetrical services.

B. EPSDT medical screenings require referral from the Medicaid Primary Care (PCP) or “Lock-In” physician. The certified agency will contact the PCP to obtain the appropriate referral for EPSDT Medical screening services.

C. Medical support and approval for the policies and procedures of the local certified health agency's Well Child Clinics and Prenatal Clinics may be provided by the agency health officer, medical director or other physician (pediatrician, family practitioner or obstetrician) agreed upon by the public health nursing staff and their health officer. A physician must sign and annually review the agency's emergency procedures for reactions to biologicals.

D. The certified health agency shall assure that a physician is available during agency hours by direct means of communication for assistance in emergencies and for consultation and referral if medical diagnosis and/or treatment is needed.

This requirement may be satisfied by agreements with one or more physicians.

Whenever possible, the certified health clinic practitioner will interact with the client's primary care physician when medical consultation is needed and will provide the primary care physician a copy of each EPSDT medical screening and obstetrical service record.

8.570 AMBULATORY SURGERY CENTERS

8.570.1 DEFINITIONS

Ambulatory Surgery Center (ASC) means an entity that operates exclusively for the

purpose of furnishing surgical services for its clients that do not require hospitalization.

An ASC may be independent or part of a hospital, but only if the building space utilized by the ASC is physically, administratively, and financially independent and distinct from other operations of the hospital.

CMS means the Centers for Medicare and Medicaid Services.

The Department refers to the Colorado Department of Health Care Policy and Financing.

Inpatient Basis in Hospitals means preventive, therapeutic, surgical, diagnostic, medical and rehabilitative services that are furnished by the Hospital for the care and treatment of inpatients and are provided in the Hospital by or under the direction of the physician.

8.570.2 REQUIREMENTS FOR PARTICIPATION 8.570.2.A. An ASC shall be certified by CMS to participate in the Medicare program as an ASC and be licensed by the Colorado Department of Public Health and Environment as an ASC.

8.570.3 COVERED SERVICES AND LIMITATIONS 8.570.3.A. Covered services are those surgical and other medical procedures that:

Are ASC procedures that are grouped into categories corresponding to the CMS defined groups.
Are commonly performed on an inpatient basis in hospitals, but may be safely performed in an ASC.
Are limited to those requiring a dedicated operating room (or suite), and generally requiring a post-operative recovery room or short-term (not overnight) convalescent room. 8.570.3.B. Covered surgical procedures are limited to those that do not generally exceed:
A total of 4 hours recovery or convalescent time. 8.570.3.C. If the covered surgical procedures require anesthesia, the anesthesia must be:
Local or regional anesthesia; or 2. General anesthesia.

8.570.4. DENTAL PROCEDURES

Qualifying clients may receive covered and medically necessary dental services in an ASC when those services cannot be delivered safely and effectively in a private office.

8.570.5 NON-COVERED SERVICES 8.570.5.A Non-covered services are those services that:

Are not commonly performed in an ASC;
May safely be performed in a physician’s office;
Generally result in extensive blood loss;
Require major or prolonged invasion of body cavities;
Directly involve major blood vessels;
Are generally emergency or life-threatening in nature;
Pose a significant safety risk to clients or are expected to require active medical monitoring at midnight of the day on which the surgical procedure is performed (overnight stay) when furnished in an ASC; or, 8. Are not listed in the annual ASC billing manual.

8.570.6. CLIENT ELIGIBILITY

Eligible Clients include any Client enrolled in Colorado Medicaid for whom a covered ASC service is a medical necessity as defined at 10 CCR 2505-10 Section 8.076.1.8.

8.570.7. PRIOR AUTHORIZATION

The physician performing the surgery shall be responsible for obtaining all necessary Prior Authorizations for those procedures requiring pre-procedure approval by the 8.570.8 REIMBURSEMENT 8.570.8.A For payment purposes, ASC surgical procedures are placed into groupers.

The Health Care Procedural Coding System (HCPCS) is used to identify surgical 8.570.8.B Reimbursement for approved surgical procedures shall be allowed only for the primary or most complex procedure. No reimbursement is allowed for multiple or subsequent procedures. No reimbursement shall be allowed for services not included on the Department approved list for covered services.

Approved surgical procedures identified in the ASC groupers shall be reimbursed a facility fee at the lower of the following:

Submitted charges; or 2. Department approved list for covered services.

8.570.9 ALLOWABLE COSTS 8.570.9.A The services payable under this rule are facility services furnished to clients in connection with covered surgical procedures specified in Section 8.570.3.

Services and items reimbursed as part of the facility fee include, at a minimum, the following:

a. Use of the facilities where the surgical procedures are performed.

b. Nursing, technician, and related services.

c. Drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances and equipment directly related to the provision of surgical procedures.

d. Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure.

e. Administrative, record keeping and housekeeping items and f. Materials for anesthesia.

g. Intra-ocular lenses (IOLs).

h. Supervision of the services of an anesthetist by the operating surgeon.

Services and items that are not reimbursed as part of the facility fee, but that may be reimbursed separately include the following:

a. Physician services.

b. Anesthetist services.

c. Laboratory, X-ray or diagnostic procedures (other than those directly related to performance of the surgical procedure.)

d. Prosthetic devices (except IOLs).

e. Ambulance services.

f. Leg, arm, back and neck braces.

g. Artificial limbs.

h. Durable medical equipment for use in the client's home.

8.571 CLINIC SERVICES - AMBULATORY SURGERY CENTER, PHYSICIAN PRIOR

AUTHORIZATION

The physician performing the surgery shall be responsible for obtaining all necessary Prior Authorizations for those procedures requiring pre-procedure approval by the 8.580 DURABLE MEDICAL EQUIPMENT – OXYGEN AND OXYGEN EQUIPMENT 8.580.1 DEFINITIONS 8.580.1.A. Concentrator means an oxygen delivery system that operates electrically to concentrate oxygen from room air. 8.580.1.B. Hypoxemia means deficient oxygenation of blood. 8.580.1.C Nursing Facility means nursing facilities, intermediate nursing facilities, and skilled nursing facilities that receive facility payment reimbursement for care. 8.580.1.D. Oxygen Concentrator is the same as a concentrator. 8.580.1.E. Oxygen Delivery System means the method by which oxygen is delivered to the client. 8.580.1.F. Portable Oxygen System means an oxygen delivery system, utilizing either concentrators or tanks, that can be easily moved with the client on a frequent basis. 8.580.1.G. Post-Acute Oxygen Therapy means providing short term oxygen lasting three months or less to address a client’s acute condition that is expected to resolve. 8.580.1.H. Stationary Oxygen Delivery System means an oxygen delivery system that cannot be easily moved with the client on a frequent basis and does not concentrate oxygen from room air. 8.580.1.I. Ventilator means a device to assist or control ventilation for a client who is unable to maintain spontaneous ventilation unassisted.

8.580.2 CLIENT ELIGIBILITY 8.580.2.A. All Colorado Medicaid clients are eligible for oxygen therapy and oxygen equipment deemed medically necessary, as defined in Section 8.076.1.8.

8.580.3 PROVIDER ELIGIBILITY 8.580.3.A. Ordering, Prescribing, Referring (OPR) Providers 1. The following providers are eligible to order, prescribe, or refer oxygen therapy and oxygen equipment when the provider is enrolled with Colorado Medicaid and licensed by the Colorado Department of Regulatory Agencies, or the licensing agency of the state in which they are licensed:

a. Doctors of Medicine (MD)

b. Doctors of Osteopathy (DO)

c. Physician Assistants d. Nurse Practitioners 8.580.3.B. Rendering Providers 1. The following providers are eligible to render oxygen therapy and oxygen equipment when the provider is enrolled with Colorado Medicaid and licensed by the licensing agency of the state in which they do business:

a. Durable Medical Equipment (DME) Providers enrolled in Colorado Medicaid, otherwise referred to as “suppliers.”

8.580.4 PLACES OF SERVICES 8.580.4.A. Eligible Places of Services 1. The following places are eligible for a client to receive oxygen and oxygen equipment:

a. Home b. Nursing Facilities and group homes c. Intermediate care facilities for individuals with intellectual disabilities d. Hospitals i. Oxygen contents and oxygen equipment provided to hospitalized clients must be provided by the hospital and cannot be submitted for direct payment by the supplier.

Reimbursement for oxygen and oxygen equipment in hospitals is provided under Section 8.580.8.A.5.

8.580.5 COVERED SERVICES AND EQUIPMENT 8.580.5.A. The following clients require a prescription for oxygen therapy and oxygen equipment, but are otherwise exempt from the coverage requirements of this subsection at Section 8.580.5:

Ventilator-dependent clients; and 2. Clients covered under the child health component of Medicaid known as Early and Periodic Screening, Diagnosis and Treatment (EPSDT), as identified in Section 8.280. 8.580.5.B. Post-Acute Oxygen Therapy 1. Post-Acute Oxygen Therapy may be provided to clients for up to ninety days with a prescription from an OPR provider identified in Section 8.580.3.A.

a. Post-Acute Oxygen Therapy requires a documented assessment of Hypoxia. 8.580.5.C. Long Term Oxygen Therapy Prescription 1. Long Term Oxygen Therapy may be provided to clients for greater than ninety days with a prescription from an OPR provider identified in Section 8.580.3.A.

a. Review and renewal of the prescription required under Section 8.580.5.C.1 is required every twelve months or when the client’s condition changes, whichever comes first. Pursuant to Public Law 116-127, the Families First Coronavirus Response Act, § 6008, continued coverage of oxygen was required during the Coronavirus Disease 2019 (COVID-19) public health emergency as it was covered prior the emergency. For the duration of the COVID-19 public health emergency, the review required every twelve months under this section, and the requirement for annual review pursuant to 42 C.F.R. 440.70(b)(3)(iii), was suspended.

Suppliers must have a completed and current prescription on file to support claims for oxygen therapy and oxygen equipment for nonventilator dependent clients aged twenty and older requiring long term oxygen therapy lasting ninety days or more. For clients certified for twentyfour consecutive months, the most recent annual review pursuant to 42 C.F.R. 440.70(b)(3)(iii) must be on file. 8.580.5.D. Portable Oxygen Systems 1. Clients aged twenty-one and above may qualify for a Portable Oxygen System either by itself or to use in addition to a Stationary Oxygen Delivery System if the following requirements are met:

a. The Section 8.580.5.B or Section 8.580.5.C requirements are satisfied, and b. The medical documentation indicates the client is mobile in their residence or mobile in the community and would benefit from the use of a Portable Oxygen System.

Portable Oxygen Systems are not covered for clients who qualify for oxygen solely based on blood gas studies obtained during sleep unless the client resides in a Nursing Facility.
If a client resides in a Nursing Facility and receives portable oxygen while sleeping outside their room, the client should be assessed for continuous oxygen need.

8.580.6 PRIOR AUTHORIZATION REQUIREMENTS 8.580.6.A. There are no prior authorization requirements for oxygen therapy and oxygen equipment.

8.580.7.A NON-COVERED SERVICES

Oxygen therapy and oxygen equipment is not covered if a client exhibits any of the following conditions:

a. Chronic angina pectoris in the absence of Hypoxemia.

b. Breathlessness without cor pulmonale or evidence of Hypoxemia.

8.580.8.A REIMBURSEMENT

To receive reimbursement, provider records must include, but are not limited to:

a. All oxygen therapy and oxygen equipment orders and prescriptions;

i. Oxygen therapy and oxygen equipment provided for Post Acute Oxygen Therapy of less than ninety days requires a documented assessment of Hypoxia under Section 8.580.5.B.1.a.

b. Record of oxygen-related items provided;

c. Documentation that the client, or the client’s caregiver, was provided with manufacturer instructions, warranty information, service manual, and operating instructions for the rendered oxygen therapy and oxygen equipment.

Medicaid will not reimburse as primary payer for DME oxygen for clients that are:

a. Dually eligible for Medicare and Medicaid, b. Aged twenty-one or above, and c. Not receiving benefits in a Nursing Facility or intermediate care facility for individuals with intellectual disabilities.

Medicaid will not reimburse as a primary payer for DME oxygen for clients that are:

a. Dually eligible for Medicare and Medicaid, b. Aged twenty-one or above, and c. Receiving Medicare-covered skilled nursing services in a Nursing Facility.

Oxygen therapy and oxygen equipment provided in a client’s home:

a. Suppliers must directly bill the Department for medically necessary liquid or gaseous oxygen equipment provided in a client’s home or place of residence, not to include Nursing Facilities.

b. Reimbursement to a rendering provider for Oxygen Therapy or Oxygen Equipment must be the lower of the provider’s billed charge or the Department’s fee schedule.

Oxygen therapy and oxygen equipment provided to hospitalized clients a. Oxygen therapy and oxygen equipment, when medically necessary and prescribed by an OPR provider for any form of oxygen for a client a hospital setting, inpatient or outpatient, must be provided by the hospital and is included in the Medicaid payment for inpatient hospital services.
Oxygen therapy and oxygen equipment provided to Nursing Facility and group home clients a. Suppliers must bill the Department directly for medically necessary liquid or gaseous oxygen therapy, and oxygen equipment needed for the administration of liquid or gaseous oxygen, if provided to clients residing in Nursing Facilities that are reimbursed at a per diem amount.

b. Oxygen Concentrators for use by clients residing in a Nursing Facility or group home being reimbursed at a per diem rate must be provided in one of the following ways:

i. Oxygen Concentrators purchased by the Nursing Facility or group home must be included in the facility cost report and reimbursed through the per diem rate. All necessary oxygenrelated supplies must be provided by the facility in accordance with Section 8.441.5.K.

ii. Clients residing in Nursing Facilities or group homes that do not purchase oxygen Concentrators must obtain equipment and supplies from an authorized supplier. The supplier must provide equipment, oxygen and supplies for use by a specific client, as ordered by the client’s OPR provider, and must bill on the state approved form.

c. Nursing Facilities and group homes must provide the following information in a certification statement to suppliers within twenty (20) days of the date the supplier delivers the oxygen therapy or oxygen equipment:

i. The name and Medicaid identification number for all Medicaid clients provided liquid or gaseous oxygen, or the equipment or supplies necessary for administration by the supplier;

ii. An indication of whether any Medicaid clients identified in (i) have Medicare Part A or Medicare Part B, or any other thirdparty resources;

iii. The name and state identification number for all Medicaid clients identified in (i) that utilize an oxygen concentrator rented, but not purchased, from the supplier. This applies only to clients in Nursing Facilities or group homes that do not purchase oxygen Concentrators;

iv. A certification guaranteeing that oxygen therapy and oxygen equipment obtained from the supplier was used only by the individual Medicaid client for which it was supplied. Where centralized oxygen systems are utilized, each Medicaid client’s oxygen usage must be documented and identified in the certification statement in liters.

d. Rendering providers (suppliers) must bill the Department for oxygen therapy and oxygen equipment based on the information provided by the Nursing Facility or group home in the Certification Statement, as required by Section 8.580.8.A.6.c. A rendering provider’s reimbursement rate for oxygen therapy and oxygen equipment must be the lower of the provider’s billed charges or the Department’s fee schedule.

8.590 DURABLE MEDICAL EQUIPMENT AND DISPOSABLE MEDICAL SUPPLIES

8.590.1 DEFINITIONS

A. Abuse, for the purposes of Section 8.590, means the intentional destruction of or damage to Durable Medical Equipment, Prosthetics, Orthotics, and Supplies that results in the need for repair or replacement.

B. Billing Manual, for the purposes of Section 8.590, means a reference document that assists providers with appropriately billing claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.

C. Cochlear Implant or cochlear prosthesis means an electrode or electrodes surgically implanted in the cochlea which are attached to an induction coil buried under the skin near the ear, and the associated unit which is worn on the body.

D. Complex Rehabilitation Technology means individually configured manual Wheelchair systems, power Wheelchair systems, adaptive seating systems, alternative positioning systems, standing frames, gait trainers, and specifically designated options and accessories, which qualify as Durable Medical Equipment that:

Are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living, including employment, identified as medically necessary to promote mobility in the home and community or prevent hospitalization or institutionalization of the member;
Are primarily used to serve a medical purpose and generally not useful in the absence of disability, illness or injury; and 3. Require certain services provided by a qualified Complex Rehabilitation Technology Supplier to ensure appropriate design, configuration, and use of such items, including patient evaluation or assessment of the member by a Qualified Health Care Professional, and that are consistent with the member’s medical condition, physical and functional needs and capacities, body size, period of need, and intended use.

E. Complex Rehabilitation Technology Professional means an individual who is certified by the Rehabilitation Engineering and Assistive Technology Society of North America or other nationally recognized accrediting organizations as an assistive technology professional.

F. Complex Rehabilitation Technology Supplier means a provider who meets all the requirements of Section 8.590.5.D. The following are terms defined in relation to complex rehabilitation technology (CRT) suppliers only, see Section 8.590.5.E.

Evaluation is when a supplier assesses the potential need for repair, replacement, and or modification. An evaluation may occur at the member’s residence, supplier’s facility, virtually, or other agreed upon location.
Order creation date is the date the evaluation is scheduled.
Repair fulfillment is when the repair has been completed, and any need for pick up or drop off equipment has occurred.

G. Disposable Medical Supplies (Supplies) means health care related items that are consumable, disposable, or cannot withstand repeated use by more than one individual. Supplies are required to address an individual medical disability, illness or injury.

H. Durable Medical Equipment (DME) means items, including Prosthetics and Orthotics, that are primarily and customarily used to serve a medical purpose, generally are not useful to an individual in the absence of a disability, illness or injury, can withstand repeated use, and can be reusable or removable.

I. Facilitative Device means DME with a retail price equal to or greater than one hundred dollars that is exclusively designed and manufactured for a member with disabilities to improve, maintain or restore self-sufficiency or quality of life through facilitative technology. Facilitative Devices do not include Wheelchairs.

J. Financial Relationship means any ownership interest, investment interest or compensation arrangement between a provider, or their officers, directors, employees or Immediate Family Members of the provider, and the entity. An ownership or investment interest may be reflected in equity, debt, or other instruments and includes, but is not limited to, mortgages, deeds of trust, notes or other obligations secured by either entity.

K. Hearing Aid means a wearable instrument or device designed or offered for the

purpose of aiding or compensating for impaired human hearing and any parts, attachments, or accessories thereto, including ear molds but excluding batteries and cords.

L. Immediate Family Member means any spouse, natural or adoptive parent, natural or adoptive child, stepparent, stepchild, sibling or stepsibling, in-laws, grandparents and grandchildren.

M. Licensed Practitioner means, for the purposes of Section 8.590, a provider who is permitted to order, prescribe, refer, or render services related to Durable Medical Equipment, Prosthetic or Orthotic Devices, and Disposable Medical Supplies within their scope of practice as defined by state law.

N. Medical Necessity means, for the purposes of Section 8.590, the definition provided at Section 8.076.1.8 and, for members under the age of 21, the definition provided at Section 8.280.4.E.2.

O. Misuse means failure to maintain or the intentional utilization of DME and Supplies in a manner not prescribed, recommended or appropriate that results in the need for repairs or replacement. Misuse also means DME and Supplies used by someone other than the member for whom it was prescribed.

P. Prosthetic or Orthotic Device means replacement, corrective or supportive devices that artificially replace a missing portion of the body, prevent or correct physical deformity or malfunction, or support a weak or deformed portion of the body.

Q. Qualified Health Care Professional means a licensed physical therapist, a licensed occupational therapist, or other licensed health care professional who performs specialty evaluations within his/her scope of practice and who has no Financial Relationship with a Complex Rehabilitation Technology Supplier.

R. Related Owner means an individual with 5% or more ownership interest in a business and one entitled to a legal or equitable interest in any property of the business whether the interest is in the form of capital, stock, or profits of the business.

S. Related Party means a provider who is associated or affiliated with, or has control of, or is controlled by the organization furnishing the DME and Supplies.

An Owner Related Individual shall be considered an individual who is a member of an owner’s Immediate Family.

T. Speech Generating Device (SGD) means a device that provides multiple methods of message formulation and is used to establish, develop or maintain the ability to communicate functional needs. These devices are electronic and computer based and can generate synthesized (computer-generated) or digitized (natural human) speech output for expressive communication.

U. Start Of Service means the date that the ordering practitioner signs the written order for durable medical equipment following the face-to-face encounter with the member.

V. Wheelchair means any wheelchair or scooter that is motor driven or manually operated for the purposes of mobility assistance, whether purchased by the Department or donated to the member.

W. Wrongful Disposition means the mismanagement of DME and Supplies by a member by selling or giving away the item reimbursed by the Department.

8.590.2 BENEFITS 8.590.2.A. All covered DME and Supplies shall, at a minimum, be:

Medically Necessary; and 2. Prescribed by a Licensed Practitioner.
At-home over-the-counter COVID-19 tests may be prescribed by a licensed pharmacist. 8.590.2.B. DME and Supplies for Members Residing in Facilities 1. DME and Supplies shall not be separately billed, except under the following circumstances:

a. The member is within fourteen days of discharge, and b. Prior authorization or training are needed to assist the member with equipment usage, and c. The equipment is needed immediately upon discharge from the facility.

Repairs and modifications to member owned DME that was purchased prior to the admission to the facility may be provided and billed separately.
Prosthetic or Orthotic Devices may only be provided during an admission in a hospital, nursing facility, or other facility if they are specifically excluded from the facility payment. 8.590.2.C. DME and Supplies shall not be duplicative or serve the same purpose as items already utilized by the member unless it is medically required for emergency or backup support. Backup equipment shall be limited to one. 8.590.2.D. All DME and Supplies reimbursed for by the Department shall become the property of the member unless the member and provider are notified otherwise by the Department at the time of purchase. 8.590.2.E. Rental equipment shall be provided if the Department determines it to be cost effective and Medically Necessary. 8.590.2.F. Supplies shall be for a specific purpose, not incidental or general purpose usage. 8.590.2.G. The following DME and Supplies categories are benefits for members regardless of age, and include but are not limited to:
Ambulation devices and accessories including but not limited to canes, crutches or walkers.
Bath and bedroom safety equipment.
Bath and bedroom equipment and accessories including, but not limited to, specialized beds and mattress overlays.
Manual or power Wheelchairs and accessories.
Diabetic monitoring equipment and related disposable supplies.
Elastic supports/stockings.
Blood pressure, apnea, blood oxygen, pacemaker and uterine monitoring equipment and supplies.
Oxygen and oxygen equipment in the member’s home, a nursing facility or other institution. The institutional oxygen benefit is fully described in

Section 8.580.

Transcutaneous and/or neuromuscular electrical nerve stimulators (TENS/NMES) and related supplies.
Trapeze, traction and fracture frames.
Lymphedema pumps and compressors.
Specialized use rehabilitation equipment.
Oral and enteral formulas and supplies.
Parenteral equipment and supplies.
Environmental controls for a member living unattended if the controls are needed to assure medical safety.
Facilitative Devices.

a. Telephone communication devices for the hearing impaired and other facilitative listening devices, except hearing aids and Cochlear Implants.

b. Computer equipment and reading devices with voice input or output, optical scanners, talking software, Braille printers and other devices that provide access to text.

c. Computer equipment with voice output, artificial larynges, voice amplification devices and other alternative and augmentative communication devices.

d. Voice recognition computer equipment software and hardware and other forms of computers for persons with disabilities.

e. Any other device that enables a person with a disability to communicate, see, hear or maneuver including artificial limbs and orthopedic footwear.

Complex Rehabilitation Technology. 8.590.2.H. The following DME are benefits to members under the age of 21:
Hearing aids and accessories.
Phonic ear.
Therapy balls for use in physical or occupational therapy treatment.
Selective therapeutic toys.
Computers and computer software when utilization is intended to meet medical rather than educational needs.
Vision correction unrelated to eye surgery. 8.590.2.I. The following Prosthetic or Orthotic Devices are benefits for members regardless of age:
Artificial limbs.
Facial Prosthetics.
Ankle-foot/knee-ankle-foot orthotics.
Recumbent ankle positioning splints.
Thoracic-lumbar-sacral orthoses.
Lumbar-sacral orthoses.
Rigid and semi-rigid braces.
Therapeutic shoes.
Orthopedic footwear, including shoes, related modifications, inserts and heel/sole replacements.
Specialized eating utensils and other medically necessary activities of daily living aids.
Augmentative communication devices and communication boards. 8.590.2.J. Repairs and replacement parts are covered under the following conditions:
The item was purchased by Health First Colorado; or 2. The item is owned by the member, member’s family, or member’s guardian;
The item is used exclusively by the member;
The item’s need for repair was not caused by member Misuse or Abuse;
The item is no longer under the manufacturer warranty. 8.590.2.K. The minimum replacement timeline for a Speech Generating Device is five years.
Stolen devices may be replaced within the five-year timeline; however, the member is limited to one-time replacement due to theft, and a police report must be provided for verification of the incident.
Replacement will not be granted within the five-year timeline for devices that are damaged, lost, misused, abused or neglected. 8.590.2.L. Repairs, replacement, and maintenance shall be:
Based on the manufacturer’s recommendations, 2. Performed by a qualified rehabilitation professional, and 3. Allowed on the member’s primary equipment or one piece of backup 4. Multiple backup equipment will not be repaired, replaced or maintained. 8.590.2.M. If repairs are frequent and repair costs approach the purchase price of new equipment, the provider shall make a request for the purchase of new equipment. The prior authorization request shall include supporting documentation explaining the need for the replacement equipment and the cost estimates for repairs on both the old equipment and the new equipment purchase. 8.590.2.N. Supplies are a covered benefit when related to the following:
Surgical, wound or burn care.
Syringes or needles.
Bowel or bladder care.
Incontinence.
Antiseptics or solutions.
Gastric feeding sets and supplies.
Tracheostomy and endotracheal care supplies.
Diabetic monitoring. 8.590.2.O. Quantities of Supplies shall not exceed one month’s supply unless they are only available in larger quantities as packaged by the manufacturer. 8.590.2.P. Health First Colorado members for whom Wheelchairs, Wheelchair component parts, and other specialized equipment were authorized and ordered prior to enrollment in a Managed Care Organization, but delivered after the Managed Care Organization enrollment shall be the responsibility of the Department. All other DME and Supplies for members enrolled in a Managed Care Organization shall be the responsibility of the Managed Care Organization. 8.590.2.Q. Items, for the purposes of Section 8.590, that are used for the following are not a benefit to a member of any age:
Routine personal hygiene.
Education.
Exercise.
Participation in sports.
Cosmetic purposes. 8.590.2.R. For members age 21 and over, the following items are not a benefit:
Hearing aids and accessories.
Phonic ears.
Therapeutic toys.
Vision correction unrelated to eye surgery. 8.590.2.S. Rental Policy.
The Department may set a financial cap on certain rental items. The monetary price for those items shall be determined by the Department and noted in the fee schedule. The provider is responsible for all maintenance and repairs as described at Section 8.590.4.L-P, until the cap is reached.
Upon reaching the capped amount, the equipment shall be considered purchased and shall become the property of the member. The provider shall give the member or caregiver all applicable information regarding the equipment. The equipment shall not be under warranty after the rental period ends.
The rental period may be interrupted for a maximum of sixty consecutive days.

a. If the rental period is interrupted for a period greater than sixty consecutive days, the rental period must begin again. The interruption must be justified, documented by a Licensed Practitioner, and maintained by the provider as described at

Section 8.590.4.E.7.

If the member changes providers, the current rental cap remains in force.

8.590.3 PRIOR AUTHORIZATION 8.590.3.A. Selected DME and Supplies require prior authorization approval. All items requiring prior authorization are listed in the Billing Manual. 8.590.3.B. Prior authorization shall not be required for Medicare covered crossover claims. 8.590.3.C. Prior authorization shall be required for members who have other primary insurance besides Medicare. 8.590.3.D. Prior authorization requests shall include the following information:

A full description of the item(s).
The requested number of items.
A full description of all attachments, accessories and/or modifications needed to the basic item(s).
The effective date and estimated length of time the item(s) will be needed.
The medical diagnosis, prognosis for improvement or deterioration, description of previous and current treatments and any other clinical information necessary to establish Medical Necessity for the member.
Descriptions of any specific physical limitations, or current functional needs the member may have that are relevant to the prior authorization consideration.
The member’s prescribing Licensed Practitioner’s, primary care physician’s and provider’s name and identification numbers.
The serial numbers for all Wheelchair repairs.
The prescribing Licensed Practitioner’s signature. The prescribing Licensed Practitioner shall either sign the authorization or attach a written prescription or letter of Medical Necessity to the authorization. 8.590.3.E. Prior authorization requests for DME must meet the prior authorization criteria at Section 8.590.3.D and the applicable DME or Supply specific criteria below:
Prior authorization requests for Speech Generating Devices shall include a communication assessment, made by a licensed speech-language pathologist, which provides documentation of:

a. The member’s communication limitations and skills;

b. A history of communication-related therapies;

c. A description of any trials required for the recommended device, including how each device trial met or failed to meet the member’s functional communication needs;

d. Evidence that alternative, natural communication methods have been ineffective;

e. The member’s ability to operate the device both cognitively and physically; and f. Expected improvement in the member’s independence or personal safety, ability to communicate medical and basic needs, provide feedback on treatment or therapy programs, and prevent secondary impairments. 8.590.3.F. Diagnostic and clinical information shall be completed prior to the Licensed Practitioner’s signature. The provider shall not complete or add information after the Licensed Practitioner has signed the document. 8.590.3.G. Requests for prior authorization shall be submitted in a timely fashion.

Requests for prior authorization submitted with a begin date in excess of three months prior to the date of submission shall include additional, updated documentation indicating the continued Medical Necessity of the request.

Retroactive approval beyond three months without such documentation shall be considered only in cases of member retroactive program eligibility. 8.590.3.H. Approval of a prior authorization does not guarantee payment or constitute a waiver of any claims processing requirements including, but not limited to, eligibility and timely filing.

8.590.4 PROVIDER RESPONSIBILITIES 8.590.4.A. Providers shall issue express warranties for Wheelchairs and Facilitative Devices and shall assure that any refund resulting from the return of a Wheelchair or other Facilitative Device is returned to the Department in compliance with Sections 6-1-401 to 6-1-412, C.R.S. and Sections 6-1-501 to 6- 1- 511, C.R.S. 8.590.4.B. The Provider shall implement a system that supports member autonomy and describes how equipment will be serviced and maintained, routine follow-up and response procedures to prevent any interruption of services to the members.

This system shall include provisions describing how service and repairs may occur at the member’s location when appropriate.

Providers shall furnish the member with written information at the time of sale on how to access service and repair. 8.590.4.C. The Provider shall implement and maintain a process for honoring all warranties expressed and implied under applicable State laws. 8.590.4.D. Providers of custom Wheelchairs, seating products and any other DME shall be able to appropriately assess and provide adequate repairs, adjustment and service by qualified rehabilitation professionals for all products they distribute. 8.590.4.E. Providers shall maintain the following for all items provided to a member:
Licensed Practitioner prescriptions.
Approved prior authorization requests.
Additional documentation received from physicians or other licensed practitioners.
Documentation that the member or caregiver has been provided with the a. Manufacturer’s instructions.

b. Warranty information.

c. Registration documents.

d. Service manual.

e. Operating guides.

Documentation for all reimbursed equipment, which shall include:

a. Manufacturer’s name and address.

b. Date acquired.

c. Acquisition cost.

d. Model number.

e. Serial number.

f. Accessories, attachments or special features included in the item.

Providers shall verify that equipment requiring repairs belongs to the presenting member.
Providers shall retain all documentation seven years.
Providers shall provide a copy of all documentation to a member or their representative, if requested. 8.590.4.F. Providers shall be responsible for delivery of and instructing the member on the proper use of the ordered/authorized equipment or supplies appropriate for the stated purpose consistent with the requirements, goals and desired outcomes at the time of the prescription and delivery. 8.590.4.G. The provider shall be responsible for member evaluation, wheelchair measurements and fittings, member education, adjustments, modifications and delivery set-up installation of equipment in the home. If modifications require the provider to fabricate customized equipment or orthotics to meet member needs, the provider shall justify the necessity and the cost of additional materials of the modifications. Modifications shall not alter the integrity, safety or warranty of the 8.590.4.H. The provider shall pick up inappropriate or incorrect items within five business days of being notified. The provider shall not bill the Department for items known to be inappropriate or incorrect and awaiting pick-up. The provider shall submit a credit adjustment to the Department within twenty business days following the pick-up date if a claim was submitted prior to notification an item was inappropriate or incorrect. 8.590.4.I. Providers shall confirm continued need for disposable supplies with the member or caretaker prior to supply shipment. 8.590.4.J. All purchased equipment shall be new at the time of delivery to the member unless an agreement was reached in advance with the member and 8.590.4.K. Providers shall provide DME and Supplies, repairs and all other services in the same manner they provide these services to non-Health First Colorado members. 8.590.4.L. Providers shall ensure the equipment provided will be warranted in accordance with the manufacturer’s warranty. The provider shall not bill Health First Colorado or the member for equipment, parts, repairs, or other services covered by the warranty. 8.590.4.M. The following requirements shall apply to warranted items:
The provider shall provide adequate repairs, adjustments and services by appropriately trained technicians for all products they distribute.
The provider shall complete services or repairs in a timely manner and advise the member on the estimated completion time.
The provider shall arrange for appropriate alternative, like equipment in the absence of member owned backup equipment. The provider shall provide the alternative equipment at no cost. If the backup equipment is not available as loan equipment, the provider shall arrange for a temporary equipment rental through the Department.
The provider shall exclude from warranty provisions, replacement or repairs to equipment that are no longer able to meet member needs due to changes in anatomical and/or medical condition that occurred after purchase.
The provider may refuse warranty services on items for which there have been documented patterns of specific member Misuse or Abuse. The provider shall notify the Department in all documented cases of Misuse or Abuse within ten business days of learning of the incident of Misuse or Abuse. 8.590.4.N. Previously used or donated DME may be provided to the member if agreed upon by the member and the Department. Approval will be coordinated by the Utilization Management Vendor. 8.590.4.O. The Provider shall assure that used or donated items provided meet the following conditions:
The item is fully serviced and reconditioned.
The item is functionally sound and in good operating condition.
The item will be repaired and have parts replaced in a manner equivalent to an item that is new. The item will have parts available for future repairs in a manner equivalent to the manufacturer’s warranty on a like item which is new.
The provider will make all adjustments and modifications needed by the member during the first year of use, except for changes and adjustments required due to growth or other anatomical changes or for repairs not covered by the manufacturer’s warranty on a like new item. 8.590.4.P. The provider shall receive and perform service and repairs in the same manner they provide services for non-Health First Colorado members for rental 8.590.4.Q. The provider shall assure the following for rental equipment:
Appropriate service to the item.
Complete services or repairs in a timely manner with an estimate of the approximate time required.
Appropriate alternative equipment during repairs.
Provision and replacement of all expendable items, including but not limited to hoses, fuses, and batteries.

8.590.5 PROVIDER REQUIREMENTS 8.590.5.A. Providers are required to be enrolled with the Colorado Medical Assistance Program and maintain a certification for Medicare accreditation through a Medicare approved accreditation agency. 8.590.5.B. Providers must have one or more physical location(s), within the State of Colorado, or within fifty (50) miles of any Colorado border and must also have:

A street address, 2. A local business telephone number, 3. An inventory, and 4. Sufficient staff to service or repair products. 8.590.5.C. Providers who do not meet the requirements of Section 8.590.5.A may apply to become a Health First Colorado provider if the DME or Supplies are medically necessary and cannot otherwise be purchased from a provider who meets the requirements of Section 8.590.5.A.
Applications from providers who do not meet the requirements of Section 8.590.5.A must be submitted to the DME Program Coordinator for approval.
Applications submitted pursuant to this section will be reviewed for approval on a case-by-case basis for those specialty items only. 8.590.5.D. To qualify as a Complex Rehabilitation Technology Supplier, a provider must meet the following requirements:
Be accredited by a recognized accrediting organization as a supplier of Complex Rehabilitation Technology;
Meet the supplier and quality standards established for DME suppliers under the Medicare or Medical Assistance Program;
Employ at least one Complex Rehabilitation Technology Professional at each physical location to:

a. Analyze the needs and capacities of a member for a Complex Rehabilitation Technology item in consultation with the evaluating clinical professionals;

b. Assess and determine the appropriate Complex Rehabilitation Technology for a member, with such involvement to include seeing the member either in person or by any other real-time means within a reasonable time frame during the determination process;

c. Provide the member with technology-related training in the proper use and maintenance of the selected Complex Rehabilitation Technology items.

Maintain a reasonable supply of parts, adequate physical facilities, and qualified and adequate service or repair technicians to provide members with prompt service and repair of all Complex Rehabilitation Technology it sells or supplies. 8.590.5.E. Only Complex Rehabilitation (CRT) Suppliers must comply with this

section for repair orders created on or after October 1, 2023,per Section 25.5-5- 323, C.R.S.

Beginning January 2024, the Department reports on CRT repair performance annually at the State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act hearing. The Department is to report on the metrics using the data received as outlined below.
The required metrics listed in Section 8.590.5.E.2 are to be reported by suppliers on all CRT repairs, including members also enrolled in Medicare coverage. Members with additional coverage other than Medicare, such as private insurance, are excluded from these reports.

a. Quality of CRT repairs shall be reported to the Department using the data point in section 8.590.5.E.2.b.8.

At the time the repair is fulfilled, regardless of the location, members will be asked to confirm that the equipment has been repaired to their satisfaction.
Members, their legal guardian, or other authorized representative may be asked to confirm verbally or in writing, provided that the answers can be verified by a signature and date.
This information may be obtained on a delivery ticket or as a separate form. This metric will be used to measure the number of repairs that were reported as satisfactory, not satisfactory, and where an answer was not obtained.

b. Metrics must be reported using the following:

Medicaid Identification Number.
Type of equipment being repaired: Manual wheelchair, power wheelchair, non-wheelchair mobility device, other 3. Does the member also have Medicare? Yes or no.
Order creation date.
Date of first available evaluation appointment (optional).
Date evaluation occurred.
Does the member have secondary/back up equipment? Yes or no.
Quality of repair answer: Satisfactory, not satisfactory, or answer not obtained.
Repair fulfillment date.
Suppliers of Complex Rehabilitation Technology are to follow the below requirements for reporting metrics to the Department.

a. Suppliers will prepare and send data listed above to the designated benefit inbox twice per calendar year, as outlined in the table below.

b. The deadlines represent the last day metrics will be accepted.

Those that fall on a holiday or weekend are due before the end of the following business day.

Date of Repair Fulfillment Deadline December 1 - May 31 June 30 June 1 - November 31 December 31 b. Complex Rehabilitation Technology Suppliers will use their own template or software to maintain and submit the metrics for each applicable repair performed. Suppliers with multiple locations are required to compile the data for the entire company into one submission.

c. All Complex Rehabilitation Technology Suppliers will provide the required data points listed above and the Department will report on each supplier’s performance as it relates to the metrics. The Department will maintain a record of the metrics received, including adherence to the reporting schedule. The Department may also request further information on the data provided either related to a batch of repairs, or repairs for a single member.

d. This information will be used to identify areas of potential improvement in the CRT repair industry and may be used in future stakeholder events, pursuant to Section 25.5-5-323, C.R.S.

8.590.6 MEMBER RESPONSIBILITIES 8.590.6.A. Members or member caregivers shall be responsible for the prudent care and use of DME and Supplies. Repairs, servicing or replacement of items are not a benefit if there is documented evidence of member Misuse, Abuse or Wrongful Disposition. 8.590.6.B. Members shall be responsible for the cost of any additional items or enhancements to equipment not deemed Medically Necessary. The member shall sign an agreement with the provider that states:

The cost of the items.
That the member was not coerced into purchasing the items.
That the member is fully responsible for the cost, servicing and repairs to the items after the warranty period is completed. 8.590.6.C. The member shall contact the point of purchase for service and repairs to covered items under warranty. Members may contact a participating provider of their choice for service and repairs to covered items not under warranty or for an item under warranty if the original point of purchase is no longer a participating provider. 8.590.6.D. The member shall become the owner of any equipment purchased by the Department and remains subject to Health First Colorado DME rules unless otherwise notified by the Department at the time of purchase. 8.590.6.E. The member shall be responsible for obtaining a police report for items being replaced due to theft, fire damage or accident. The police report shall be attached to the prior authorization requesting replacement of the item. 8.590.6.F. The member shall be responsible for reporting to the manufacturer, dealer or alternative warranty service provider instances where a Wheelchair or Facilitative Device does not conform to the applicable express warranty. 8.590.6.G. The member or caregiver shall be responsible for routine maintenance on all equipment purchased or rented by the Department. Routine maintenance is the servicing described in the manufacturer’s operating manual as being performed by the user to properly maintain the equipment. Non-performance of routine maintenance shall be considered Misuse. Routine maintenance includes, but is not limited to:
Cleaning and lubricating moving parts.
Adding water to batteries.
Checking tire pressure.
Other prescribed Manufacturer procedures. 8.590.6.H. The member utilizing rental equipment shall be responsible for notifying the provider of any change of address. The member shall be responsible for any rental fee accrued during the time the equipment’s location is unknown to the provider. 8.590.6.I. The member shall not remove rental equipment from Colorado.

8.590.7 REIMBURSEMENT 8.590.7.A. A provider, as defined at Section 25.5-4-414, C.R.S., is prohibited from making a referral to an entity providing DME and Supplies under the Medical Assistance Program if the provider or an Immediate Family member of the provider has a Financial Relationship with the entity unless the Financial Relationship meets the requirements of an exception to the prohibitions contained in 42 U.S.C. Section 1395nn. 8.590.7.B. If a provider refers a Health First Colorado member for DME and Supplies services in violation of Section 25.5-4-414, C.R.S., or this rule, then the Department may 1. Deny any claims for payment from the provider;

Require the provider to refund payments for services or items;
Refer the matter to the appropriate agency for investigation for fraud; or 4. Terminate the provider’s Health First Colorado provider participation agreement. 8.590.7.C. Invoices received from Related Owners or Related Parties shall not be accepted. Only invoices received from unrelated manufacturers or wholesale distributors shall be recognized as allowable invoices. 8.590.7.D. The provider shall not bill the Department for authorized accessory items included by the manufacturer as part of a standard package for an item. 8.590.7.E. The provider shall credit the cost of any accessory or part removed from a standard package to the Department. 8.590.7.F. Members and providers may negotiate in good faith a trade-in amount for DME items no longer suitable for a member because of growth, development or a change in anatomical and or medical condition. Such trade-in allowances shall be used to reduce the cost incurred by the Department for a replacement item. 8.590.7.G. The refund amount due the Department on a returned Wheelchair or Facilitative Device shall be agreed upon by the dealer or manufacturer; wherever the item was returned, and the Department. 8.590.7.H. Reimbursement for allowable modifications, service, and repairs on DME is as follows:
Labor for modifications, service, and repairs on DME shall be reimbursed at the lesser of submitted charges or the rate specified on the Department’s fee schedule.
Parts that are listed on the Department’s fee schedule, with a HCPCS code, that have a maximum allowable reimbursement rate shall be reimbursed at the lesser of submitted charges or the rate specified on the Department fee schedule.
Manually priced parts are reimbursed according to the same methodology used for purchased equipment, as described in Section 8.590.7.K.
The provider shall not be reimbursed for labor or parts in excess of unit limitations.
Reimbursement for a modification that requires the original equipment provider to supply a part from their own inventory or stock is contingent upon the provider submitting supporting documentation that demonstrates the need and actual cost of the parts to be used in the modification. 8.590.7.I. Reimbursement for used equipment shall include:
A written, signed and dated agreement from the member accepting the 2. Billing the Department, the lesser of 60% of the maximum allowable reimbursement indicated in the most recent Health First Colorado Bulletin or 60% of the provider’s usual submitted charges.

a. For used equipment subject to the upper payment limit provisions of section 1903(i)(27) of the Social Security Act, the maximum allowable reimbursement will be the lower of 100% of the applicable Medicare used reimbursement rate effective as of January 1 and posted by July 1 of each year, or the provider’s submitted charges. 8.590.7.J. Reimbursement for purchased or rented equipment shall include, but is not limited to:

All elements of the manufacturer’s warranties or express warranties.
All adjustments and modification needed by the member to make the item useful and functional.
If item is delivered, set-up and installation of equipment in an appropriate room in the home, if applicable.
Training and instruction to the member or caregiver in the safe, sanitary, effective and appropriate use of the item and necessary servicing and maintenance to be done by the member or caregiver.
Training and instruction on the manufacturer’s instructions, servicing manuals and operating guides. 8.590.7.K. Reimbursement rate for a purchased item shall be as follows:
Fee schedule items, with a HCPCS code, that have a maximum allowable reimbursement rate, shall be reimbursed at the lesser of submitted charges or the Department fee schedule rate.
Manually priced items that do not have an assigned fee schedule rate shall be reimbursed at the lesser of submitted charges or current manufacturer suggested retail price (MSRP) less the percentage listed in the Billing Manual for such items.
Manually priced items that do not have an assigned fee schedule rate and have no MSRP shall be reimbursed at the lesser of submitted charges or by invoice of actual acquisition cost, minus any discount to the provider as set forth in policy, plus the percentage listed in the Billing Manual for such items.
Continuous Glucose Monitors (CGMs) may be reimbursed through either the pharmacy or medical benefit effective November 1, 2025.

a. CGMs with an assigned wholesale acquisition cost are reimbursed at the lower of the following:

i. Usual and Customary Charge as defined in Section 8.800.A; or ii. Wholesale Acquisition Cost (WAC), as defined in Section 8.800.A, plus 10.00 percent.

b. CGMs without an assigned WAC are reimbursed at the lower of the i. Usual and Customary Charge; or ii. Manufacturer’s Suggested Retail Price (MSRP);

When no MSRP is available, CGMs without an assigned WAC are reimbursed at the lower of the a. Usual and Customary Charge; or b. Actual invoiced acquisition cost. 8.590.7.L. Reimbursement for rental items shall be billed and paid in monthly increments unless otherwise indicated in the Billing Manual. 8.590.7.M. Reimbursement for members eligible for both Medicare and Health First Colorado shall be made in the following manner:
The provider shall bill Medicare first unless otherwise authorized by the 2. If Medicare makes payment, Health First Colorado reimbursement will be based on appropriate deductibles and co-payments.
If Medicare denies payment, the provider shall be responsible for billing the Department. Reimbursement is dependent upon the following conditions:

a. A copy of the Explanation of Medicare Benefits shall be maintained in the provider’s files when billing electronically or attached to the claim if it is billed manually; or b. Health First Colorado reimbursement shall not be made if the Medicare denial is based upon provider submission error. 8.590.7.N. Face-to-Face Encounters 1. Compliance with this section is required as a condition of payment for DME requiring face-to-face encounters.

For DME specified in the Billing Manual, a face-to-face encounter must be performed related to the primary reason a member requires the DME.
The face-to-face encounter must occur no more than six months before the DME is first provided to a member.
The face-to-face encounter must be conducted by one of the following practitioners:

a. The Licensed Practitioner responsible for prescribing the DME;

b. A nurse practitioner or clinical nurse specialist, working in collaboration with the prescribing Licensed Practitioner; or c. A physician assistant under the supervision of the prescribing Licensed Practitioner.

A practitioner may conduct a face-to-face encounter via telehealth or telemedicine if those services are covered by the Medical Assistance Program.
If a non-physician practitioner performs a face-to-face encounter they must communicate the clinical findings of the face-to-face encounter to the Licensed Practitioner responsible for prescribing the related DME. Those clinical findings must be incorporated into a written or electronic document included in the member’s medical record.
A Licensed Practitioner who prescribes DME requiring face-to-face encounters must document the following:

a. That the face-to-face encounter was related to the primary reason the member required the prescribed DME;

b. The name of the practitioner who performed the face-to-face encounter;

c. The date of the face-to-face encounter; and d. That the face-to-face encounter occurred within the required timeframe. 8.590.7.O. Reimbursement for Complex Rehabilitation Technology provided to members is subject to the following conditions:

The billing provider is a Complex Rehabilitation Technology Supplier;
The member has been evaluated or assessed, for selected Complex Rehabilitation Technology identified in the Billing Manual, by:

a. A Qualified Health Care Professional; and b. A Complex Rehabilitation Technology Professional employed by the billing provider.

The Complex Rehabilitation Technology is provided in compliance with all applicable federal and state laws, rules, and regulations, including those rules governing the Medical Assistance Program. 8.590.7.P. Reimbursement for Speech Generating Devices (SGD), accessories, and software provided to members is subject to the following conditions:
The member has a medical condition resulting in a severe expressive communication impairment; and 2. The SGD, accessories and software is used primarily as a communication device; and 3. The SGD, accessories or software are recommended by a Speech Language Pathologist after a communication assessment as described at

Section 8.590.3.E.1; and a. The recommended device, software or application should be capable of modifications to meet the needs for supportive functional communication when possible. The recommended software or application must be compatible with the prescribed SGD.

b. Accessories and supplies that do not have a primary medical use will not be covered, which includes any items that are unnecessary for operation of the SGD, or are unrelated to the SGD.

i. Covered accessories include but are not limited to:

Replacement lithium ion batteries;
Non-electric SGD communication board;
Mounting systems designated for securing the SGD within reach of the member;
Safety and protection accessories designated to maintain the life expectancy of the device;
Accessories not otherwise classified may be approved to enhance the use of the SGD system as the member’s condition changes; and 6. Orthotic and prosthetic supplies and accessories, and/or service components of another HCPCS L code.
Other forms of treatment have been considered or ruled out; and 5. The member’s communication impairment will benefit from the SGD, accessories, or software.

10 CCR 2505-10, SECTION 8.500-8.599, APPENDIX A: PEDIATRIC PERSONAL

CARE SERVICES BENEFIT COVERAGE STANDARD

Capitalized terms within this Benefit Coverage Standard that do not refer to the title of a benefit, program, or organization, have the meaning specified in the Definitions section.

A. BRIEF COVERAGE STATEMENT

This Benefit Coverage Standard describes Pediatric Personal Care (PC)

Services benefits for Colorado Medicaid clients under 21 years of age. PC Services are Medically Necessary services provided to assist the client with PC Tasks in order to meet the client’s physical, maintenance, and supportive needs.

This assistance may take the form of Hands-On Assistance, Supervision, or Cuing the client to complete the PC Task.

B. RELATED SERVICES ADDRESSED IN OTHER BENEFIT COVERAGE

STANDARDS

Home Health 2. Private Duty Nursing C. ELIGIBLE PROVIDERS 1. Ordering, Prescribing, Referring (OPR) Providers In accordance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, all 485 Plans of Care—or other form with identical content—must be signed by one of the following:

a. Physician i) Doctor of Medicine (MD), or ii) Doctor of Osteopathic Medicine (DO)

b. Advanced Practice Nurse 2. Personal Care Workers As a condition of reimbursement, Personal Care Workers (PCW) must meet all of the following requirements:

a. Not excluded from participation in any federally funded health care programs, b. Employed by or providing services under a contract with a licensed Class A or Class B Home Care Agency (HCA) that is enrolled as a Colorado Medicaid provider;

c. Completion of the Department's PC Services provider training; and has verified experience in the provision of PC Services for clients, as regulated by the Colorado Department of Public Health and Environment (CDPHE) at 6 CCR 1011-1, Chapter 26, Section 8.5.

D. AGENCY REQUIREMENTS

As a condition of reimbursement, Home Care Agencies (HCAs) must meet all of the following requirements:

Licensed by the State of Colorado as either a Class A or Class B Agency in good standing;
Maintain up-to-date personnel files for each PCW, containing proof of current training, education, and PCW competency, as appropriate to the client’s needs and as required by CDPHE; and 3. Comply with the requirements outlined in the Personal Care Worker Supervision section of this Benefit Coverage Standard.

E. ELIGIBLE PLACES OF SERVICE

Pediatric PC Services are covered under this benefit when provided in a client's Residence or outside a client’s Residence, subject to the limitations listed in the Non-Covered Services section of this Benefit Coverage Standard.

F. ELIGIBLE CLIENTS

Pediatric PC Services are a benefit for Colorado Medicaid clients who:

Are 20 years of age or younger; and 2. Qualify for moderate to total assistance with at least one Personal Care Ta s k G. GENERAL REQUIREMENTS For Medicaid clients ages 20 and younger, Pediatric PC Services are covered in accordance with the provisions of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program found at 10 CCR 2505-10 Section 8.280.
Requirements of Covered Services Pediatric PC Services are covered only when:

a. Medically Necessary, as defined in Colorado Medicaid’s EPSDT

rule at 10 C.C.R. 2505-10, Section 8.280;

b. Provided to assist the client with PC Tasks, in order to meet the client’s physical, maintenance, and supportive needs;

c. Provided on an intermittent basis;

d. Provided for the sole benefit of the client;

e. Prior authorized and delivered in a manner consistent with professional standards, Colorado licensure requirements, and all other applicable state and federal regulations;

f. Ordered by a licensed physician, as regulated by the Department of Regulatory Agencies (DORA), or an advanced practice nurse, as licensed by DORA; and g. Provided under a current, written 485 Plan of Care, signed by the Ordering Provider.

Documentation Requirements The HCA is required to maintain a record for each client. The record for each client must include all of the following:

a. A 485 Plan of Care completed by the Ordering Provider. This constitutes a written order for PC services. The 485 Plan of Care must be updated at least annually, or more frequently if required by the needs or condition of the individual client, and must include:

i) The frequency of each PC Task required by the client.

ii) A range of the frequency for each PC Task required by the client on an as-needed basis. An order for a PC Task “PRN” or “as needed” must be accompanied by a range of the frequency with which the client may require that PC Task to be provided.

iii) Documentation or explanation for each PC Task that is required more frequently than the defined Usual Frequency for that task.

b. Evidence of Care Coordination between the HCAs, when the client is receiving other services from another agency, including but not limited to Medicaid Home Health services, Medicaid HCBS waiver programs, and services from other payers.

c. Documentation of consultations with relevant medical staff when clients have complex needs or when there are potentially dangerous situations identified.

d. A written explanation of how the requested PC Services do not overlap with any other services the client is receiving from another agency.

e. All other client file information, as required by Colorado Medicaid, and by CDPHE, as outlined in rule at 6 C.C.R. 1011-1, Chapter 26, Section 6.20.

H. COVERED SERVICES

Under the description of each task below, Usual Frequency of Task refers to the number of times a typical client is likely to need a task performed. A PC Task will be performed at the usual frequency, unless otherwise specified on the 485 Plan of Care. If a client needs a PC Task performed more frequently than the usual frequency for that PC Task, it must be specified on the 485 Plan of Care.

Covered Pediatric PC Services include assistance with the following PC Tasks:

Bathing/Showering a. Included in Task:

Bathing/shower includes: Preparing bathing supplies and equipment, assessing the water temperature, applying soap (including shampoo), rinsing off, and drying the client; cleaning up after the bath, shower, bed bath, or sponge bath as needed; all transfers and ambulation related to the bathing/showering task; and all hair care, pericare, and skin care provided in conjunction with the bathing/showering task.

b. Usual Frequency of Task: Once daily.

c. Factors that Make Task Personal Care:

Client is able to maintain balance and bear weight reliably, or able to use safety equipment (such as a shower bench) to safely complete the bathing/showering; client’s skin is unbroken; client is independent with assistive devices; or when a PCW is assisting a medically-skilled care provider, caregiver, or Unpaid Family d. Factors that Make Task Skilled:

There is the presence of open wound(s), stoma(s), broken skin and/or active chronic skin disorder(s); or client is unable to maintain balance or to bear weight reliably due to illness, injury, or disability,

history of falls, or a temporary lack of mobility due to surgery or other exacerbation of illness, injury, or disability.

e. Special Considerations:

A second person may be staffed when required to safely bathe the client, when supported by documentation that illustrates that the client requires moderate to total assistance to safely complete this task.

Dressing a. Included in Task:

Dressing includes putting on and taking off clothing, including pantyhose or socks and shoes. Dressing includes getting clothing out and may include braces and splints if purchased over the counter and/or or not ordered by a Qualified Physician.

b. Usual Frequency of Task: Up to two times daily.

c. Factors that Make Task Personal Care:

Client only needs assistance with ordinary clothing and application of support stockings of the type that can be purchased without a physician’s prescription; when assistance is needed with transfers and positioning related to dressing and undressing, which may include the cleaning and maintenance of braces, prosthesis, or other DME; or when a PCW is assisting a skilled care provider, caregiver, or Unpaid Family Caregiver who is competent in providing the application of an ace bandage and anti-embolic or pressure stockings or placement of braces or splints that can be obtained only with a prescription of a Qualified Physician, or when the client is unable to assist or direct care.

d. Factors that Make Task Skilled:

Client requires assistance with the application of anti-embolic or pressure stockings, placement of braces or splints that can be obtained only with a prescription of a Qualified Physician, or when the client is unable to assist or direct care. Services may also be skilled when the client experiences a temporary lack of mobility due to surgery or other exacerbation of illness, injury, or disability.

e. Special Considerations:

A PCW may be staffed with a skilled care provider or Unpaid Family Caregiver when required to safely dress the client, and when supported by documentation that illustrates that the client requires moderate to total assistance to safely complete this task.

Feeding a. Included in Task:

Feeding includes ensuring food is the proper temperature, cutting food into bite-size pieces, or ensuring the food is at the proper consistency for the client, up to and including placing food in client's mouth.

b. Usual Frequency of Task: Up to three times daily.

c. Factors that Make Task Personal Care:

The client can independently chew and swallow without difficulty and be positioned upright; the client is able to eat or be fed with adaptive utensils.

d. Factors that Make Task Skilled:

The client requires syringe feeding and tube feeding, which may be performed by a CNA who has been deemed competent to administer feedings via tube or syringe;

Oral feeding when: The client is unable to communicate verbally, non-verbally, or through other means; t he client is unable to be positioned upright; the client is on a modified texture diet; the client has a physiological or neurogenic chewing and/or swallowing problem; or w hen a structural issue (such as cleft palate), or other documented swallowing issue exists.

The client has a history of aspirating food or is on mechanical ventilations that may create a skilled need for feeding assistance, or; when oral suctioning is required.

e. Special Considerations: total assistance to safely complete this task. If a client requires snacks in addition to three meals per day, this need must be specified in the 485 Plan of Care.

Medication Reminders a. Included in Task:

Medication Reminders include verbally communicating to a client that it is time for medication, and/or opening and handing a prefilled medication reminder container to a client.

b. Factors that Make Task Personal Care:

PCWs may assist clients with medication reminders by: inquiring whether medications were taken; verbally prompting the client to take medications; handing the appropriately marked medication reminder container to the client; and opening the appropriately marked medication reminder container for the client if the client is physically unable to open the container.

All medication (prescription medications and all over-the-counter medications) must be pre-selected by the client, the client's Unpaid Family Caregiver, a nurse, CNA, or a pharmacist, and stored in prefilled medication reminder boxes which are marked with day and time of dosage.

c. Factors that Make Task Skilled:

Medication reminders are PCW tasks unless the client requires services within the scope of a certified CNA.

Ambulation/Locomotion a. Included in Task:

Walking or moving from place to place with or without an assistive device (including wheelchair).

b. Factors that Make Task Personal Care:

A PCW may assist clients with ambulation only if the client has the ability to balance and bear weight reliably, when the client is independent with an assistive device, or when the PCW is assisting a skilled care provider or Unpaid Family Caregiver who is competent in providing the skilled aspect of care.

c. Factors that Make Task Skilled:

Ambulation is considered a skilled task when the client: is unable to assist in the task, direct care, or when hands-on assistance is required for safe ambulation.

The task is also considered skilled when a client is unable to maintain balance, unable to bear weight reliably, or has not been deemed independent with assistive devices ordered by a Qualified Physician.

d. Special Considerations:

Ambulation may not be the standalone reason for a visit.

Transferring and positioning into and out of assistive devices is not ambulation, and is addressed in the transferring and positioning

section of this standard. Documentation must illustrate the need for moderate to total assistance to safely complete this task.

Meal Preparation a. Included in Task:

Meal preparation includes preparing, cooking, and serving food to a client. Includes formula preparation and ensuring food is a proper consistency based on the client’s ability to swallow safely.

b. Usual Frequency of Task: Up to three times daily.

c. Factors that Make Task Personal Care:

All meal preparation is a PC task, except as defined in the Factors that Make Task Skilled portion of this section.

d. Factors that Make Task Skilled:

Meal preparation is considered a skilled task when the client’s diet requires nurse oversight to administer correctly. Meals must have a modified consistency.

e. Special Considerations:

Hygiene – Hair Care/Grooming a. Included in Task:

Hair care includes shampooing, conditioning, drying, styling, and combing; it does not include perming, hair coloring, or other styling.

b. Usual Frequency of Task: Up to twice daily.

c. Factors that Make Task Personal Care:

PCWs may assist clients with the maintenance and appearance of their hair. Hair care within these limitations includes: shampooing with non-medicated shampoo or medicated shampoo that does not require a physician’s prescription; and drying, combing, and styling of hair.

d. Factors that Make Task Skilled:

Hair care is considered a skilled task when the client requires shampoo or conditioner that is prescribed by a qualified physician and dispensed by a pharmacy; or when the client has one or more open wounds or stomas on the head.

e. Special Considerations: total assistance to safely complete this task. Active and chronic skin issues such as dandruff and cradle cap do not make this task skilled.

Hygiene – Mouth Care a. Included in Task:

Mouth care includes brushing teeth, flossing, use of mouthwash, denture care, or swabbing with a toothette.

b. Usual Frequency of Task: Up to three times daily.

c. Factors that Make Task Personal Care:

A PCW may assist and perform mouth care, including denture care and basic oral hygiene.

d. Factors that Make Task Skilled:

Mouth care is considered a skilled task when the client: is unconscious; has difficulty swallowing; is at risk for choking and aspiration; has decreased oral sensitivity or hypersensitivity; has an injury or medical disease of the mouth; is on medications that increase the risk of dental problems, bleeding, injury, or disease of the mouth; or requires oral suctioning.

e. Special Considerations: total assistance to safely complete this task. The presence of gingivitis, receding gums, cavities, or other general dental problems does not make mouth care skilled.

Hygiene - Nail Care a. Included in Task:

Nail care includes soaking, filing, and cuticle care.

b. Usual Frequency of Task: Up to one time weekly.

c. Factors that Make Task Personal Care:

A PCW may assist with nail care, which includes soaking of nails, pushing back cuticles with or without utensils, and filing of nails. A PCW may not assist with nail trimming.

d. Factors that Make Task Skilled:

Nail care is considered a skilled task when the client: has a medical condition that involves peripheral circulatory problems or loss of sensation; is at risk for bleeding or is at a high risk for injury secondary to the nail care; or requires nail trimming.

Skilled nail care may only be completed by a CNA who has been deemed competent in nail care for this population.

e. Special Considerations:

Hygiene – Shaving a. Included in Task:

Shaving includes assistance with shaving of face, legs, and underarms with a safety or electric razor.

b. Usual Frequency of Task: Up to one time daily. Task may be completed with bathing or showering.

c. Factors that Make Task Personal Care:

A PCW may assist a client with shaving with an electric or a safety razor.

d. Factors that Make Task Skilled:

Shaving is considered a skilled task when the client: has a medical condition that involves peripheral circulatory problems or loss of sensation; has an illness or takes medications that are associated with a high risk for bleeding; has broken skin at or near shaving site; has a chronic active skin condition; or is unable to shave him or herself.

e. Special Considerations:

Hygiene – Skin Care a. Included in Task:

Skin care includes applying lotion or other skin care products, only when not completed in conjunction with bathing or toileting (bladder or bowel). May be provided in conjunction with positioning.

b. Factors that Make Task Personal Care:

A PCW may provide general skin care assistance only when a client’s skin is unbroken and when no chronic skin problems are active.

The skin care provided by a PCW must be preventive, rather than therapeutic, in nature. It includes the application of skin care lotions and solutions not requiring a physician’s prescription.

c. Factors that Make Task Skilled:

Skin care is considered a skilled task when the client: requires skin care lotions or solutions requiring a physician’s prescription; has broken skin, wound(s), or an active chronic skin problem; or is unable to apply product independently due to illness, injury, or disability.

d. Special Considerations:

Skin care completed in conjunction with bathing and toileting, as ordered on the 485 Plan of Care, is not included in this task.

Toileting – Bowel Care a. Included in Task:

Bowel Care includes changing and cleaning an incontinent client, or providing hands-on assistance with toileting. This includes returning the client to pre-bowel movement status, transfers, skin care, ambulation, and positioning related to elimination.

b. Factors that Make Task Personal Care:

A PCW may assist a client to and from the bathroom; provide assistance with bedpans and commodes; provide pericare; or change clothing and pads of any kind used for the care of incontinence.

A PCW may assist a skilled care provider or Unpaid Family c. Factors that Make Task Skilled:

Bowel Care is considered a skilled task when: the client is unable to assist or direct care; has broken skin or recently healed skin breakdown (less than 60 days); requires skilled skin care associated with bowel care; or has been assessed as having a high and ongoing risk for skin breakdown.

d. Special Considerations:

A PCW may be aided by a skilled care provider or Unpaid Family Caregiver when required to safely complete Bowel Care with the client. Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.

Toileting – Bowel Program a. Included in Task:

Bowel Program includes emptying the ostomy bag, as ordered by the client's Ordering Provider. This includes skin care at the site of the ostomy and returning the client to pre-bowel program status.

b. Factors that Make Task Personal Care:

A PCW may empty ostomy bags and provide client-directed assistance with other ostomy care only when there is no need for skilled bowel program care, for skilled skin care, or for observation or reporting to a nurse.

A PCW may not perform digital stimulation, insert suppositories, or give an enema.

c. Factors that Make Task Skilled:

Bowel Program is considered a skilled task when: the client requires the use of digital stimulation, suppositories, or enemas; or when the client requires skilled skin care at the ostomy site.

d. Special Considerations:

Toileting – Catheter Care a. Included in Task:

Catheter Care includes perineal care and emptying catheter bags.

This includes transfers, skin care, ambulation, and positioning related to catheter care.

b. Usual Frequency of Task: Up to two times a day.

c. Factors that Make Task Personal Care:

A PCW may empty urinary collection devices such as catheter bags when there is no need for observation or reporting to a nurse; and provide pericare for clients with indwelling catheters.

d. Factors that Make Task Skilled:

Catheter Care is considered a skilled task when: emptying indwelling or external urinary collection devices and there is a need to record and report the client’s urinary output to the client’s nurse; task involves insertion, removal, and care of all catheters; changing from a leg to a bed bag and cleaning of tubing and base; or if the indwelling catheter tubing needs to be opened for any reason and the client is unable to do so independently.

e. Special Considerations:

Catheter Care may not be the sole purpose of the visit.

Toileting – Bladder Care a. Included in Task:

Bladder Care includes assistance with toilet, bedpan, urinal, or diaper use, as well as emptying and rinsing the commode or bedpan after each use. This includes transfers, skin care, ambulation, and positioning related to bladder care. This task concludes when the client is returned to his or her pre-urination state.

b. Factors that Make Task Personal Care:

A PCW may assist a client to and from the bathroom, provide assistance with bedpans, urinals, and commodes; provide pericare; and change clothing and pads of any kind used for the care of incontinence.

c. Factors that Make Task Skilled:

Bladder care is considered a skilled task when the client: is unable to assist or direct care; has broken skin or recently healed skin breakdown (less than 60 days); requires skilled skin care associated with bladder care; or has been assessed as having a high and ongoing risk for skin breakdown.

d. Special Considerations:

A PCW may assist a skilled care provider or Unpaid Family 16. Mobility – Positioning a. Included in Task:

Positioning includes moving the client from a starting position to a new position while maintaining proper body alignment and support to a client’s extremities, and avoiding skin breakdown.

b. Factors that Make Task Personal Care:

A PCW may assist a client with positioning when the client is able to identify to the provider, verbally, non-verbally, or through other means including but not limited to, a legally responsible adult or adaptive technologies, when his or her position needs to be changed, and only when skilled skin care is not required in conjunction with positioning. Positioning includes alignment in a bed, wheelchair, or other furniture; and the placement of padding required to maintain proper alignment. The PCW may receive direction from or assist a skilled care provider or Unpaid Family c. Factors that Make Task Skilled:

Positioning is considered a skilled task when the client is: unable to communicate verbally, non-verbally, or through other means; or unable to perform this task independently due to illness, injury, disability, or temporary lack of mobility due to surgery. Positioning includes adjusting the client’s alignment or posture in a bed, wheelchair, other furniture, assistive devices, or Durable Medical Equipment that has been ordered by a Qualified Physician.

d. Special Considerations:

Positioning and padding may not be the sole purpose for the PC visit. Positioning is not considered a separate task when a transfer is performed in conjunction with bathing, bladder care, bowel care, or other PC Tasks that require positioning.

If PC positioning is required for the completion of a skilled care task, visits must be coordinated to effectively schedule these services. A PCW may be accompanied by a skilled care provider or Unpaid Family Caregiver when required to safely position the client.

Mobility - Transfer a. Included in Task:

Transfers include moving the client from a starting location to a different location in a safe manner. It is not considered a separate task when a transfer is performed in conjunction with bathing, bladder care, bowel care, or other PC Task.

b. Factors that Make Task Personal Care:

A PCW may assist with transfers only when the client has sufficient balance and strength to reliably stand, pivot, and assist with the transfer to some extent. Adaptive equipment, including, but not limited to, wheelchairs, tub seats, and grab bars, and safety devices may be used in transfers if: the client and PCW are fully trained in the use of the equipment; the client, or client’s Unpaid Family Caregiver, can direct the transfer step-by-step; or when the PCW is deemed competent by the employer HCA in the specific transfer technique for the client. A gait belt may be used in a transfer as a safety device if the PCW has been properly trained in its use. A lift is not an included safety device and may not be used in PC transfers.

c. Factors that Make Task Skilled:

Transfers are considered a skilled task when the client: is unable to communicate verbally, non-verbally, or through other means; is not able to perform this task independently due to illness, injury, disability, or temporary lack of mobility due to surgery; lacks the strength and stability to stand or bear weight reliably; is not deemed independent in the use of assistive devices or Durable Medical Equipment that has been ordered by a Qualified Physician; or when the client requires a mechanical lift, such as a Hoyer lift, for safe transfer. In order to transfer clients via a mechanical lift, the CNA must be deemed competent in the particular mechanical lift used by the client.

d. Special Considerations:

Transfers may be completed with or without mechanical assistance.

Transferring shall not be the sole purpose for the visit. A transfer is not considered a separate task when performed in conjunction with bathing, bladder care, bowel care, or other PC Task. A PCW may be aided by a skilled care provider or Unpaid Family Caregiver when required to safely transfer the client. A PCW may assist the Unpaid Family Caregiver with transferring the client, provided the client is able to direct and assist with the transfer. Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.

I. LIMITATIONS

Medicaid clients ages 21 and older are not eligible for Pediatric PC 2. The use of physical Behavioral Interventions such as restraints is prohibited, per CDPHE’s consumer rights regulations. 6 C.C.R. 1011-1,

Chapter 26, Section 6.

All PCWs and HCAs must comply with all applicable Colorado and federal requirements, rules, and regulations.
All Pediatric PC Services will be reimbursed at the Medicaid Pediatric PC Services rate, regardless of whether the PCW providing PC Services holds credentials for CNA, RN, or other skilled profession.
If a client requires a Skilled Transfer to complete a PC Task, the associated PC Task will be considered skilled in nature. PC Tasks considered skilled in nature are not covered PC Services, and will not be reimbursed by Colorado Medicaid under the Pediatric PC Services benefit.
PC Tasks provided as required components of skilled care tasks are not covered PC Services, and will not be reimbursed by Colorado Medicaid under the Pediatric PC Services benefit.
Clients eligible for the Pediatric PC Services benefit who are also eligible for the Colorado Department of Human Services Home Care Allowance program, described in rule at 9 C.C.R. 2503-5, Section 3.570, may receive services through one program, but not both.
If a PC Task is provided to a client by a PCW and a Skilled Care worker, but only one staff person is required, the PCW will not be reimbursed by Colorado Medicaid under the Pediatric PC Services benefit.
If a PC Task is provided to a client by two PCWs from different HCAs, but only one PCW is required, Colorado Medicaid will reimburse solely the HCA with a history of providing that particular PC Task to the client.
Two staff may be reimbursed for the same PC service for a client only when two people are required to safely provide the service, two staff were approved by prior authorization for the service, and there is no other person available to assist in providing this service.
HCAs may decline to perform a specific task or service, regardless of whether the task is a covered Pediatric PC Service, if the supervisor or the PCW documents a concern regarding the safety of the client or the PCW.

J. PERSONAL CARE WORKER SUPERVISION

PCWs must periodically receive onsite supervision by a Registered Nurse, the clinical director, home care manager, or other home care employee who is in a designated supervisory capacity and is available to the PCW at all times. This onsite supervisory visit must occur at least every 90 days, or more often as necessary for problem resolution, skills validation of the PCW, client-specific or procedure-specific training of the PCW, observation of client's condition and care, and assessment of client's satisfaction with services. At least one of the assigned PCWs must be present at the onsite supervisory visit.
Each PCW must have a complete and up-to-date personnel file that demonstrates that the PCW has:

a. Signed and dated evidence that he/she has received training and orientation on the HCA’s written policies and procedures;

b. Signed and dated evidence that he/she has received training and is competent to provide the client’s specific PC Tasks;

c. A signed and dated job description that clearly delineates his/her responsibilities and job duties;

d. Proof that he/she is current and up to date on all training and education required by CDPHE at 6 C.C.R. 1011-1 Chapter 26,

Section 8.6;

e. Signed and dated competency information regarding training and skills validation for client-specific personal care and homemaking tasks;

f. Signed and dated evidence that he/she has been instructed in basic first aid, and training in infection control techniques, including universal precautions;

g. Information on any complaints received regarding the PCW, and documentation on the outcome and follow-up of the complaint investigation.

K. PRIOR AUTHORIZATION REQUEST (PAR) REQUIREMENTS

Approval of the PAR does not guarantee payment by Medicaid. The presence of an approved or partially approved PAR does not release the HCA from the requirement to bill Medicare or other third party insurance prior to billing Medicaid.
All Pediatric PC Services require prior authorization by Colorado Medicaid or its Designated Review Entity using the approved utilization management tool.
Pediatric PC Services PARs may be submitted for up to a full year of anticipated services unless: the client is not expected to need a full year of services; the client’s eligibility is not expected to span the entire year; or as otherwise specified by Colorado Medicaid or its Designated Review Entity.
A PAR will be pended by Colorado Medicaid or its Designated Review Entity if all of the required information is not provided in the PAR, or additional information is required by the Designated Review Entity to complete the review.
PARs must be submitted to Colorado Medicaid or its Designated Review Entity in accordance with 10 CCR 2505-10 § 8.058.
It is the HCA’s responsibility to provide sufficient documentation to support the medical necessity for the requested services.
When a PAR includes a request for reimbursement for two staff members at the same time (excluding supervisory visits) to perform two-person transfers or another PC Task, documentation supporting the need for two people and the reason adaptive equipment cannot be used must be included.
All other information determined necessary by Colorado Medicaid or its Designated Review Entity to review a request and the appropriateness of the proposed treatment plan must be provided.

L. NON-COVERED SERVICES

The following services are not covered under the Pediatric PC Services benefit:

Services that are not prior authorized by the Colorado Medicaid Designated Review Entity;
In accordance with Section 1905(a) of the Social Security Act, any services provided by the client’s parents, foster parents, legal guardians, spouses, and other persons legally responsible for the well-being of the client;
Services provided by an individual under 18 years of age;
Services provided by a person not employed by the HCA;
Services provided through an Individual Residential Services and Supports (IRSS) or Group Residential Services and Supports (GRSS) program; or in any Medicaid-reimbursed setting, including, but not limited to medical offices, hospitals, hospital nursing facilities, alternative care facilities, and Intermediate Care Facilities for Persons with Intellectual Disabilities (ICF/ID).
PC Services that are covered under the client’s Individualized Education Program (IEP) or Individual Family Service Plan (IFSP);
Tasks that are defined as Skilled Care Services in the Home Health Services Rule at 10 CCR 2505-10 § 8.520;
Homemaker services, or tasks that are performed to maintain a household. These tasks are considered to be non-medical tasks and include grocery shopping, laundry, and housekeeping;
Exercise and range of motion services;
Protective Oversight services.
Services provided for the purpose of companionship, respite, financial management, child care, education, or home schooling; for the benefit of someone other than the Medicaid client; that are not justified by the documentation provided by the client's medical or functional condition (even when services have been prior authorized); or that are not appropriate for the client’s needs;
Visits that occur for the sole purpose of supervising or training the PCW;
Any services that are reimbursable by another insurance agency or other state, federal, or private program;
PC Services provided during a Skilled Care Services visit;
Services provided by the client’s Unpaid Family Caregiver; or 16. Assistance with services that are being provided as a reasonable accommodation as part of the Americans with Disabilities Act (ADA), the Rehabilitation Act of 1973, or Part B of the Individuals with Disabilities Education Act (IDEA).

M. DEFINITIONS

The following definitions are applicable only within the scope of this Benefit Coverage Standard. 485 Plan of Care. Refers to a CMS-485 Home Health Certification and Plan of Care, or a form that is identical in content. A 485 Plan of Care is a coordinated plan developed by the Home Care Agency as ordered by the Ordering Provider for provision of services to a client, and periodically reviewed and signed by the physician in accordance with Medicare requirements.

Behavioral Intervention. Techniques, therapies, and methods used to modify or minimize verbally or physically aggressive, combative, destructive, disruptive, repetitious, resistive, self-injurious, sexual, or otherwise inappropriate behaviors outlined on the 485 Plan of Care. Behavioral Interventions exclude frequent verbal redirection or additional time to transition or complete a task, which are

part of the general service to the client's needs.

Care Coordination. The planned organization of client care tasks between two or more participants (including the client) involved in a client’s care to facilitate the appropriate delivery of health care and other health care support services.

Organizing care involves the marshalling of personnel and other resources needed to carry out all required client care tasks, and is managed by the exchange of information among participants responsible for different aspects of care with the understanding that this information is or will be incorporated into the current or future medical care of the client.

Centers for Medicare and Medicaid Services (CMS). The federal government agency that works with states to run the Medicaid program. CMS is also responsible for the Medicare program.

Certified Nurse Aide (CNA). An employee of a Home Health Agency with a CNA certification. A CNA must have a current, active Colorado CNA certification and be employed by a Class A Home Health Agency. The CNA must have completed all required continuing education and training and have verified experience in the provision of Skilled Care Services.

Class A Agency. A Home Care Agency that provides any Skilled Care Service.

Class A Agencies may also provide Personal Care Services.

Class B Agency. A Home Care Agency that provides only Personal Care Services. Class B Agencies may not provide any Skilled Care Services.

Colorado Medicaid. Colorado Medicaid is a free or low-cost public health insurance program that provides health care coverage to low-income individuals, families, children, pregnant women, seniors, and people with disabilities.

Colorado Medicaid is funded jointly by the federal and state government, and is administered by the Colorado Department of Health Care Policy and Financing.

Cuing. Providing a prompt or direction to assist a client in performing PC Tasks he/she is physically capable of performing but unable to independently initiate.

Designated Review Entity. An entity that has been contracted by the Department to review Prior Authorization Requests (PARs) for medical necessity and appropriateness.

Exacerbation. A sudden or progressive increase in severity of a client’s condition or symptoms related to a chronic illness, injury, or disability.

Hands-On Assistance. Performing a personal care task for a client.

Home Care Agency (HCA). Refers collectively to Class A Agencies, which provide Home Health Services, and Class B agencies, which provide Personal Care Services. Home Care Agency is defined in full at 6 CCR 1011-1, Chap. 26 § 3.11. When used in this Benefit Coverage Standard without a Class A or Class B designation, the term encompasses both types of agency.

Home Health Agency (HHA). An agency that is licensed as a Class A Home Care Agency in Colorado that is Medicare certified to provide Skilled Care Services. Agencies must be actively enrolled as a Medicare and Medicaid Home Health provider in order to provide services to Medicaid clients. An agency that is licensed as a Class A Home Care Agency may also provide Personal Care Services based on the agency’s policies and procedures.

Home Health Services. Services and care that, due to the inherent complexity of the service, can only be performed safely and correctly by a trained and licensed/certified nurse (RN or LPN), therapist (PT, OT, or SLP), or CNA.

Homemaker Services. General household activities provided in the Residence of an eligible client in order to maintain a healthy and safe home environment for the client, when the person ordinarily responsible for these activities is absent or unable to manage these tasks.

Intermittent Basis. Personal Care Services visits that have a distinct start time and stop time and are task-oriented with the goal of meeting a client’s specific needs for that visit.

Medically Necessary. Medical Necessity for Pediatric Personal Care Services is defined at 10 C.C.R. 2505-10, § 8.280.1.

Ordering Provider. A client’s primary care physician, personal physician, advanced practice nurse, or other specialist who is responsible for writing orders and overseeing the client’s 485 Plan of Care. This may include an alternate physician who is authorized by the Ordering Provider to care for the client in the Ordering Provider’s absence.

Personal Care Agency (PCA). A Class B Home Care Agency that is licensed by the Colorado Department of Public Health and Environment.

Personal Care (PC) Services. The provision of assistance, hands-on support with, or supervision of specific Personal Care Tasks to assist clients with activities of daily living.

Personal Care (PC) Tasks. Any of 17 daily living tasks described in the PC Benefit Coverage Standard.

Personal Care Worker (PCW). An employee of a licensed Home Care Agency who has completed the required training to provide Personal Care Services, or who has verified experience in the provision of Personal Care Services for clients, as regulated by the Colorado Department of Public Health and Environment at 6 C.C.R. 1011-1 Section 8.6. A client’s Unpaid Family Caregiver cannot be a PCW for that client.

Prior Authorization Request (PAR). A PAR is a request for determination that covered Medicaid services are medically necessary.

Protective Oversight. Monitoring a client to reduce or minimize the likelihood of injury or harm due to the nature of the client’s injury, illness, or disability.

Qualified Physician. A primary care physician, personal physician, or other specialist who is currently licensed and in good standing.

Rendering Provider. The provider administering the service.

Residence. The physical structure in which the client lives. The Residence may be temporary or permanent. A Residence may be the client's own house, an apartment, a relative's home, or other temporary accommodation where the client resides. The Residence may not be a nursing facility or other institution, as defined by CMS and the State of Colorado.

Skilled Care Services. Services and care that, due to the inherent complexity of the service, can only be performed by a trained and licensed/certified nurse (RN or LPN), therapist (PT, OT or SLP), or CNA.

Skilled Nursing Services. Services provided by an actively licensed Registered Nurse, and services provided by a Licensed Practical Nurse under the direction of a Registered Nurse, in accordance with applicable state and federal laws, including but not limited to the Colorado Nurse Practice Act §§ 12-38-101 to -133, C.R.S., and 42 C.F.R 484.30.

Skilled Transfer. Supporting or enabling the movement of a client from place to place when the client does not have sufficient balance and strength to reliably stand and pivot and assist with the transfer to some extent. Adaptive and safety equipment may be used in transfers, provided that the skilled care worker is fully trained in the use of the equipment.

State Plan. An agreement between Colorado and the federal government describing how the Department administers its Medicaid program. The State Plan sets out groups of individuals to be covered, services to be provided, and the methodologies for providers to be reimbursed. It gives an assurance that the Department will abide by federal rules and may claim federal matching funds for its program activities.

Supervision. The act of ensuring that a client is performing a PC Task correctly and safely. Supervision may include actively intervening to ensure that a PC Task is completed without injury.

Unpaid Family Caregiver. A person who provides care to a client without reimbursement by the Department or other entity. Family members of a client will not be reimbursed by the Department for care provided to that client. Family members include, but are not limited to, parents, foster parents, legal guardians, spouses, and other persons legally responsible for the well-being of the client.

Usual Frequency of Task. The number of times a typical person is likely to need a task performed. A task will be performed at the Usual Frequency, unless otherwise specified on the 485 Plan of Care.

Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first

section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.600 MEDICAL ASSISTANCE - SECTION 8.600 Case Management, Supports Intensity Scale, Laboratory and X-Ray {#sec-10-ccr-2505-10-8.600 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.600}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

MEDICAL ASSISTANCE - SECTION 8.600 CASE MANAGEMENT, SUPPORTS

INTENSITY SCALE, LABORATORY AND X-RAY

10 CCR 2505-10 8.600 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

8.607 CASE MANAGEMENT SERVICES

8.607.2 DETERMINATION OF DEVELOPMENTAL DISABILITY

A. Any person, his/her legal guardian, parent(s) of a minor or such person(s) authorized by law may submit a written request for a determination of whether the applicant has a developmental disability.

B. A determination of developmental disability does not constitute a determination of eligibility for services or supports. The Case Management Agencies shall determine whether a person has a developmental disability and therefore may be eligible to receive services and supports pursuant to Sections 25.5-10-202(2) and 211, C.R.S., in accordance with criteria as specified by the Department.

Eligibility for Medicaid funded programs specific to persons with developmental disabilities shall be determined pursuant to Medical Services Board rules C. The developmental disability determination shall be made according to Department procedures, which shall identify the qualifications of person(s) making such a determination.

D. A request for determination of developmental disability shall be submitted to the Case Management Agency in the designated service area where the person resides, including temporary residence such as incarceration or hospitalization.

E. At the time of request, the Case Management Agency shall:

Provide the applicant any required forms and a list of the minimum required documents and information necessary for the determination of developmental disability; and, 2. Provide the applicant with information on where to obtain testing for the level of intellectual functioning and adaptive behavior, if requested. The responsibility for obtaining such assessments shall be with the applicant and/or legal guardian.

F. The applicant and/or legal guardian shall provide all documentation and information necessary for the determination of developmental disability within 90 calendar days of the request.

The Case Management Agency may request additional documentation and/or information, as needed, to complete the determination of developmental disability.
The applicant and/or legal guardian may have additional assessments completed and submitted to the Case Management Agency for consideration.

G. If the applicant and/or legal guardian has not provided the documentation and information necessary for the determination within 90 calendar days of the request, the Case Management Agency shall:

Close the request and notify the applicant in writing according to the procedures established at Section 8.607.2.L.4; or, 2. The Case Management Agency may, at the request of the applicant and/or legal guardian, extend the deadline for providing the necessary documentation and information by up to an additional ninety (90) calendar days.

a. In no case shall the deadline for providing the necessary documentation and information exceed one hundred eighty (180) calendar days.

b. The Case Management Agency shall provide a written update to the applicant no less than every ninety (90) calendar days until a determination of developmental disability is completed or the request is closed.

c. If the extended deadline for providing the necessary documentation and information has expired and there is still insufficient information to make a determination of developmental disability, the Case Management Agency shall close the request and notify the applicant and/or legal guardian in writing according to the procedures established at Section 8.607.2.L.4.

H. For all applicants, the Case Management Agency shall enter into the Department's designated data system and shall permanently maintain a written and/or electronic record of the developmental disability determination on a Department prescribed form. The record, at a minimum, shall include:

The name of the applicant;
The applicant's date of birth;
The date of the determination of developmental disability;
A description of the rationale for the developmental disability determination including, at minimum, assessment scores and diagnoses;
The name(s) and title(s) of the person(s) involved in making the determination.

I. All information and assessments used to determine a developmental disability shall be current so as to accurately represent the applicant's abilities at the time of determination.

Assessments of adaptive behavior shall have been completed within three (3) years of the request.
Assessments of intellectual functioning shall have been completed as follows:

a. If an individual is between five and 18 years of age, at least one intellectual assessment shall have been completed to determine the individual's impairment of general intellectual functioning; or, b. If an individual is 18 years of age or older and there is only one intellectual assessment available to determine the individual's impairment of general intellectual functioning, the assessment shall have been completed when the individual was at least 18 years of age and shall have been completed within 10 years of the request; or, c. If there is historical pattern of consistent scores, based on two or more intellectual assessments, that demonstrates an impairment of general intellectual functioning, the assessments may be used regardless of the individual's age at the time of determination.

An established neurological condition shall be documented as follows:

a. A diagnosed neurological condition shall be determined by a licensed medical professional practicing within the scope of their license; or, b. If a specific diagnosis is not possible, a written statement from a licensed medical professional, practicing within the scope of their license, or a licensed psychologist may be used as long as there is a documented effort to determine a diagnosis and the available assessment information reasonably supports a conclusion that a neurological impairment is present.

The effects of mental illness or physical or sensory impairment must be considered to determine the extent to which such impairments are the sole contributing factor to the impairment of general intellectual functioning or limitations to adaptive behavior.

J. Prior to July 1, 2015, the Case Management Agency shall make the determination of developmental disability within 90 calendar days of the receipt of all necessary information. On or after July 1, 2015, the Case Management Agency shall make the determination of developmental disability within 30 calendar days of the receipt of all necessary information.

K. The date of the developmental disability determination shall be the date that the Department prescribed form and all documentation and information necessary for the determination of developmental disability was received by the Case Management Agency.

If a delay to the determination of developmental disability is due to the actions or inactions of the Case Management Agency, the original date of request shall be used.

L. The Case Management Agency making the developmental disability determination shall, in writing, notify the applicant or legal guardian, and the authorized person requesting the determination, if other than the applicant or legal guardian, and other such persons as designated by the applicant, of the decision. Such notification shall:

Be mailed to the person within seven calendar days of the date of determination;
Be provided in such alternative means of communication as to reasonably ensure that the information has been communicated in an understandable form; and, 3. For persons determined to have a developmental disability, contain an explanation of the process that will occur and notice that, at a minimum, an Individualized Plan shall be developed upon enrollment into a developmental disability service;
For persons determined not to have a developmental disability or persons whose request is closed without the determination of a developmental disability, state the reasons for the determination or closure, and provide a written Long-Term Care Notice of Action form in accordance with the provisions of Section 8.057 regarding the applicant's right to appeal the decision to the Office of Administrative Courts.

M. Applicants determined not to have a developmental disability may request a new determination of developmental disability at any time upon receipt of new or missing required information, and a new request date shall be established.

N. A determination of developmental disability shall be accepted by other Case Management Agencies, service agencies and Regional Centers.

O. A determination of developmental disability shall be permanent and shall not require renewal or review unless:

The member-identified team determines that developmental disability services are no longer needed due to improvement in a person's condition and recommends a redetermination; or, 2. Information from a new evaluation becomes available which demonstrates sufficient improvement in a person's condition such that the determination should be reviewed.

8.660 LABORATORY AND X-RAY

8.660.1 DEFINITIONS 8.660.1.A. Anatomical Laboratory Services mean examinations of tissues derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or the assessment of a medical condition. 8.660.1.B. Certified Clinical Laboratory means a provider who possesses a certificate of waiver or a certificate of registration from the Centers for Medicare and Medicaid Services or its designated agency as meeting Centers for Medicare and Medicaid Services guidelines and whose personnel and director are qualified to perform laboratory services. 8.660.1.C. Clinical Laboratory Services mean microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, pathological or other examinations of fluids derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or the assessment of a medical condition. 8.660.1.D. Definitive Drug Testing means the use of highly specific, quantitative laboratory methods, including but not limited to liquid chromatography–tandem mass spectrometry (LC-MS/MS) and gas chromatography–mass spectrometry (GC-MS), to identify and measure the concentration of individual drugs and drug metabolites in a patient specimen. Definitive Drug Testing confirms the presence or absence of a substance, provides specific analyte identification, and reports exact concentrations of the substances. 8.660.1.E. Independent Certified Laboratory means a certified laboratory that performs diagnostic tests and is independent both of the attending or consulting physician's office and of a hospital except where a hospital laboratory has obtained Medicare certification as an independent laboratory and is billing for recipients who are not admitted as patients in the hospital. 8.660.1.F. X-Ray Services mean services performed by a provider whose x-ray equipment has been certified by the Colorado Department of Public Health and Environment as meeting Medicare guidelines and whose personnel and director are qualified to operate said equipment.

8.660.2 CONDITIONS OF PARTICIPATION 8.660.2. A Certified Clinical Laboratories and providers of X-Ray Services shall enroll as providers in the Medical Assistance Program. 8.660.2.B. All participating laboratories, including out-of-state independent clinical laboratories, must be certified by the state agency to participate under Health First Colorado. All laboratories must provide proof of certification status through the provision of the CLIA (Clinical Laboratory Improvement Amendments of 1988) number to the Department. 8.660.2.C. Providers of X-Ray Services shall be certified by the Colorado Department of Public Health and Environment and must provide proof of Medicare certification on the Health First Colorado provider enrollment forms.

8.660.3 LIMITATIONS AND BENEFITS 8.660.3.A. Laboratory and X-Ray Services are a benefit under all of the following conditions:

The services have been authorized by a licensed physician.
The services are performed to diagnose conditions and illnesses with specific symptoms.
The services are performed to prevent or treat conditions that are benefits under the Medical Assistance Program.
The services are not routine diagnostic tests performed without apparent relationship to treatment or diagnosis for a specific illness, symptom, complaint or injury.
The laboratory services are performed by a certified laboratory in accordance with the Clinical Laboratory Improvement Amendments of 1988 (CLIA).
The X-Ray Services are performed by a provider certified by the Colorado Department of Public Health and Environment and enrolled as a Health First Colorado provider. 8.660.3.B. Collection, handling and/or conveyance of specimens for transfer from physicians' offices to a Certified Clinical Laboratory is reimbursable to the physician. 8.660.3.C. Transfer of a specimen from one Certified Clinical Laboratory to another is a benefit and is reimbursable to the first certified laboratory if the laboratory's equipment is not functioning or the laboratory is not certified to perform the tests ordered by the physician. 8.660.3.D Adult members aged 21 and over are limited to 12 units of service per state fiscal year for Definitive Drug Testing.

8.660.4 BILLING PROCEDURES 8.660.4.A. Certified providers of clinical laboratory and X-Ray Services must bill the Department directly using the designated billing method, the correct Current Procedural Terminology and Healthcare Common Procedure Coding System procedure codes and modifiers as required. Providers must bill the amount of their usual and customary charges to the general public. 8.660.4.B. Laboratory tests and x-rays performed under the personal supervision of the authorizing physician must be billed directly on the physician's services claim form. 8.660.4.C. Laboratory tests and x-rays not performed by the authorizing physician or under his/her direct personal supervision cannot be billed by the physician except for physicians in a Certified Clinical Laboratory group practice. A Certified Clinical Laboratory group practice may only bill for those laboratory and X-Ray Services actually performed or supervised by a physician member of the group or performed by a qualified employee of the group. Payment must be made to the authorizing physician or the group practice. 8.660.4.D. Laboratory and X-Ray Services performed by a hospital-based or independent laboratory or x-ray provider and submitted to an unrelated physician for interpretation may only be billed by the laboratory or x-ray provider for the technical component. 8.660.4.E. Practitioner and clinic providers rendering professional interpretation and not direct laboratory or X-Ray Services may only bill the professional component.

8.660.5 REIMBURSEMENT 8.660.5.A. Reimbursement for certified laboratory and X-Ray Services must be the lowest of the following:

Submitted charges.
Fee schedule as determined by the Department. 8.660.5.B. Services rendered by a hospital-based laboratory during an inpatient stay are included in the hospital Diagnosis Related Group or inpatient rate and must not be billed or reimbursed separately. 8.660.5.C. Each certified laboratory provider must be reimbursed for only those tests performed in the specialties or sub-specialties for which it is certified. 8.660.5.D. Reimbursement for out-of-state certified independent clinical laboratory or X- Ray Services must be subject to Department reimbursement rates. 8.660.5.E. The reimbursement methodology at 8.660.5.A - 8.660.5.D does not apply to payments for those services/procedures that are reimbursed under a capitated or contracted agreement accomplished through competitive bid or other arrangement. ______________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first

section, 10 CCR 2505-10. Prior versions can be accessed from the History link that appears above the text in 10 CCR 2505-10. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.700 MEDICAL ASSISTANCE - SECTION 8.700 Federally Qualified Health Centers, Women's Health Services {#sec-10-ccr-2505-10-8.700 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.700}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE - SECTION 8.700 FEDERALLY QUALIFIED HEALTH CENTERS, WOMEN'S HEALTH SERVICES 10 CCR 2505-10 8.700 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

8.700 FEDERALLY QUALIFIED HEALTH CENTERS

8.700.1 DEFINITIONS 8.700.1.A. Federally Qualified Health Center (FQHC) means a hospital-based or freestanding center that meets the FQHC definition found in Title 42 of the Code of Federal Regulations, Part 405, Subpart X (2015). Title 42 of the Code of Federal Regulations, Part 405, Subpart X (2015) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. These regulations are available for public inspection at the Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Pursuant to C.R.S. 24-4-103(12.5)(V)(b), the agency shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule: 8.700.1.B. Visit means a one-on-one, face-to-face, interactive audio, interactive video, or interactive data communication encounter between a center client and physician, dentist, dental hygienist, dental therapist, physician assistant, nurse practitioner, nurse-midwife, visiting nurse, clinical psychologist, podiatrist, clinical social worker, licensed marriage and family therapist, licensed professional counselor, or licensed addiction counselor providing the services set forth in

Section 8.700.3.A. Group sessions do not generate a billable encounter for any FQHC services.

A visit includes a one-on-one or face-to-face encounter, or an interactive audio, interactive video, or interactive data communication encounter in accordance with Section 8.095, between a center client and a supervised person pursuing mental health therapy licensure as a licensed clinical social worker, licensed professional counselor, licensed marriage and family therapist, or psychologist in the state of Colorado providing services set forth in Section 8.700.3.A. The supervised person must hold a candidate permit as a licensed professional counselor or a candidate permit as a licensed marriage and family therapist, or a candidate permit as a psychologist, or a candidate permit as a clinical social worker candidate (SWC), or a be a licensed social worker. Group sessions do not generate a billable encounter for any FQHC services. 8.700.1.C. The visit definition includes interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounters in accordance with Section 8.095.
Any health benefits provided through interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) must meet the same standard of care as in-person care in accordance with Section 8.095.

8.700.2 CLIENT CARE POLICIES 8.700.2.A The FQHCs health care services shall be furnished in accordance with written policies that are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member of the group shall not be a member of the FQHC staff. 8.700.2.B The policies shall include:

A description of the services the FQHC furnishes directly and those furnished through agreement or arrangement. See Section 8.700.3.A.3.
Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or client referral, the maintenance of health care records and procedures for the periodic review and evaluation of the services furnished by the FQHC.
Rules for the storage, handling and administration of drugs and biologicals.

8.700.3 SERVICES 8.700.3.A The following services may be provided by a certified FQHC:

General services a. Outpatient primary care services that are furnished by a physician, dentist, dental hygienist, physician assistant, nurse practitioner, nurse midwife visiting nurse, clinical psychologist, podiatrist, clinical social worker, licensed marriage and family therapist, licensed professional counselor, licensed addiction counselor or supervised person pursuing mental health licensure as defined in their respective practice acts.

i. Outpatient primary care services that are furnished by a supervised person pursuing mental health therapy licensure as a licensed clinical social worker, licensed professional counselor, licensed marriage and family therapist, or psychologist in the state of Colorado as defined in their respective practice acts.

b. Part-time or intermittent visiting nurse care.

c. Services and medical supplies, other than pharmaceuticals, that are furnished as a result of professional services provided under

Section 8.700.3.A.1.a and b.

Emergency services. FQHCs furnish medical emergency procedures as a first response to common life-threatening injuries and acute illness and must have available the drugs and biologicals commonly used in life saving procedures.
Services provided through agreements or arrangements. The FQHC has agreements or arrangements with one or more providers or suppliers participating under Medicare or Medicaid to furnish other services to clients, including physician services (whether furnished in the hospital, the office, the client’s home, a skilled nursing facility, or elsewhere) and additional and specialized diagnostic and laboratory services that are not available at the FQHC. 8.700.3.B A certified FQHC may also provide any service authorized for payment outside the per visit encounter rate by Section 8.700.6.B.

8.700.4 PHYSICIAN RESPONSIBILITIES 8.700.4.A A physician shall provide medical supervision and guidance for physician assistants and nurse practitioners, prepare medical orders, and periodically review the services furnished by the clinic. A physician shall be present at the clinic for sufficient periods of time to fulfill these responsibilities and must be available at all times by direct means of communications for advice and assistance on patient referrals and medical emergencies. A clinic operated by a nurse practitioner or physician assistant may satisfy these requirements through agreements with one or more physicians.

8.700.5 ALLOWABLE COST 8.700.5.A The following types and items of cost for primary care services are included in allowable costs to the extent that they are covered and reasonable:

Compensation for the services of a physician, dentist, dental hygienist, physician assistant, nurse practitioner, nurse-midwife, visiting nurse, qualified clinical psychologist, podiatrist, clinical social worker, licensed marriage and family therapist, licensed professional counselor and licensed addiction counselor and licensure candidates for clinical psychologist, clinical social worker, licensed marriage and family therapist, and licensed professional counselor who owns, is employed by, or furnishes services under contract to an FQHC.
Compensation for the duties that a supervising physician is required to perform.
Costs of services and supplies related to the services of a physician, dentist, dental hygienist, physician assistant, nurse practitioner, nursemidwife, visiting nurse, qualified clinical psychologist, podiatrist, clinical social worker, licensed marriage and family therapist, licensed professional counselor or licensed addiction counselor.
Overhead cost, including clinic or center administration, costs applicable to use and maintenance of the entity, and depreciation costs.
Costs of services purchased by the clinic or center. 8.700.5.B Unallowable costs include but are not limited to expenses that are incurred by an FQHC and that are not for the provision of covered services, according to applicable laws, rules, and standards applicable to the Medical Assistance Program in Colorado. An FQHC may expend funds on unallowable cost items, but these costs may not be used in calculating the per visit encounter rate for Medicaid clients.

Unallowable costs, include, but are not necessarily limited to, the following:

Offsite Laboratory/X-Ray;
Costs associated with clinics or cost centers which do not provide services to Medicaid clients; and, 3. Costs of services reimbursed separately from the FQHC encounter rate as described in Section 8.700.6.B.

8.700.6 REIMBURSEMENT 8.700.6.A FQHCs shall be reimbursed separate per visit encounter rates based on 100% of reasonable cost for physical health services, dental services, and specialty behavioral health services. An FQHC may be reimbursed for up to three separate encounters with the same client occurring in one day and at the same location, so long as the encounters submitted for reimbursement are any combination of the following: physical health encounter, dental encounter, or specialty behavioral health encounter. Distinct dental encounters are allowable only when rendered services are covered and paid by the Department’s dental Administrative Service Organization (ASO). Distinct specialty behavioral health encounters are allowable only when rendered services are covered and paid by either the Regional Accountable Entity (RAE) or through the short-term behavioral health services in the primary care setting policy. 8.700.6.B The following services are reimbursed separately from the FQHC encounter rate. These services shall be reimbursed in accordance with the 1. Long-Acting Reversible Contraception (LARC) devices shall be reimbursed separately from the FQHC encounter rate. In addition to payment of the encounter rate for the insertion of the device(s), the LARC device(s) must be billed in accordance with Section 8.730 and shall be a. Submitted charges, or b. Fee schedule as determined by the Department.

Services provided in an inpatient hospital setting shall be reimbursed the lower of:

a. Submitted charges, or b. Fee schedule as determined by the Department.

The provision of complete dentures and partial dentures must be billed in accordance with Section 8.201. and Section 8.202. and shall be a. Submitted charges, or b. Fee schedule as determined by the Department.
Dental services provided in an outpatient hospital setting shall be a. Submitted charges, or b. Fee schedule as determined by the Department.
The Prenatal Plus Program shall be billed and reimbursed in accordance with Section 8.748.
The Nurse Home Visitor Program shall be billed and reimbursed in accordance with Section 8.749.
An FQHC that operates its own pharmacy that serves Medicaid clients must obtain a separate Medicaid billing number for pharmacy and bill all prescriptions utilizing this number in accordance with Section 8.800.
(“A FQHC subsidiary that serves Medicaid members must enroll as a Health First Colorado provider and submit claims for any subsidiary location services using a National Provider Identifier (NPI) that is distinct from that of its parent FQHC. The subsidiary must bill all associated services utilizing this number to be reimbursed the lower of:

a. Submitted charges, or b. Fee schedule as determined by the Department Subsidiary services shall bill utilizing the numbers in accordance with the following Sections:

a. Labs and X-Ray Services: Section 8.660 b. Optometry: Section 8.203 c. Physical Therapy: Section 8.200.3 d. Occupational Therapy: Section 8.200.3 e. Chiropractic Care: Section 8.751 9. Antagonist injections for substance use disorders provided at the FQHC shall be reimbursed the lower of:

a. Submitted charges; or b. Fee schedule as determined by the Department. 8.700.6.C A physical health encounter, a dental encounter, and a specialty behavioral health encounter on the same day and at the same location shall count as three separate visits.

Encounters with more than one health professional, and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except when the client, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment. 8.700.6.D Encounter rates calculations Effective July 1, 2018, FQHCs will be paid three separate encounter rates for three separate services: physical health services, dental services, and specialty behavioral health services. Physical health services are covered services reimbursed through the Department’s MMIS, except the shortterm behavioral health services in the primary care setting policy. Dental services are services provided by a dentist or dental hygienist that are reimbursed by the Department’s dental ASO. Specialty behavioral health services are behavioral health services covered and reimbursed by either the RAE or by the MMIS through the short-term behavioral health services in the primary care setting policy. The Department will perform an annual reconciliation to ensure each FQHC has been paid at least their per visit Prospective Payment System (PPS) rate. If an FQHC has been paid below their per visit PPS rate, the Department shall make a one-time payment to make up for the difference.
The PPS rate is defined by Section 702 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) included in the Consolidated Appropriations Act of 2000, Public Law 106-554, Dec. 21, 2000. BIPA is incorporated herein by reference. No amendments or later editions are incorporated.

Copies are available for a reasonable charge and for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Any material that has been incorporated by reference in this rule may be examined at any state publications depository library.

Each alternative payment rate shall be the lower of the service specific annual rate or the service specific base rate. The annual rate and the base rate shall be calculated as follows:

a. The annual rate for the physical health rate shall be the FQHCs current year’s audited, calculated, and inflated cost per visit for physical health services and visits. The annual rate for the dental rate shall be the FQHCs current year’s audited, calculated, and inflated cost per visit for dental services and visits provided by a dentist or dental hygienist.

The annual rate for the specialty behavioral health rate shall be the FQHCs current year’s audited, calculated, and inflated cost per visit for behavioral health services and visits either covered and reimbursed by the RAE or by the shortterm behavioral health services in the primary care setting policy.

b. The new base rates shall be the audited, calculated, inflated, and weighted average encounter rate for each separate rate, for the past three years. Base rates are recalculated (rebased) annually. Initial Base rates shall be calculated when the Department has two year’s data of costs and visits.

c. Beginning July 1, 2020, a portion of the FQHCs physical health alternative payment methodology rates are at-risk based on the FQHC’s quality modifier. An FQHC’s quality modifier is determined by the FQHC’s performance on quality indicators in the previous Calendar Year.

New FQHCs shall file a preliminary FQHC Cost Report with the Department. Data from the preliminary report shall be used to set reimbursement base rates for the first year. The base rates shall be calculated using the audited cost report showing actual data from the first fiscal year of operations as an FQHC. These shall be the FQHCs base rates until the FQHC’s final base rates are set.

a. New base rates may be calculated using the most recent audited Medicaid FQHC cost report for those FQHCs that have received their first federal Public Health Service grant with the three years prior to rebasing, rather than using the inflated weighted average of the most recent three years audited encounter rates.

The Department shall audit the FQHC cost report and calculate the new annual and base reimbursement rates. If the cost report does not contain adequate supporting documentation, the FQHC shall provide requested documentation within ten (10) business days of request. Unsupported costs shall be unallowable for the calculation of the FQHCs new encounter rate.

a. Freestanding and hospital-based FQHCs shall file the Medicaid cost reports with the Department on or before the 90th day after the end of the FQHCs’ fiscal year. FQHCs shall use the Medicaid FQHC Cost Report developed by the Department to report annual costs and encounters. An extension of up to 75 days may be granted based upon circumstances. Failure to submit a cost report within 180 days after the end of a freestanding FQHCs’ fiscal year shall result in suspension of payments.

b. The new reimbursement encounter rates for FQHCs shall be effective 120 days after the FQHCs fiscal year end. The old reimbursement encounter rates (if less than the new audited rate) shall remain in effect for an additional day above the 120-day limit for each day the required information is late; if the old reimbursement encounter rates are more than the new rate, the new rates shall be effective the 120th day after the FQHCs fiscal year end.

c. Effective December 11, 2020, FQHC cost reports with fiscal year ends between May 31, 2020 and March 31, 2021 will be set using the previous year’s rates multiplied by the Medicare Economic Index (MEI).

d. Effective September 28, 2021, FQHC cost reports with fiscal year ends between May 31, 2021 and March 31, 2022 will be set using the previous year’s rates multiplied by 2.7%.

e. Starting with FQHC cost reports with fiscal year end May 31, 2022 the Department will restart the base rate setting process. For the first cost report submitted by an FQHC with fiscal year end May 31, 2022 and after, base rates will be set based on one year’s worth of data. For the second cost report submitted by an FQHC with fiscal year end May 31, 2022 and after, base rates will be set as a weighted average of two years’ worth of data. After this, base rates will be set as specified in 8.700.6.D.2.

If an FQHC changes its scope of service after the year in which its base PPS rate was determined, the Department will adjust the FQHC’s PPS rate in accordance with section 1902(bb) of the Social Security Act.

a. An FQHC must apply to the Department for an adjustment to its PPS rate whenever there is a documented change in the scope of service of the FQHC. The documented change in the scope of service of the FQHC must meet all of the following conditions:

i. The increase or decrease in cost is attributable to an increase or decrease in the scope of service that is a covered benefit, as described in Section 1905(a)(2)(C) of the Social Security Act, and is furnished by the FQHC.

ii. The cost is allowable under Medicare reasonable cost principles set forth in 42 CFR Part 413.5.

iii. The change in scope of service is a change in the type, intensity, duration, or amount of services, or any combination thereof.

iv. The net change in the FQHC’s per-visit encounter rate equals or exceeds 3% for the affected FQHC site. For FQHCs that file consolidated cost reports for multiple sites in order to establish the initial PPS rate, the 3% threshold will be applied to the average pervisit encounter rate of all sites for the purposes of calculating the cost associated with a scope-ofservice change.

v. The change in scope of service must have existed for at least a full six (6) months.

b. A change in the cost of a service is not considered in and of itself a change in scope of service. The change in cost must meet the conditions set forth in Section 8.700.6.D.5.b and the change in scope of service must include at least one of the following to prompt a scope-of-service rate adjustment. If the change in scope of service does not include at least one of the following, the change in the cost of services will not prompt a scope-of-service rate adjustment.

i. The addition of a new service not incorporated in the baseline PPS rate, or deletion of a service incorporated in the baseline PPS rate;

ii. The addition or deletion of a covered Medicaid service under the State Plan;

iii. Changes necessary to maintain compliance with amended state or federal regulations or regulatory requirements;

iv. Changes in service due to a change in applicable technology and/or medical practices utilized by the FQHC;

v. Changes resulting from the changes in types of patients served, including, but not limited to, populations with HIV/AIDS, populations with other chronic diseases, or homeless, elderly, migrant, or other special populations that require more intensive and frequent care;

vi. Changes resulting from a change in the provider mix, including, but not limited to:

a. A transition from mid-level providers (e.g. nurse practitioners) to physicians with a corresponding change in the services provided by the FQHC;

b. The addition or removal of specialty providers (e.g. pediatric, geriatric, or obstetric specialists) with a corresponding change in the services provided by the FQHC (e.g. delivery services);

c. Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and/or residents; or, d. Changes in operating costs attributable to capital expenditures (including new, expanded, or renovated service facilities), regulatory compliance measures, or changes in technology or medical practices at the FQHC, provided that those expenditures result in a change in the services provided by the FQHC.

c. The following items do not prompt a scope-of-service rate adjustment:

i. An increase or decrease in the cost of supplies or existing services;

ii. An increase or decrease in the number of encounters;

iii. Changes in office hours or location not directly related iv. Changes in equipment or supplies not directly related v. Expansion or remodel not directly related to a change in scope of service;

vi. The addition of a new site, or removal of an existing site, that offers the same Medicaid-covered services;

vii. The addition or removal of administrative staff;

viii. The addition or removal of staff members to or from an existing service;

ix. Changes in salaries and benefits not directly related x. Change in patient type and volume without changes in type, duration, or intensity of services;

xi. Capital expenditures for losses covered by insurance; or, xii. A change in ownership.

d. An FQHC must apply to the Department by written notice within ninety (90) days of the end of the FQHCs fiscal year in which the change in scope of service occurred, in conjunction with the submission of the FQHC’s annual cost report. Only one scope-of-service rate adjustment will be calculated per year. However, more than one type of change in scope of service may be included in a single application.

e. Should the scope-of-service rate application for one year fail to reach the threshold described in Section 8.700.6.D.5.b.4, the FQHC may combine that year’s change in scope of service with a valid change in scope of service from the next year or the year after. For example, if a valid change in scope of service that occurred in FY 2016 fails to reach the threshold needed for a rate adjustment, and the FQHC implements another valid change in scope of service during FY2018, the FQHC may submit a scope-of-service rate adjustment application that captures both of those changes.

An FQHC may only combine changes in scope of service that occur within a three-year time frame, and must submit an application for a scope-of-service rate adjustment as soon as possible after each change has been implemented.

Once a change in scope of service has resulted in a successful scope-of-service rate adjustment, either individually or in combination with another change in scope of service, that change may no longer be used in an application for another scope-of-service rate adjustment.

f. The documentation for the scope-of-service rate adjustment is the responsibility of the FQHC. Any FQHC requesting a scope-of-service rate adjustment must submit the following to the Department:

i. The Department’s application form for a scope-ofservice rate adjustment, which includes:

a. The provider number(s) that is/are affected by the change(s) in scope of service;

b. A date on which the change(s) in scope of service was/were implemented;

c. A brief narrative description of each change in scope of service, including how services were provided both before and after the change;

d. Detailed documentation such as cost reports that substantiate the change in total costs, total health care costs, and total visits associated with the change(s) in scope; and e. An attestation statement that certifies the accuracy, truth, and completeness of the information in the application signed by an officer or administrator of the FQHC;

ii. Any additional documentation requested by the Department. If the Department requests additional documentation to calculate the rate for the change(s) in scope of service, the FQHC must provide the additional documentation within thirty (30) days. If the FQHC does not submit the additional documentation within the specified timeframe, the Department, at its discretion, may postpone the implementation of the scope-of-service rate adjustment.

g. The reimbursement rate for a scope-of-service change applied for January 30, 2017 or afterwards will be calculated as follows:

i. The Department will first verify the total costs, the total covered health care costs, and the total number of visits before and after the change in scope of service. The Department will also calculate the Adjustment Factor (AF = covered health care costs/total cost of FQHC services) associated with the change in scope of service of the FQHC. If the AF is 80% or greater, the Department will accept the total costs as filed by the FQHC. If the AF is less than 80%, the Department will reduce the costs other than covered health care costs (thus reducing the total costs filed by the FQHC) until the AF calculation reaches 80%. These revised total costs will then be the costs used in the scope-of-service rate adjustment calculation.

ii. The Department will then use the appropriate costs and visits data to calculate the adjusted PPS rate.

The adjusted PPS rate will be the average of the costs/visits rate before and after the change in scope of service, weighted by visits.

iii. The Department will calculate the difference between the current PPS rate and the adjusted PPS rate. The “current PPS rate” means the PPS rate in effect on the last day of the reporting period during which the most recent scope-of-service change occurred.

iv. The Department will check that the adjusted PPS rate meets the 3% threshold described above. If it does not meet the 3% threshold, no scope-of-service rate adjustment will be implemented.

v. Once the Department has determined that the adjusted PPS rate has met the 3% threshold, the adjusted PPS rate will then be increased by the Medicare Economic Index (MEI) to become the new PPS rate.

h. The Department will review the submitted documentation and will notify the FQHC in writing within one hundred twenty (120) days from the date the Department received the application as to whether a PPS rate change will be implemented. Included with the notification letter will be a rate-setting statement sheet, if applicable. The new PPS rate will take effect one hundred twenty (120) days after the FQHC’s fiscal year end.

i. Changes in scope of service, and subsequent scope-ofservice rate adjustments, may also be identified by the Department through an audit or review process.

i. If the Department identifies a change in scope of services, the Department may request the documentation as described in Section 8.700.6.D.5.g from the FQHC. The FQHC must submit the documentation within ninety (90) days from the date of the request.

ii. The rate adjustment methodology will be the same as described in Section 8.700.6.D.5.h.

iii. The Department will review the submitted documentation and will notify the FQHC by written notice within one hundred twenty (120) days from the date the Department received the application as to whether a PPS rate change will be implemented.

Included with the notification letter will be a ratesetting statement sheet, if applicable.

iv. The effective date of the scope-of-service rate adjustment will be one hundred twenty (120) days after the end of the fiscal year in which the change in scope of service occurred.

j. An FQHC may request a written informal reconsideration of the Department’s decision of the PPS rate change regarding a scope-of-service rate adjustment within thirty (30) days of the date of the Department’s notification letter. The informal reconsideration must be mailed to the Department of Health Care Policy and Financing, 1570 Grant St, Denver, CO 80203. To request an informal reconsideration of the decision, an FQHC must file a written request that identifies specific items of disagreement with the Department, reasons for the disagreement, and a new rate calculation. The FQHC should also include any documentation that supports its position. A provider dissatisfied with the Department’s decision after the informal reconsideration may appeal that decision through the Office of Administrative Courts according to the procedures set forth in 10 CCR 2505-10

Section 8.050.3, PROVIDER APPEALS.

The performance of physician and mid-level medical staff shall be evaluated through application of productivity standards established by the Centers for Medicare and Medicaid Services (CMS) in CMS Publication 27, Section 503; “Medicare Rural Health Clinic and FQHC Manual”. If an FQHC does not meet the minimum productivity standards, the productivity standards established by CMS shall be used in the FQHCs’ rate calculation.
The Department offers a second Alternative Payment Methodology (APM 2) that is able to pay FQHCs through a Per Member Per Month (PMPM) rate. This reimbursement methodology will convert the FQHC’s current Physical Health cost per visit rate into an equivalent PMPM rate using historical patient utilization, member designated attribution, and the Physical Health cost per visit rate for the specific FQHC. FQHCs may opt into APM 2 PMPM annually.

Physical health services rendered to patients not attributed to the FQHC, or attributed based on geographic location, will pay at the appropriate encounter rate. Members who are dually eligible for Medicare and Medicaid are excluded APM 2 member populations and attribution because Medicare is the primary payer. Dental and specialty behavioral health services for all patients will be paid at the appropriate encounter rate. Year 2 rates for FQHCs participating in APM 2 will be set using trended data. Year 3 rates will be set using actual data.

FQHCs may voluntarily elect to join APM 2 PMPM or the Chronic Condition Incentive Payment, or both. FQHCs will be eligible to earn incentive payment, which will not factor into rate-setting for APM 1 or APM 2, for participating in Chronic Condition Incentive Payment. Incentive payment thresholds will be specific to each FQHC. The Department will share thresholds each FQHC must meet to be eligible to receive incentive payments. Services that comprise the targets will also be published. FQHCs may opt into the APM 2 Chronic Conditions Incentive Payment quarterly on the first date of the calendar quarter. FQHCs will agree to the thresholds and services for incentive payments in the letter sent annually by the Department which confirms participation in the program. The Chronic Conditions Incentive Payment will be paid when FQHCs provide physical health services to full benefit Medicaid beneficiaries attributed to the FQHC, who are not geographically attributed or dually eligible for Medicare, and must also be diagnosed with one or more the following chronic conditions: asthma, chronic obstructive pulmonary disease, coronary artery disease, hypertension, arrythmia/heart blockage, heart failure, gastro-esophageal reflux disease, Crohn’s disease, ulcerative colitis, low back pain, osteoarthritis, and/or diabetes.
The Department will perform an annual reconciliation to ensure the PMPM reimbursement compensates APM 2 providers in an amount that is no less than their PPS per visit rate. The Department shall perform PPS reconciliations should the FQHC participating in APM 2 realize additional cost, not otherwise reimbursed under the PMPM, incurred as a result of extraordinary circumstances that cause traditional encounters to increase to a level where PMPM reimbursement is not sufficient for the operation of the FQHC.
PMPM and encounter rates for FQHC participating in APM 2 shall be effective on the 1st day of the month that falls at least 120 days after an FQHC’s fiscal year end. 8.700.6.E The Department shall notify the FQHC of its rates.

8.700.8 REIMBURSEMENT FOR OUTSTATIONING ADMINISTRATIVE COSTS 8.700.8.A The Department shall reimburse freestanding FQHCs for reasonable costs associated with assisting clients in the Medicaid application process. Beginning with the 2019 Cost Report Cycle, this outstationing payment shall be made based upon actual cost and is included as an allowable cost in an FQHC cost report.

8.700.8.B

Hospitals with hospital-based FQHCs shall receive federal financial participation for reasonable costs associated with assisting potential beneficiaries in the Medicaid application process. For any hospital-based FQHC Medicaid cost report audited and finalized after July 1, 2005, Denver Health Medical Center shall receive federal financial participation for eligible expenditures. To receive the federal financial participation, Denver Health Medical Center shall provide the state’s share of the outstationing payment by certifying that the audited administrative costs associated with outstationing activities are eligible Medicaid public expenditures. Such certifications shall be sent to the Safety Net Programs Manager.
Hospitals with hospital-based FQHCs shall receive federal financial participation for reasonable costs associated with assisting potential beneficiaries in the Medicaid application process. Effective with the hospital cost report year 2010 and forward, the Department will make an interim payment to Denver Health Medical Center for estimated reasonable costs associated with outstationing activities based on the costs included in the as-filed Medicare cost report. This interim payment will be reconciled to actual costs after the cost report is audited. Denver Health Medical Center shall receive federal financial participation for eligible expenditures. To receive the federal financial participation, Denver Health Medical Center shall provide the state’s share of the outstationing payment by certifying that the interim estimated administrative costs and the final audited administrative costs associated with outstationing activities are eligible Medicaid public expenditures. Such certifications shall be sent to the Safety Net Programs Manager. 8.711.1 through 8.712 Repealed, effective June 30, 2005 8.715 BREAST AND CERVICAL CANCER PROGRAM 8.715.1 DEFINITIONS Breast and Cervical Cancer Program (BCCP) means the Medicaid program established, operated and monitored by the Department.

Colorado Women's Cancer Control Initiative (CWCCI) means the program administered by the Colorado Department of Public Health and Environment and funded by the Centers for Disease Control and the National Breast and Cervical Cancer Early Detection Program.

In Need of Treatment means services necessary to determine the extent and proper course of cancer or precancerous treatment as well as definitive cancer treatment itself.

Treatment can include surgery, radiation, chemotherapy and approved medications following treatment as determined by the client's physician and the Department.

National Breast and Cervical Cancer Early Detection Program (NBCCEDP) means the program where the Centers for Disease Control (CDC) provides breast and cervical screening services to underserved women. In Colorado, the CDC provider is the Department of Public Health and Environment's Colorado Women's Cancer Control Initiative.

Presumptive Eligibility for BCCP means the temporary eligibility for benefits that begin on the date a Qualified Entity determines the client meets eligibility requirements for the BCCP and the client signs the presumptive eligibility form. Women identified by the CWCCI as being In Need of Treatment for breast or cervical cancer or a precancerous condition shall apply for presumptive eligibility on a simplified Medicaid application.

Qualified Entity means a provider contracted with the Department of Public Health and Environment under a cooperative agreement with the CDC to support activities related to the NBCCEDP. A qualified entity shall provide breast and cervical cancer assessment services for the CWCCI.

State Designated Entity means an agency acting on behalf of and at the direction of the Department and whose function may include, but is not limited to, processing eligibility determinations and assisting clients with the application process.

8.715.2 ELIGIBILITY REQUIREMENTS 8.715.2.A. Members shall meet all requirements of the CWCCI program. 8.715.2.B. Members shall enroll for screening at participating Breast and Cervical Cancer assessment sites through the CWCCI. 8.715.2.C. Members shall:

Be a woman who has not yet attained the age of 65.
Be a resident of Colorado.
With the exception of individuals who meet the criteria in Section 8.100.3(G)(1)(g)(viii), be a citizen of the United States or a qualified alien as described in 8.100.3(G)(1)(g)(ii)-(iv) and 8.100.3(G)(1)(g)(vi)-(vii).
Have been screened by a Qualified Entity and found to be In Need of Treatment for breast or cervical cancer, including precancerous conditions as determined through pathological tests.
Not have creditable coverage as described in 8.715.3.
Not be eligible under another Medicaid program.
Be a member who has previously qualified and enrolled in a NBCCED program in another state and chooses to transfer her enrollment to CWCCI. 8.715.2.D. Members shall not have been previously screened or received treatment for breast or cervical cancer prior to July 1, 2002. 8.715.2.E. Members shall not be considered to be In Need of Treatment if it is determined she only requires routine follow-up monitoring services. 8.715.2.F. Members shall be willing to seek Medicaid approved breast or cervical cancer or precancerous treatment within three months of the date of eligibility. If a member does not seek such treatment within three months of the date of presumptive eligibility, the member shall be removed from the program on the last day of the third month. The member will be re-entered in the BCCP program at such time as treatment is scheduled to begin. If treatment has not been started within one month of the scheduled date, the member will be disenrolled.

8.715.3 CREDITABLE COVERAGE 8.715.3.A. Creditable coverage shall include coverage of any individual as defined at 10-16-102, C.R.S. (2002). 8.715.3.B. The following are not considered creditable coverage:

Limited scope coverage such as that which covers only dental, vision or long term care;
Coverage only for a specific disease or illness (unless the specific disease or illness includes breast or cervical cancer); or 3. A medical care program run by the Indian Health Services or a tribal organization. 8.715.3.C. An individual who otherwise has creditable coverage may qualify for the program if:
The individual is in a period of exclusion for treatment of breast or cervical cancer; or 2. The individual has exhausted her lifetime limits on benefits under the plan for breast or cervical cancer. 8.715.3.D. Individuals who have coverage that contains yearly limited drug benefits, yearly limits on outpatient visits or high deductibles shall be considered to have creditable coverage.

8.715.4 PRESUMPTIVE ELIGIBILITY 8.715.4.A. Presumptive eligibility shall be determined by Qualified Entities. 8.715.4.B. The Department shall make available to Qualified Entities:

Information on the BCCP presumptive eligibility form and card;
Information on how to obtain the Medicaid application; and 3. Information on how to assist CWCCI personnel and individuals on application completion and filing. 8.715.4.C. Qualified Entities shall determine presumptive eligibility based on verbal confirmation by the potential client that she meets CWCCI criteria and shall enroll the clients who appear to be eligible. 8.715.4.D. Presumptive eligibility shall begin on the date the client completes the BCCP presumptive eligibility form and the Qualified Entity determines the client meets all eligibility criteria. 8.715.4.E. All potential clients shall be required to complete the BCCP presumptive eligibility form and the Medicaid application at the same time. 8.715.4.F. The Qualified Entity shall submit the presumptive eligibility form, a copy of the presumptive eligibility card, the CWCCI history and physical, the diagnosis pathology report and the signed consent form to the Department. 8.715.4.G. The Designated Entity shall process the Medicaid application within thirty calendar days of receipt. 8.715.4.H. The presumptive eligibility period shall end on the following:
The date on which a formal determination is made on the client's Medicaid application; or 2. If a full determination cannot be made on the basis of the BCCP presumptive eligibility form and the client fails to complete the Medicaid application, then eligibility will end on last day of the month following the month in which the client was determined to be presumptively eligible.

8.715.5 ELIBILITY PERIOD 8.715.5.A. Eligibility shall begin on the date the client is determined to be presumptively eligible. 8.715.5.B. The client shall be eligible to receive services for up to one year from the date of initial eligibility unless she is no longer In Need of Treatment or no longer meets program eligibility requirements. 8.715.5.C. If the client remains in treatment beyond one year, renewed eligibility shall be determined consistent with BCCP and Medicaid requirements. 8.715.5.D. A period of renewed eligibility begins each time the client is screened under the CWCCI program and is found to be In Need of Treatment for breast or cervical cancer and meets all other eligibility criteria. 8.715.5.E. A client may be determined no longer eligible for the program if:

She does not complete the Medicaid application; or 2. She is no longer In Need of Treatment for breast or cervical cancer or qualified precancerous conditions when the client's provider notifies the Department; or 3. She reaches the age of 65; or 4. She obtains other creditable coverage describe in 8.715.3. 8.715.5.F. Clients who are determined no longer eligible shall be notified in writing as described in 8.715.6(B).

8.715.6 NOTIFICATION 8.715.6.A. The BCCP presumptive eligibility form shall include a statement of the applicant's rights and responsibilities. 8.715.6.B. The Department shall notify clients who are no longer In Need of Treatment for the BCCP in writing thirty days prior to their disenrollment date.

This notice will be provided only to those clients who have completed their course of treatment per their provider.

Copies of the notice shall be sent to the client, her designated representative if applicable, the CWCCI site, the State Designated Entity and the client's provider.
The notification shall include information regarding appeal rights described in 10 C.C.R. 2505-10, Section 8.057. 8.715.6.C. The Department shall notify clients who no longer meet the BCCP eligibility criteria at least ten days prior to program termination.

8.715.7 BENEFITS 8.715.7.A. Eligible clients shall receive all Medicaid benefits included in the State Plan. 8.715.7.B. Breast reconstructive surgery shall be a covered benefit when completed up to seven months following a mastectomy. 8.715.7.C. Breast or cervical cancer or precancerous treatment provided prior to the NBCCED program implementation or client enrollment into the BCCP is not a covered benefit. 8.715.7.D. Clients eligible for this program shall receive all mental health services through the Mental Health Assessment Service Agency of the county in which the client resides.

8.715.8 ROLES/RESPONSIBILITIES 8.715.8.A. County Departments of Human/Social Services shall:

Assist in providing information to the client about services and benefits available through the program;
Assist the client in accessing health care services or contact the appropriate agencies for services, such as the enrollment broker, mental health provider and transportation provider;
Assist the client in applying for and accessing other benefits for which she may qualify, such as home care allowance, food stamps and financial assistance; and 4. Assist the Department by notifying the Department when a client's eligibility status changes. 8.715.8.B. Clients shall notify the Department and healthcare providers if the client receives creditable coverage or if a third party is responsible for illness or injury to the client. 8.715.8.C. Providers shall respond to inquiries from the Department and provide information required to verify the client's In Need of Treatment status within ten calendar days of the Department's request. 8.715.8.D. Provider's shall follow Medicaid billing instructions and obtain prior authorizations when necessary. 8.715.8.E. The State Designated Entities shall have the following responsibilities:
To determine whether a client is eligible for Medicaid in any other eligibility group;
To complete review of the Medicaid application form within fifteen days of receipt;
To notify the client she has thirty days to submit addition information if needed and if the information is not received the client will be found ineligible;
To inform the client of her appeal rights if eligibility is denied; and 5. To disenroll the client from the BCCP when notified the client is no longer in Need of Treatment. 8.726 TEEN PREGNANCY PREVENTION PILOT PROGRAM [Repealed eff. 09/30/2025]

8.730 FAMILY PLANNING SERVICES 8.730.1 Definitions Family Planning Services mean those services provided to individuals of childbearing age, including sexually active minors, where the intent of that service is to delay, prevent, or plan for a pregnancy. Family Planning Services may include physical examinations, evaluation, treatments, counseling, supplies , prescriptions, and follow-up services.

Institutionalized Individual means an individual who is (a) involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility (including a psychiatric hospital or other facility) for the care and treatment of a mental illness; or (b) confined, under a voluntary commitment in a psychiatric hospital or other facility, for the care and treatment of a mental illness.

Mentally Incompetent Individual means an individual who has been declared mentally incompetent by a federal, state, or local court for any purpose, unless the individual has been declared competent for purposes that include the ability to consent to sterilization.

Sterilization means any medical procedure, treatment, or operation (except for a hysterectomy) for the purpose of rendering an individual permanently incapable of reproducing and that requires informed consent 8.730.2 Client Eligibility 8.730.2.A. All Medicaid clients of childbearing age are eligible for family planning 8.730.3 Provider Eligibility 8.730.3.A. The following Medicaid enrolled providers may offer family planning services:

Physician 2. Osteopath 3. Nurse Practitioner 4. Certified Nurse-Midwife 5. Physician Assistant 6. Clinical Nurse Specialist 7. Certified Registered Nurse Anesthetist 8. Family Planning Clinic 9. Public Health Agency 10. Non-physician Practitioner Group 8.730.3.B. Eligible places of service include:
Office 2. Clinic 3. Public Health Agency 4. Home 5. School 6. School-based Health Center 7. Federally Qualified Health Center 8. Rural Health Center 9. Hospital 10. Ambulatory Surgery Center 11. Telemedicine may be provided in accordance with Section 8.095. 8.730.4 Covered Services 8.730.4.A. Office Visits 1. A comprehensive, annual family planning visit (where the intent of the visit is related to pregnancy prevention or planning) is covered only once per state fiscal year, no less than ten months apart, and may include: physical examinations, evaluation, treatments, counseling, supplies, contraceptives and prescriptions. Additional family planning follow-up visits and services are covered when medically necessary. 8.730.4.B. Sterilization 1. Sterilization is covered for a client who is:

a. 21 years of age or older;

b. Is mentally competent;

c. Is not institutionalized; and, d. Has given written informed consent where at least one of the following conditions apply:

i. At least 30 days, but no more than 180 days have passed between the date of informed consent and the date of sterilization;

ii. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery and at least 72 hours have passed since the date of informed consent; or iii. In the case of emergency abdominal surgery, at least 72 hours have passed since the date of informed consent.

A client with an intellectual and developmental disability is protected under C.R.S. 25.5-10-231 and C.R.S. 25.5-10-232 with respect to sterilization rights and competency to give consent for sterilization.

a. The above statutes are applicable except for clients aged between eighteen and twenty-one years. For any signed sterilization consent to be considered valid, any client, including those with an intellectual and developmental disability, is required to be 21 years or older. 8.730.4.C. Contraceptives 1. All FDA-approved contraceptives, including emergency contraceptives, are a covered benefit. 8.730.5 Documentation 8.730.5.A. Services 1. For family planning services and supplies, the provider shall document the intention of the service as it relates to delay, prevention, or for planning a 8.730.5.B. Sterilization Consent Form 1. Submission of a valid signed sterilization consent form is required prior to reimbursement. The sterilization consent form shall be signed and dated by:

a. The client to be sterilized;

b. The interpreter, if one was provided;

c. The person who obtained the consent; and d. The physician who will perform the sterilization procedure.

If an interpreter is provided, the interpreter shall, by signing the consent form, certify that he or she translated the information presented orally, read the consent form and explained its contents to the client, and that, to the best of the interpreter's knowledge, the client understood the information provided.
The person who obtained the consent shall, by signing the consent form, certify that he or she provided the client with all of the information set forth in 8.730.5.B.6. and, to the best of his or her knowledge, the client appeared mentally competent, and knowingly and voluntarily consented to be sterilized.
The physician performing the sterilization shall, by signing the consent form, certify that:

a. He or she provided the client with all of the information set forth in 8.730.5.B.6;

b. To the best of his or her knowledge the client appeared mentally competent, and knowingly and voluntarily consented to be sterilized;

c. Except in the case of premature delivery or emergency abdominal surgery, the physician shall further certify that at least 30 days but less than 180 days have passed between the date of the client's signature on the consent form and the date upon which the sterilization was performed;

d. In the case of premature delivery or emergency abdominal surgery performed within 30 days of consent, the physician shall certify that the sterilization was performed less than 30 days, but more than 72 hours, after informed consent was obtained because of premature delivery or emergency abdominal surgery; and, e. In the case of premature delivery, the physician shall state the expected date of delivery, or in the case of emergency abdominal surgery, the physician shall describe the emergency.

Informed consent for sterilization cannot be obtained when a client is:

a. In labor or childbirth;

b. Seeking to obtain or obtaining an abortion; or c. Under the influence of substances that impair the individual's decision making capabilities.

Informed consent is valid only when the client has been offered and given:

a. Answers to any questions concerning the procedure;

b. A copy of the consent form;

c. A copy of the signed consent form; and, d. Orally provided the following information:

i. The ability to withhold or withdraw consent to the procedure at any time before the sterilization without affecting the right to future care or treatment and without loss or withdrawal of any federally funded program benefits to which the client might otherwise be entitled.

ii. A description of available alternative methods of family planning and birth control.

iii. That the sterilization procedure is considered to be irreversible.

iv. An explanation of the specific sterilization procedure to be performed.

v. A description of the discomforts and risks that may accompany or follow the sterilization procedure including an explanation of the type and possible effects of any anesthetic to be used.

vi. A description of the benefits or advantages that may be expected as a result of the sterilization.

vii. That the sterilization will not be performed for at least 30 days but less than 180 days from consent except under the circumstances specified in 8.730.4.B.1.d.ii, or 8.730.4.B.1.d.iii.

The consent is not valid unless the information specified in 8.730.5.B.6. is effectively communicated to any client who is blind, deaf, or otherwise disabled.
An interpreter shall be provided if the client to be sterilized does not understand the language used on the consent form or the language used by the person obtaining consent.
The client to be sterilized may have a witness of his or her choice present when consenting to the procedure. 8.730.6. Non-covered Services 8.730.6.A. The following services are not covered benefits for Medicaid clients:
Sterilization reversal 2. Infertility treatment and testing 8.730.7. Prior Authorization 8.730.7.A. Prior authorization is not required for family planning services. 8.730.8. Reimbursement 8.730.8.A. Reimbursement for family planning services requires an appropriate Family Planning diagnostic code along with use of the family planning (FP) modifier.

8.731 WOMEN’S HEALTH SERVICES 8.731.1 Definitions BRCA means a mutation in breast, ovarian, tubal, or peritoneal cancer susceptibility genes. The mutation may be either BRCA1 or BRCA2.

BRCA Screening means to assess whether a member has a documented biological family history of breast, ovarian, tubal, or peritoneal cancer that may be associated with an increased risk for potential mutation in breast cancer susceptibility genes (BRCA1 and BRCA2).

Sterile/Sterility means permanently rendered incapable of reproducing. 8.731.2 Member Eligibility 8.731.2.A. All female and transgender Health First Colorado members are eligible for women’s health services. 8.731.3. Provider Eligibility 8.731.3.A. All Health First Colorado enrolled providers are eligible to provide women’s health services when it is within the scope of the provider’s practice. 8.731.4. Covered Services 8.731.4.A. Women’s Health Services are covered when medically necessary, as defined at Section 8.076.1.8, and within the limitations described in this Section 8.731 and other applicable Department regulations. . 8.731.4.B. All services are covered as often as clinically indicated, unless otherwise restricted under this rule. 8.731.4.C. The following services are covered:

Annual gynecological exam 2. Cervical cancer screening and follow-up a. Cervical cancer screenings are only covered once per state fiscal year, unless clinical indication requires additional screening.

b. Further diagnostic and treatment procedures are covered as clinically indicated.

Sexually transmitted disease/infection testing, risk counseling, and treatment 4. Human Papillomavirus (HPV) vaccination is covered as outlined in Section 8.815.4.
BRCA screening, genetic counseling, and testing a. BRCA screening, genetic counseling, and testing is only covered for members over the age of 18.

b. BRCA screening is covered and must be conducted prior to any BRCA-related genetic testing.

c. The provider shall make genetic counseling available to members with a positive screening both before and after genetic testing, if the provider is able, and genetic counseling is within the provider’s scope of practice. If the provider is unable to provide genetic counseling, the provider shall refer the member to a genetic counselor.

d. Genetic testing for breast cancer susceptibility genes BRCA1 and BRCA2 is covered for members with a positive screening.

Mammography a. Mammography is covered for members based on the United States Preventive Services Task Force Breast Cancer Screening Final Recommendation Statement or for members who have been clinically assessed as high risk for, or have a history of, breast disease. The U.S. Preventive Services Task Force Breast Cancer Screening Final Recommendation Statement (April 30, 2024) is hereby incorporated by reference. The incorporation of the Final Recommendation Statement excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103 (12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17 Avenue, Denver, Colorado, 80203. Certified copies of incorporated materials are provided at cost upon request. issuer at https://www.uspreventiveservicestaskforce.org/uspstf/recommendat ion/breast-cancer-screening.
Mastectomy a. Mastectomy is covered for members who have a positive genetic test as a BRCA mutation carrier.

b. Bilateral mastectomy is a covered benefit when there is a known breast disease in either breast.

c. Prophylactic bilateral mastectomy is a covered benefit for members who have tested positive for the BRCA1 or BRCA2 mutation or have a personal history of breast disease.

d. For members who have undergone a mastectomy, a maximum of two mastectomy brassieres are covered per year.

Breast reconstruction is covered within five years of a mastectomy.
Breast reduction procedures are covered for members with macromastia and there is a documented failure of alternative treatment for macromastia.
Hysterectomy a. Hysterectomy is covered when performed solely for medical reasons and when all of the following conditions are met:

i) The member is over the age of 20, or is a BRCA1 or BRCA2 carrier over the age of 18;

ii) The person who secures the authorization to perform the hysterectomy has informed the member, or the member’s authorized representative, as defined in Section 8.057.1, orally and in writing that the hysterectomy will render the member Sterile;

iii) The member, or the member’s authorized representative, as defined in Section 8.057.1, has acknowledged in writing, that the member or representative has been informed the hysterectomy will render the member Sterile; and iv) The Department or its designee has been provided with a copy of the written acknowledgment under Section 8.731.4.C.10.a.iii. The acknowledgement must be received by the Department or its designee before reimbursement for any services related to the procedure will be made.

b. A written acknowledgment of Sterility from the member is not required if either of the following circumstances exist:

i) The member is already Sterile at the time of the hysterectomy; or, ii) The member requires a hysterectomy because of a lifethreatening emergency in which the physician determines prior acknowledgement is not possible.

c. If an acknowledgement of Sterility is not required because of the

Section 8.731.4.C.10.b exceptions, the physician who performs the hysterectomy shall certify in writing that either:

i) The member was already Sterile, stating the cause of that sterility; or, ii) The hysterectomy was performed under a life-threatening emergency situation in which the physician determined prior acknowledgement was not possible. The physician must include a description of the emergency.

d. The Department or its designee must be provided with a copy of the physician’s written certificate under Section 8.731.4.C.10.c. The acknowledgement must be received by the Department or its designee before reimbursement for any services related to the procedure will be made. 8.731.5 Non-Covered Services 8.731.5.A. Prophylactic bilateral mastectomy is not covered when:

There is no known breast disease present or personal history of breast disease, or, 2. The member does not test positive for the BRCA1 or BRCA2 mutation. 8.731.5.B. Hysterectomy for the sole purpose of sterilization.
If more than one purpose for the hysterectomy exists, but the purpose of sterilization is primary, the hysterectomy is not a covered service. 8.731.5.C. Routine BRCA genetic testing for members whose family history is not associated with an increased risk of BRCA gene mutation is not covered. 8.731.6. Prior Authorization 8.731.6.A. All breast reconstruction and reduction procedures require prior authorization. 8.731.6.B. All BRCA genetic testing requires prior authorization.

8.732. MATERNITY SERVICES

8.732.1 DEFINITIONS

High-Risk Pregnancy means pregnancy that threatens the health or the life of the mother or her fetus. Risk factors can include existing health conditions, weight and obesity, multiple births, older maternal age, and other factors.

8.732.2. CLIENT ELIGIBILITY 8.732.2.A. Medicaid-enrolled pregnant or postpartum clients are eligible for maternity services. Women remain eligible throughout their pregnancy and maintain eligibility until the end of the month in which 60 days have passed post- 8.732.3. PROVIDER ELIGIBILITY 8.732.3.A. All Colorado Medicaid-enrolled providers are eligible to provide maternity services when it is within the scope of the providers' practice.

8.732.4. COVERED SERVICES 8.732.4.A. Maternity services are covered when medically necessary and within the limitations described in this Section 8.732 and under 10 CCR 2505-10 as applicable. 8.732.4.B. Prenatal and Post-Partum Office Visits 1. One initial, comprehensive, prenatal visit including history and physical exam is covered.

Subsequent prenatal visits are covered at a frequency that follows nationally recognized standards of care based on client risk factors and complicating diagnoses.
Postpartum visits are covered at a frequency that follows nationally recognized standards of care. Generally, one to two postpartum visits are considered routine for uncomplicated pregnancies and deliveries.

Guidelines for screening, diagnostic, and monitoring services are located at Sections 8.732.4.D and 8.732.4.E. 8.732.4.C. Ultrasounds 1. A maximum of two routine ultrasounds are covered per low-risk 2. Clients with High-Risk Pregnancies may receive more than two ultrasounds when clinically indicated in accordance with nationally recognized standards of care for indication and frequency. Clinical indication must be clearly documented in the client record. 8.732.4.D. Additional Screening, Diagnostic, and Monitoring Services 1. The following services are covered only when clinically indicated in accordance with nationally recognized standards of care for indications and frequency.

a. Amniocentesis b. Fetal biophysical profile c. Fetal non-stress test d. Fetal echocardiogram e. Fetal fibronectin f. Chorionic villus sampling 2. The clinical indication must be clearly documented in the medical record. 8.732.4.E. Effective July 1, 2022, Genetic Screening, including but not limited to Non- Invasive Prenatal Testing (NIPT), and Genetic Counseling are covered in accordance with nationally recognized standards of care. Screening coverage is available for women carrying a singleton gestation who meet national standard guidelines. 8.732.4.F. Diabetic supplies are covered for members diagnosed with gestational diabetes mellitus (GDM), in accordance with nationally recognized standards of care for GDM. 8.732.4.G. Labor and Delivery services including admission to the hospital, the admission history and physical examination, and management of labor and delivery services. 8.732.4.H. Home births may be performed by physicians (MD/DOs) certified nursemidwives (CNMs), certified midwives (CMs), certified professional midwives/direct-entry midwives (CPMs/DEMs). All providers are required to carry malpractice insurance that covers home births.

8.732.5 NON-COVERED SERVICES 8.732.5.A. The following services are not covered:

Home pregnancy tests 2. Three and four dimensional ultrasounds 3. Ultrasounds performed solely for the purpose of determining the sex of the fetus or to provide a keepsake picture 4. Paternity testing 5. Lamaze classes 6. Birthing classes 7. Parenting classes 8. Home tocolytic infusion therapy 8.732.6. PRIOR AUTHORIZATION 8.732.6.A. Prior Authorization is not required for services under § 8.732, with the following exception:
Services under Section 8.732.4.E may require prior authorization.

8.732.7. LACTATION SUPPORT SERVICES

8.732.7.A. DEFINITIONS

Lactation Consultant means an International Board Certified Lactation Consultant (IBCLC) with current certification by the International Board of Lactation Consultant Examiners.
Certified Lactation Counselor (CLC) means a professional who has a current certification by the Academy of Lactation Policy and Practice, Inc.

(ALPP).

Certified Lactation Educator (CLE) means a professional who has a current certification by the Childbirth and Postpartum Professional Association (CAPPA).
Lactation Support Services include training and counseling the breastfeeding (or lactating) member about breastfeeding and human lactation, and providing comprehensive, skilled care and evidence-based information for breastfeeding and human lactation, from pre-conception to weaning.

8.732.8 MEMBER REQUIREMENTS 8.732.8.A. Members must be pregnant or postpartum, or a pediatric member who is breastfeeding, to be eligible for Lactation Support Services.

8.732.9 PROVIDER REQUIREMENTS 8.732.9.A. Enrolled Medicaid providers who provide Lactation Support Services must be at least 18 years of age. 8.732.9.B. Lactation Support Services must be provided by individuals with training in advanced lactation support:

Lactation Consultants may provide Lactation Support Services without supervision.
Lactation Counselors and Lactation Educators may provide Lactation Support Services under the general supervision of enrolled Physicians (MDs/DOs), Physician Assistants (PAs), Advanced Practice Nurses (APNs), Certified Nurse Midwives (CNMs), or Lactation Consultants. 8.732.9.C. The following provider types may provide Lactation Support Services if within their scope of practice according to state licensing requirements and laws and the provider has training in advanced lactation support:
Certified Professional Midwife / Direct Entry Midwife (DEM);
Certified Midwife;
Certified Nurse Midwife (CNM);
Licensed Physician (MD/DO);
Licensed Physician Assistant (PA)
Licensed Advanced Practice Nurse (APN);
Licensed Registered Nurse (RN).

8.732.10 COVERED SERVICES 8.732.10.A Lactation Support Services are recommended by a physician or other licensed practitioner of the healing arts to provide lactation support services to eligible members. 8.732.10.B. Lactation Support Services can be provided individually or in a group setting.

8.733 EPISODE BASED PAYMENTS

8.733.1 DEFINITIONS 8.733.1.A. Episode means a defined group of related Medicaid-covered services provided to a specific patient over a specific period of time. A Maternal Episode includes the Delivery Episode Trigger; Prenatal Pre-Trigger Window; Delivery Trigger Window; and Post-Partum Post-Trigger Window.

Delivery Episode Trigger means the date of a qualifying live delivery event.
Prenatal Pre-Trigger Window means the 280-day period prior to the delivery episode trigger window and includes all relevant care for the patient provided during that period.
Delivery Trigger Window means the time period when the mother is in the hospital for the delivery episode trigger.
Postpartum Post-Trigger Window means the 60-day time period following the delivery episode trigger window and includes all relevant care and any complications that might occur for the mother during that period. 8.733.1.B. Episode Cohort means a Principal Accountable Provider’s (PAP) maternity Episodes eligible for either positive or negative incentives after exclusions, cost outliers, and services not relevant to the Prenatal Pre-Trigger, Delivery Trigger, and Post-Partum Post-Trigger Windows have been removed. 8.733.1.C. Gross Episode Performance means the aggregated average performance of a PAP compared to each prospective target set by each Threshold without the Department’s share calculated, for either the Behavioral Health or Non-Behavioral Health subsets of Episodes. 8.733.1.D. High-Risk Pregnancy means pregnancy that threatens the health or the life of the mother or her fetus. Risk factors can include existing health conditions, weight and obesity, multiple births, older maternal age, and other factors. 8.733.1.E. Net Episode Performance means the Gross Episode Performance of a PAP multiplied by the Department’s share of fifty percent, for either the Behavioral Health or Non-Behavioral Health subsets of Episodes. 8.733.1.F. Performance Period means a twelve-month period, beginning on November 1 of each year, for which the Department will measure Episode performance of all providers delivering services during the course of a specific Episode. For an Episode to be included within the Performance Period, the end date for the Episode must fall within the Performance Period. 8.733.1.G. Principal Accountable Provider (PAP) means the provider that is held accountable for both the quality and cost of care delivered to a patient for an entire Episode. PAPs for maternity Episodes are willing obstetrical groups who agree in writing to participate in the program with the Department. 8.733.1.H. Threshold means the prospective cost target for performance for both the upper and lower incentive benchmarks for the Behavioral Health and non- Behavioral Health subsets within a PAP’s Episode Cohort.
Acceptable means the dollar value such that a provider with an average reimbursement below the dollar value incurs a positive incentive payment.
Commendable means the specific dollar value such that a provider with an average reimbursement below the dollar value is eligible for a positive incentive payment if all Quality Metrics linked to the incentive payment are met. 8.733.1.I. Quality Metrics means measures determined by the Department that will be used to evaluate the quality of care delivered during a specific Episode, including the extent to which care reduces disparate outcomes based on race and ethnicity and improves patient experience.

8.733.2 MATERNITY 8.733.2.A. Maternity Bundled Payment Pilot Program 1. Using Episode-based payments, the Department modifies its payment methodology for maternity services, as defined in Section 8.732, for PAPs to recognize the quality and efficiency of maternity services provided, including the extent to which services reduce health disparities and improve the patient experience.

Maternity Episode definitions and appropriate Quality Metrics are based on evidence-based practices derived from peer-reviewed medical literature, public health data on infant and maternal morbidity and mortality and effective responses, historical provider performance, and clinical information furnished by providers rendering services during maternity Episodes.
Medicaid-covered services during a maternity Episode will be included in the Prenatal Pre-Trigger Window, Delivery Trigger Window, and Post- Partum Post-Trigger Window. The services considered as a part of the episode shall not be limited solely to those provided by the PAP.
The Department through a stakeholder advisory process that is majority currently or former Medicaid members who have received maternity services and majority people of color shall review the maternity bundled payment pilot. The process shall meet and review data on the maternity bundled payment pilot at least quarterly. 8.733.2.B. Maternity Episode Program Incentive Payments 1. Incentive payments to a PAP are based upon an Episode Cohort within a Performance Period.
Since program participation is voluntary, PAPs are only subject to positive incentives. Positive incentive payments may be made retrospectively after the end of the Performance Period.
When calculating a PAP’s Episode Cohort, the Department excludes the Episodes which have the presence of the following:

a. The member is dually eligible for Medicare and Medicaid at any time during the Episode.

b. Third-party liability on any claim within a maternity Episode.

c. PAP provided no prenatal services for to the member.

d. Member died during Episode.

e. Incomplete set of claims for an Episode.

f. No professional claim for delivery.

When calculating a PAP’s Episode Cohort, the Department will remove cost outliers via a statistical methodology determined by the Department’s actuarial contractor.
When calculating a PAP’s Episode Cohort, the Department will remove services that are not part of the relevant care for the Prenatal Pre-Trigger, Delivery Episode, and Post-Partum Post-Trigger Windows.
Each participating PAP will have two sets of Acceptable and Commendable Thresholds calculated based on their historical costs for Episodes.

a. The first set of Thresholds will be calculated based on historical costs for Episodes that contain a flag for Behavioral Health (including Substance Use Disorder (SUD) or Mental Health).

b. The second set of Thresholds will be calculated based on historical costs for Episodes that do not contain a flag for Behavioral Health (SUD and Mental Health).

c. It is the responsibility of the PAP to review each set of Acceptable and Commendable Thresholds provided by the Department before the start of the Performance Period.

Incentive payments for a PAP’s Episodes within the Performance Period will be calculated in two separate subsets.

a. The first subset comprises Episodes that have a flag for Behavioral Health (SUD or Mental Health).

b. The second subset comprises Episodes that do not have a flag for Behavioral Health (SUD or Mental Health).

In order for a PAP to be eligible for positive incentives for a subgroup, the PAP must do the following:

a. Meet the Quality Metrics set for each Performance Period by the Department. The Department shall present on quality measures to the Program Improvement Advisory Committee (PIAC) before measures are tied to payment. Subject to data availability and quality limitations, the Department at a minimum shall monitor the following within the limitations of data availability and data quality:

i. Patient education ii. All cause readmissions iii. Severe maternal morbidity iv. Maternal Gestational Hypertension, Pre-eclampsia, HELLP syndrome, eclampsia v. Premature birth vi. Patient Experience The Department shall review all findings through the stakeholder advisory process identified in 8.733.2.A (4). If warranted, the Department may update the list of quality metrics monitored.

Subject to the limitations of data availability, if the Department seeks improved PAP performance for a quality metric, that quality metric may be tied to payment.

b. During the first year that a PAP joins the program, the PAP’s performance relative to quality metrics (including metrics tied to payment) will only be tracked and reported to the provider to create a baseline. Starting the second year of a PAP’s participation in the program, the Department will apply quality metrics tied to payment.

c. In determining a PAP’s incentive payments, starting the second year the Department will also consider whether the PAP provided the same or a greater number of services and/or resources to members within the subgroup who experience racism as compared to members in the subgroup who do not experience racism.

If the PAP's aggregated average Gross Episode Performance for each subset is lower than each Commendable Threshold, the PAP shall receive a positive incentive payment.
If the PAP's aggregated average Gross Episode Performance for each subset is higher than each Acceptable Threshold, the PAP will not be liable for a negative incentive payment as a financial penalty.
If the average Episode reimbursement for each subset is between each set of Acceptable and Commendable Thresholds, the PAP shall not receive a positive incentive payment or incur a negative incentive payment.
Incentive payments are separate from, and do not alter, the reimbursement methodology for Medicaid-covered services set forth in Department rules and guidance.
Consideration of the aggregate cost and quality of care is not a retrospective review of the medical necessity of care rendered to any particular member.
Nothing in this rule prohibits the Department from engaging in any retrospective review or other program integrity activity.
PAPs may contest the Department’s incentive payment determination.

PAPs who contest the Department’s determination must submit in writing the reason for contesting the determination within 60 calendar days of receiving the notice of payment. The Department will review all contested determinations within 30 calendar days of receipt of the notice. The PAP has the right to file an appeal with the Office of Administrative Courts in accordance with Section 8.050.3. 8.733.2.C Maternity Bundled Payment Program Participation 1. Participation is not mandatory in the Maternity Bundled Payment program for qualified obstetrical groups.

Participation by obstetrical groups in the Maternity Bundled Payment program does not limit a patient’s ability to change providers mid-episode for any reason, 3. Medicaid-covered obstetrical groups who participate in the maternity bundled payment program will allow the Department to extract clinical data from their electronic medical records. Information extracted from electronic medical records will be used by the Department to monitor the quality of care and the number of services being provided to members within the subgroup who experience health disparities based on race and ethnicity.
Obstetrical groups who participate in the maternity bundled payment will be required to participate in cultural competency training selected by the Department, to be inclusive of the importance of racial congruence between patients and providers and hiring and retention strategies for maintaining a diverse staff.
Obstetrical groups that are interested in becoming PAPs will do the a. Submit a letter of intent to participate in the pilot program application on the program webpage (https://docs.google.com/forms/d/e/1FAIpQLSdKvszulXC- ZMSOe8xpCJKaCwN4Z52D-HiVVGpHp21yoJ_8zg/viewform) to start the application process.

b. The Department will notify PAP applicants that it received their applications. The Department will contact applicants to arrange meetings for a collaborative review of their preliminary cost thresholds.

c. Following this meeting, when the applicant reviews and accepts the program’s cost thresholds, details, and requirements, the applicant may sign a Program Participation Agreement and a Thresholds Acceptance Letter to confirm their participation.

8.734 DOULA SERVICES

8.734.1 DEFINITIONS 8.734.1.A “Certification Pathway” means the pathway to Medicaid enrollment through which a Doula provider receives required Doula-related training by a Department-approved training program. 8.734.1.B “Doula” means a trained birth companion who provides personal, nonmedical support to pregnant and postpartum people and their families prior to childbirth, during labor and delivery, and during the postpartum period. 8.734.1.C “Doula Provider Attestation Form” means a Department-approved form that is required for Medicaid enrollment as a Doula provider and attests to completing the Certification Pathway or Experience Pathway, maintaining current CPR certification, and signing the Doula Code of Conduct. 8.734.1.D “Doula Code of Conduct” means a Department-approved form that outlines the conduct and standards of practice requirements for Medicaidenrolled Doula providers to uphold a high level of ethical responsibility and personal conduct, to act with cultural humility and respect for human rights, and to maintain professional practices in relation to record-keeping, confidentiality, professional boundaries, business competence, and professional growth. 8.734.1.E “Experience Pathway” means the pathway to Medicaid enrollment that allows a Doula provider to attest to training, birth attendance, and related knowledge and competencies in place of completing training through a Department-approved training program via the Certification Pathway.

8.734.2 PURPOSE 8.734.2.A. Doula services will be used to provide support for pregnant and postpartum people throughout the perinatal period, which may improve birthrelated outcomes. Doula services are provided as preventive services to promote the physical and mental health of the member during the perinatal period.

8.734.3 MEMBER ELIGIBILITY 8.734.3.A. A member must be pregnant, in the postpartum period, or had a pregnancy end within the previous 12 months to be eligible for Doula services.

8.734.4 PROVIDER REQUIREMENTS 8.734.4.A Enrolled Medicaid providers who provide Doula services must:

Be at least 18 years of age;
Enroll as a Doula provider through either the Certification Pathway or the Experience Pathway;

a. The Certification Pathway requires:

i. Completion of a training program that is approved by the Department; and, ii. Attendance at a minimum of three (3) births within the last five (5) years.

b. The Experience Pathway requires:

i. Attendance at ten (10) births in the role of a Doula with five (5) births being within the past two (2) years;

ii. Submission of four (4) letters of recommendation that include two (2) letters from clinical members of a birth team (e.g., Nurse, Nurse Practitioner, Midwife, Obstetrician) for a previously attended birth, and two (2) letters from previous clients; and, iii. Attesting to having knowledge and competency in specific prenatal, labor/delivery, postpartum lactation, and newborn areas of care.

Complete the Doula Provider Attestation Form;
Submit a copy of current CPR certification; and 5. Sign the Doula Code of Conduct.

8.734.5 COVERED SERVICES 8.734.5.A Doulas will provide non-clinical services for birthing people during pregnancy, childbirth and the postpartum period. Services include:

Perinatal support services, including pre- and postnatal care;
Labor support.

8.734.6 NON-COVERED SERVICES 8.734.6.A The following services are not covered:

Doula services do not include diagnosis of medical conditions, provision of medical advice, or any type of clinical assessment, exam, or procedure.

8.735 GENDER-AFFIRMING CARE 8.735.1 Definitions Gender-Affirming Hormone Therapy means a course of hormone replacement therapy intended to induce or change secondary sex characteristics.

Gender-Affirming Surgery means a surgery to change primary or secondary sex characteristics to affirm a person’s gender identity. Also known as gender confirmation surgery or sex reassignment surgery.

Gender Dysphoria means either: gender dysphoria, as defined in the Diagnostic Statistical Manual of Mental Disorders, 5th Edition (DSM-5), codes 302.85 or 302.6; or gender identity disorder, as defined in the International Classification of Disease, 10th Edition (ICD-10), codes F64. 1-9, or Z87.890.

Gonadotropin-Releasing Hormone Therapy means a course of reversible pubertal or gonadal suppression therapy used to block the development of secondary sex characteristics in adolescents. 8.735.2 Client Eligibility 8.735.2.A. Clients with a clinical diagnosis of Gender Dysphoria are eligible for the gender-affirming care benefit, subject to the service-specific criteria and restrictions detailed in Section 8.735.4. 8.735.3 Provider Eligibility 8.735.3.A. Enrolled providers are eligible to provide gender-affirming care if:

Licensed by the Colorado Department of Regulatory Agencies or the licensing agency of the state in which the provider practices;
Services are within the scope of the provider’s practice; and 3. Knowledgeable about gender diverse identities and expressions, and the assessment and treatment of Gender Dysphoria. 8.735.4 Covered Services 8.735.4.A. The following requirements apply to all covered gender-affirming care:
Client has a clinical diagnosis of Gender Dysphoria;
Requested service is medically necessary, as defined in Section 8.076.1.8.;
Any co-existing physical and behavioral health conditions do not interfere with diagnostic clarity or capacity to consent, and associated risks and benefits have been discussed;
Client has given informed consent for the service; and 5. Subject to the exceptions in §13-22-103, C.R.S., if client is under 18 years of age, client’s parent(s) or legal guardian has given informed consent for the service. 8.735.4.B. Requests for services for clients under 21 years of age are evaluated in accordance with the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program criteria detailed in Section 8.280. 8.735.4.C. Behavioral health services are covered in accordance with Section 8.212. 8.735.4.D. Hormone Therapy 1. Covered hormone therapy services are limited to the following:

a. Gonadotropin-Releasing Hormone (GnRH) Therapy i) GnRH therapy is a covered service for a client who:

Meets the criteria at Section 8.735.4.A.;
Meets the applicable pharmacy criteria at Section 8.800; and 3) Has reached Tanner Stage 2.

b. Gender-Affirming Hormone Therapy i) Gender-Affirming Hormone Therapy is a covered service for a client who:

Meets the criteria at Section 8.735.4.A.;
Meets the applicable pharmacy criteria at Section 8.800;
Has been informed of the possible reproductive effects of hormone therapy, including the potential loss of fertility, and the available options to preserve fertility;
Has reached Tanner Stage 2; and 5) If under 18 years of age, demonstrates the emotional and cognitive maturity required to understand the potential impacts of the treatment.

ii) Other Gender-Affirming Hormone Therapy requirements 1) Prior to beginning Gender-Affirming Hormone Therapy, a licensed health care professional who has competencies in the assessment of transgender and gender diverse people must determine that any behavioral health conditions that could negatively impact the outcome of treatment have been assessed and the risks and benefits have been discussed with the client; and 2) For the first twelve (12) months of Gender-Affirming Hormone Therapy, client must receive medical assessments at a frequency determined to be clinically appropriate by the prescribing provider. 8.735.4.E. Permanent Hair Removal 1. Permanent hair removal is a covered service when:

a. Client meets the criteria at Section 8.735.4.A.; and b. Used to treat a surgical site. 8.735.4.F. Surgical Procedures 1. Gender-Affirming Surgery is a covered service for a client who:

a. Meets the criteria at Section 8.735.4.A.1.–4;

b. Is 18 years of age or older;

c. Has completed six (6) continuous months of hormone therapy, unless hormone therapy is not clinically indicated or is inconsistent with the client’s desires, goals, or expressions of individual gender identity;

i) This requirement does not apply to mastectomy surgeries;

ii) Twelve (12) continuous months of hormone therapy are required for mammoplasty, unless hormone therapy is not clinically indicated or is inconsistent with the client’s desires, goals, or expressions of gender identity;

d. Understands the potential effect of the Gender-Affirming Surgery on fertility.

Requests for surgery for clients under 18 years of age will be reviewed by the Department and considered based on medical circumstances and clinical appropriateness of the request;
Rendering surgical providers must retain the following documentation for each client:

a. A signed statement from a licensed health care professional who has competencies in the assessment of transgender and gender diverse people, demonstrating that:

i) Criteria in Section 8.735.4.F.1.a.–d. have been met; and ii) A post-operative care plan is in place.

Covered Gender-Affirming Surgeries include:

a. Genital surgery;

b. Breast/chest surgery; and c. Facial and neck surgery.

Requests for other medically necessary Gender-Affirming Surgeries will be reviewed by the Department and considered based on medical circumstances and clinical appropriateness of the request.
Pre- and post-operative services are covered when:

a. Related to a surgical procedure covered under Section 8.735.4.F;

b. Medically necessary, as defined in Section 8.076.1.8. 8.735.5 Prior Authorization 8.735.5.A. Prior authorization is required for hormone therapy services listed in

Section 8.735.4.D. in accordance with pharmacy benefit prior authorization criteria at Section 8.800.7. 8.735.5.B. Surgical services may require prior authorization. 8.735.5.C. All prior authorization requests must provide documentation demonstrating that the applicable requirements in Section 8.735.4 have been met. 8.735.6 Non-Covered Services 8.735.6.A. The following services are not covered under the gender-affirming care benefit:

Any items or services excluded from coverage under Section 8.011.1.
Reversal of surgical procedures covered under Section 8.735.4.F.

8.740 RURAL HEALTH CLINICS

8.740.1 DEFINITIONS

Rural Health Clinic (RHC) means a clinic or center that:

Has been certified as a Rural Health Clinic under Medicare.
Is located in a rural area, which is an area that is not delineated as an urbanized area by the Bureau of the Census.
Has been designated by the Secretary of Health and Human Services as a Health Professional Shortage Area (HPSA) through the Colorado Department of Public Health and Environment.
Is not a rehabilitation facility or a facility primarily for the care and treatment of mental diseases.

Visit means a face-to-face encounter, or an interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounter in accordance with Section 8.095, between a clinic client and a health professional providing the services set forth in 8.740.4.

Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as inperson care.

8.740.2 REQUIREMENTS FOR PARTICIPATION 8.740.2.A. A Rural Health Clinic shall be certified under Medicare. 8.740.2.B. A Rural Health Clinic providing laboratory services shall be certified as a clinical laboratory in accordance with 10 C.C.R 2505-10, Section 8.660.

8.740.3 CLIENT CARE POLICIES 8.740.3.A. The Rural Health Clinic’s health care services shall be furnished in accordance with written policies that are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member of the group shall not be a member of the Rural Health Clinic staff. 8.740.3.B. The policies shall include:

A description of the services the Rural Health Clinic furnishes directly and those furnished through agreement or arrangement. See section 8.740.4.A.4.
Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or client referral, the maintenance of health care records and procedures for the periodic review and evaluation of the services furnished by the Rural Health Clinic.
Rules for the storage, handling and administration of drugs and biologicals.

8.740.4 SERVICES 8.740.4.A. The following services may be provided by a certified Rural Health Clinic:

General services a. Outpatient primary care services that are furnished by a physician assistant, clinical psychologist, clinical social worker, nurse practitioner, nurse midwife, licensed professional counselor, licensed marriage and family therapist, or licensed addiction counselor as defined in their respective practice acts.

b. Part-time or intermittent visiting nurse care.

c. Services and medical supplies, other than pharmaceuticals, that are furnished as a result of professional services provided under 8.740.4.A.1.a and b.

Laboratory services. Rural Health Clinics furnish basic laboratory services essential to the immediate diagnosis and treatment of the client.
Emergency services. Rural Health Clinics furnish medical emergency procedures as a first response to common life-threatening injuries and acute illness and must have available the drugs and biologicals commonly used in life saving procedures.
Services provided through agreements or arrangements. The Rural Health Clinic has agreements or arrangements with one or more providers or suppliers participating under Medicare or Medicaid to furnish other services to clients, including inpatient hospital care; physician services (whether furnished in the hospital, the office, the client’s home, a skilled nursing facility, or elsewhere) and additional and specialized diagnostic and laboratory services that are not available at the Rural Health Clinic.

8.740.5 PHYSICIAN RESPONSIBILITIES 8.740.5.A. A physician shall provide medical supervision and guidance for physician assistants and nurse practitioners, prepare medical orders, and periodically review the services furnished by the clinic. A physician shall be present at the clinic for sufficient periods of time to fulfill these responsibilities and must be available at all times by direct means of communications for advice and assistance on client referrals and medical emergencies. A clinic operated by a nurse practitioner or physician assistant may satisfy these requirements through agreements with one or more physicians.

8.740.6 ALLOWABLE COSTS 8.740.6.A. The following types and items of cost shall be included in allowable costs to the extent that they are covered and reasonable:

Compensation for the services of a physician who owns, is employed by, or furnishes services under contract to a Rural Health Clinic.
Compensation for the duties that a supervising physician is required to perform.
Costs of services and supplies incident to the services of a physician, physician assistant, clinical psychologist, clinical social worker, nurse practitioner, nurse-midwife, licensed professional counselor, licensed marriage and family therapist, or licensed addiction counselor.
Overhead costs, including clinic or center administration, costs applicable to use and maintenance of the entity and depreciation costs.
Costs of services purchased by the Rural Health Clinic.

8.740.7 REIMBURSEMENT 8.740.7.A. The Department shall reimburse Rural Health Clinics a per visit encounter rate. Encounters with more than one health professional, and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except when the client, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment. An RHC may be reimbursed for up to two separate encounters with the same client occurring in the same day and at the same location, so long as the two encounters submitted for reimbursement are a physical health and a behavioral health service. 8.740.7.B. Rural Health Clinic rates are updated annually on January 1 The encounter rate shall be the higher of:

The Prospective Payment System (PPS), as defined by Section 702 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) included in the Consolidated Appropriations Act of 2000, Public Law 106-554, BIPA is incorporated herein by reference. No amendments or later editions are incorporated. The Acute Care Benefits Section Manager at the Colorado Department of Health Care Policy and Financing may be contacted at 1570 Grant Street, Denver, Colorado 80203, for a copy of BIPA, or the materials may be examined at any publications depository library.
The Alternative Payment Methodology (APM) rate.

a. The APM rate for hospital based Rural Health Clinics shall be based on actual costs.

i. The interim rate for Rural Health Clinics shall be the higher of the current year PPS rate and the most recent audited and finalized cost per visit from the Medicare cost report.

ii. After a Rural Health Clinic’s Medicare cost report has been audited and finalized, the Department shall perform a reconciliation for the services provided by the Rural Health Clinic during the year the cost report covers. If the Department’s interim rate was below the finalized rate, a one-time payment will be made to the Rural Health Clinic. If the Department’s interim rate was above the finalized rate and the PPS rate, the Department will recoup the difference from the RHC.

b. The APM rate for freestanding Rural Health Clinics is the Medicare upper payment limit for Rural Health Clinics. 8.740.7.C. New RHCs shall be reimbursed an interim per visit encounter rate, which shall be calculated as follows:

For new freestanding RHCs, the interim rate will be the average of other freestanding RHC’s APM rates in the new RHC’s Regional Accountable Entity (RAE).
For new hospital-based RHCs, the interim rate will be calculated based on the following options in the following order:

a. The per visit encounter rate established by a Medicare rate letter; or b. A sister clinic’s per visit encounter rate.

A hospital-based RHC’s interim rate will be updated if the RHC provides an updated Medicare rate letter. The new rate will be effective the following January 1 8.740.7.D. PPS rates for new RHCs shall be calculated as follows:

For new freestanding RHCs, the PPS rate shall be calculated based on the average of other freestanding RHC’s PPS rates in the new RHC’s RAE.
For new hospital-based RHCs, the PPS rate shall be calculated based on an average of two year’s audited cost and visit data from the RHC’s Medicare cost report. 8.740.7.E. The following services are reimbursed separately from the Rural Health Clinic per visit encounter rate. These services shall be reimbursed in accordance with the following:
The Department will reimburse Long-Acting Reversible Contraception (LARC) and Non-surgical Transcervical Permanent Female Contraceptive Devices separate from the Rural Health Clinic per visit encounter rate.

Reimbursement will be the lower of:

a. 340B acquisition costs;

b. Submitted charges; or c. Fee schedule as determined by the Department.

Telehealth Remote Monitoring (Remote Patient Monitoring) services will be reimbursed separate from the Rural Health Clinic per visit encounter rate. Reimbursement will be the lower of:

a. Submitted charges; or b. Fee schedule as determined by the Department. 8.740.7.F. PPS Change in Scope 1. If an RHC changes its scope of service after the year in which its base PPS rate was determined, the Department will adjust the RHC’s PPS rate in accordance with section 1902(bb) of the Social Security Act.

a. An RHC must apply to the Department for an adjustment to its PPS rate whenever there is a documented change in the scope of service of the RHC. The documented change in the scope of service of the RHC must meet all of the following conditions:

ii. The cost is allowable under Medicare reasonable cost principles set forth in 42 CFR Part 413.5 iii. The change in scope of service is a change in the type, intensity, duration, or amount of services, or any combination thereof.

iv. The net change in the RHC’s per-visit encounter rate equals or exceeds 3% for the affected RHC. For RHCs that file consolidated cost reports for multiple sites in order to establish the initial PPS rate, the 3% threshold will be applied to the average per-visit encounter rate of all sites for the purposes of calculating the cost associated with the scope-of-service change.

v. The change in scope must have existed for at least a full six (6) months.

b. A change in the cost of a service is not considered in and of itself a change in scope of service. The change in cost must meet the conditions set forth in Section 8.740.7.F.1.a. and the change in scope of service must include at least one of the following to prompt a scope-of-service rate adjustment. If the change in scope of service does not include at least one of the following, the change in the cost of services will not prompt a scope-of-service rate adjustment.

i. The addition of a new service not incorporated in the baseline PPS rate, or deletion of a service incorporated in the baseline PPS rate;

ii. The addition or deletion of a covered Medicaid service under the State Plan;

iii. Changes necessary to maintain compliance with amended state or federal regulations or regulatory requirements;

iv. Changes in service due to a change in applicable technology and/or medical practices utilized by the RHC;

vi. Changes resulting from a change in the provider mix, including, but not limited to:

a. A transition from mid-level providers (e.g. nurse practitioners) to physicians with a corresponding change in the services provided by the RHC;

b. The addition or removal of specialty providers (e.g. pediatric, geriatric, or obstetric specialists) with a corresponding change in the services provided by the RHC (e.g. delivery services);

c. Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and/or residents; or, d. Changes in the operating costs attributable to capital expenditures (including new, expanded, or renovated service facilities), regulatory compliance measures, or changes in technology or medical practices at the RHC, provided that those expenditures result in a change in the services provided by the RHC.

c. The following are examples of items that do not prompt a scope-ofservice rate adjustment:

i. An increase or decrease in the cost of supplies or existing services;

ii. An increase or decrease in the number of encounters;

iii. Changes in office hours or location not directly related to a change in scope of service;

iv. Changes in equipment or supplies not directly related to a change in scope of service;

v. Expansion or remodel not directly related to a change in scope of service;

vi. The addition of a new site, or removal of an existing site, that offers the same Medicaid-covered services;

vii. The addition or removal of administrative staff;

viii. The addition or removal of staff members to or from an existing service;

ix. Changes in salaries and benefits not directly related to a change in scope of service.

x. Change in patient type and volume without changes in type, duration, or intensity of services;

xi. Capital expenditures for losses covered by insurance; or, xii. A change in ownership.

d. An RHC must apply to the Department by written notice within one hundred and fifty (150) days of the end of the RHC’s fiscal year in which the change in scope of service occurred. Only one scope-ofservice rate adjustment will be calculated per year. However, more than one type of change in scope of service may be included in a single application.

e. Should the scope-of-service rate application for one year fail to reach the threshold described in Section 8.740.7.F.1.a.iv, the RHC may combine that year’s change in scope of service with a valid change in scope of service from the next year or the year after. For example, if a valid change in scope of service that occurred in FY 2021 fails to reach the threshold needed for the rate adjustment, and the RHC implements another valid change in scope of service during FY 2022, the RHC may submit a scope-of-service rate adjustment application that captures both of those changes. An RHC may only combine changes in scope of service that occur within a three-year time frame and must submit an application for a scope-of-service rate adjustment as soon as possible after each change has been implemented. Once a change in scope of service has resulted in a successful scope-of-service rate adjustment either individually or in combination with another change in scope of service, that change may no longer be used in an application for another scope of service rate adjustment.

f. The documentation for the scope-of-service rate adjustment is the responsibility of the RHC. Any RHC requesting a scope-of-service rate adjustment must submit the following to the Department:

i. The Department’s application form for a scope-of-service rate adjustment, which includes;

a. The provider number(s) that is/are affected by the change(s) in scope of service;

b. A date on which the change(s) in scope of service was/were implemented;

c. A brief narrative description of each change in scope of service, including how services were provided both before and after the change;

ii. Any additional documentation requested by the Department.

If the Department requests additional documentation to calculate the rate for the change(s) in scope of service, the RHC must provide the additional documentation within thirty (30) days. If the RHC does not submit the additional documentation within the specified timeframe, the Department, at its discretion, may postpone the implementation of the scope-of-service rate adjustment.

g. The reimbursement rate for a scope-of-service change applied for January 1, 2022 or afterwards will be calculated as follows:

i. The Department will first verify the total costs, the total covered health care costs, and the total number of visits before and after the change in scope of service. The Department will also calculate the Adjustment Factor (AF = covered health care costs/total cost of RHC services) associated with the change in scope of service of the RHC. If the AF is 80% or greater, the Department will accept the total costs as filed by the RHC. If the AF is less than 80%, the Department will reduce the costs other than covered health care costs (thus reducing the total costs filed by the RHC) until the AF calculation reaches 80%. These revised total costs will then be the costs used in the scope-of-service rate adjustment calculation.

ii. The Department will then use the appropriate costs and visits data to calculate the adjusted PPS rate. The adjusted PPS rate will be the average of the costs/visits rate before and after the change in scope of service, weighted by visits.

iv. The Department will check that the adjusted PPS rate meets the 3% threshold above. If it does not meet the 3% threshold, no scope-of-service rate adjustment will be implemented.

v. Once the Department has determined that the Adjusted PPS rate has met the 3% threshold, the adjusted PPS rate will then be increased by the Medicare Economic Index (MEI) to become the new PPS rate.

h. The Department will review the submitted documentation and will notify the RHC in writing within one hundred twenty (120) days from the date the Department received the application as to whether a PPS rate change will be implemented. Included with the notification letter will be a rate-setting statement sheet, if applicable. The new PPS rate will take effect the following January 1 j. An RHC may request a written informal reconsideration of the Department’s decision of the PPS rate change regarding a scopeof-service rate adjustment within thirty (30) days of the date of the Department’s notification letter. The informal reconsideration must be mailed to the Department of Health Care Policy and Financing, 1570 Grant St, Denver, CO 80203. To request an informal reconsideration of the decision, an RHC must file a written request that identifies specific items of disagreement with the Department, reasons for the disagreement, and a new rate calculation. The RHC should also include any documentation that supports its positions.

A provider dissatisfied with the Department’s decision after the informal reconsideration may appeal that decision through the Office of Administrative Courts according to the procedures set forth in 10 CCR 2505-10 Section 8.050.3, PROVIDER APPEALS.

8.745 SPECIAL CONNECTIONS

8.745.1 DEFINITIONS

A. Assessment means an evaluation that is designed to determine the level of substance use and the comprehensive treatment needs of a pregnant member with a substance use disorder.

B. Case Management means medically necessary coordination and planning services provided with or on behalf of a member who is pregnant or parenting (up to child’s first birthday) with a substance use disorder. This includes treatment/service planning, linkage to other service agencies and monitoring.

C. Individual/Family Counseling and Therapy means planned therapeutic activity or counseling and outlining the treatment/service plan of a member who is pregnant or parenting (up to child’s first birthday) with a substance use disorder.

Problem(s) identified by an assessment are listed in the treatment/service plan.

The intended outcome is the management, reduction/resolution of the identified problem(s).

D. Group Counseling means a planned therapeutic or counseling activity in a group setting with 2 or more pregnant and parenting (up to child’s first birthday) women with substance use disorders (other than a family therapy session) in an effort to change the individual behavior of each person in the group through interpersonal exchange. Group services are designed to assist members with a primary substance use disorder in achieving their treatment goals.

E. Enhanced Prenatal Care education means services to help a member develop health and life management skills.

F. Residential Treatment means a structured treatment program to provide therapy and treatment toward rehabilitation. Residential Treatment Includes a planned program of professionally directed evaluation, care and treatment for the restoration of functioning for pregnant and parenting (up to child’s first birthday) women with substance use disorders.

8.745.2 DETERMINATION OF CLIENT ELIGIBILITY 8.745.2.A. To receive an Assessment, the client shall be:

Medically verified to be pregnant.
Determined either presumptively eligible or eligible for Medicaid.
Self-referred or referred by a health care practitioner as being at risk of a poor birth outcome due to substance use during the prenatal period and in need of special assistance in order to reduce such risk. 8.745.2.B. To receive substance use disorder services, the client shall meet the following conditions:
Received an Assessment and met the screening criteria as determined by the Office of Behavioral Health of the Colorado Department of Human 2. Received a prior authorization from the Office of Behavioral Health of the Colorado Department of Human Services.

8.745.3 PROVIDER ELIGIBILITY 8.745.3.A. Eligible providers shall meet the following criteria:

Be enrolled as a Colorado Medicaid provider 2. Contract with and obtain certification from the Office of Behavioral Health of the Colorado Department of Human Services as a substance use disorder treatment program for the delivery of these specialized substance use disorder services 8.745.4 REIMBURSABLE SERVICES 8.745.4.A. Special Connections Program services are limited to services performed by or under the supervision of licensed clinicians or licensed health care practitioners as defined in 10 CCR 2505-10, Section 8.746.1. Reimbursable services are:
One Assessment per pregnancy.
Substance use disorder treatment services including case management, substance use disorder individual and family counseling, substance use disorder group counseling, residential treatment and/or enhanced prenatal care education.
Urine screening and monitoring. 8.745.4.B. Services may be provided as outpatient or residential. Room and board are not covered services.

8.745.5 REIMBURSEMENT

Reimbursement for services provided shall be the lowest of:

Submitted charges; or 2. Fee schedule as determined by the Department.

8.746 OUTPATIENT FEE-FOR-SERVICE SUBSTANCE USE DISORDER

TREATMENT

8.746.1 DEFINITIONS

Community Behavioral Health Services Program means the program described at 10 CCR 2505-10 Section 8.212, by which program-enrolled Medicaid clients receive behavioral health treatment services.

Day Treatment Program means a non-residential treatment program designed for children and adolescents under the age of 21 who have an emotional, behavioral, and neurobiological, or substance use disorder diagnosis, and may be at high risk for out-ofhome placement. Day Treatment Program services include family, group, and individual psychotherapy; parent-child education; skill and socialization training focused on improving functional and behavioral deficits; and intensive coordination with schools or other child service agencies.

Health First Colorado is Colorado’s Medicaid Program, the free or low cost public health insurance program that provides health care coverage to low-income individuals, families, children, pregnant women, seniors, and people with disabilities. Colorado Medicaid is funded jointly by the federal and state government, and is administered by the Colorado Department of Health Care Policy and Financing.

Intensive Outpatient Psychiatric Rehabilitation Services are those that focus on maintaining and improving functional abilities for the client through a time-limited, multifaceted approach to treatment.

Licensed Clinician means a provider who is a clinical social worker licensed pursuant to CRS 12-43-404, marriage and family therapist licensed pursuant to CRS 12-43-504, professional counselor licensed pursuant to CRS 12-43-603, addiction counselor licensed pursuant to CRS 12-43-804, or psychologist (Psy.D/Ph.D) licensed pursuant to CRS 12-43-304.

Licensed Health Practitioner means an advanced practice nurse licensed pursuant to CRS 12-38-111.5, physician/psychiatrist licensed pursuant to CRS 12-36-101, or physician assistant licensed pursuant to CRS 12-36-107.4.

Residential Treatment means a short-term residential treatment program offering 24hour intensive residential treatment, habilitative, and rehabilitative services for up to 30 days in a highly structured, community-oriented environment.

State Fiscal Year (SFY) is July 1 – June 30.

8.746.2 ELIGIBLE PROVIDERS

Providers eligible to render services are limited to the following:

a. Licensed Health Practitioners who are also:

i) Certified in addiction medicine by the American Society of Addiction Medicine (ASAM), the American Board of Addiction Medicine (ABAM), or the American Board of Preventive Medicine (ABPM); or ii) Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction Counselors (LAC) by the Department of Regulatory Agencies (DORA); or iii) National Certified Addiction Counselors II (NCAC II) or Master Addiction Counselors (MAC) by the National Association of Alcohol and Drug Abuse Counselors (NAADAC); or iv) Certified in addiction psychiatry by the American Board of Psychiatry and Neurology certified in Addiction Psychiatry (ABPN).

b. Licensed Clinicians.

8.746.3 TREATMENT PLANNING 8.746.3.A. An approved treatment plan must be in place for each client prior to the client receiving services. An initial assessment is required to establish a treatment plan. Treatment plans require approval from a licensed provider indicated in Section 8.746.2 with the authority to approve treatment plans within their scope of practice. 8.746.3.B. All rendered services must be medically necessary, as defined in Section 8.076.1.8., and must be detailed in the client’s treatment plan and progress notes. Initial substance use disorder assessments are exempt from inclusion in the approved treatment plan. 8.746.3.C. Approved treatment plans must identify treatment goals and must explain how the proposed treatment services will achieve those stated goals. 8.746.3.D. Approved treatment plans must identify the treatment services planned for use over the course of treatment. The amount, frequency, and duration of these treatment services must be included in the approved treatment plan.

8.746.4 ELIGIBLE CLIENTS

To be eligible for the Outpatient Fee-for-Service Substance Use Disorder Treatment benefit, client:

a. Must currently be enrolled in Colorado Medicaid; and b. Must not be enrolled in the Community Behavioral Health Services program pursuant to 10 C.C.R. 2505-10 Section 8.212.

i) All Colorado Medicaid clients are automatically enrolled in the Community Behavioral Health Services program, unless one of the following is true:

Client is not eligible for enrollment in the Community Behavioral Health Services program, per 10 CCR 2505-10 Section 8.212.1.A.; or 2) Client is approved for an individual enrollment exemption, as set forth at 10 CCR 2505-10 Section 8.212.2.

8.746.5 LIMITATIONS

Clients are not required to obtain a referral from their Primary Care Physician (PCP) or Primary Care Medical Provider (PCMP) to receive these services.
Clients must have a treatment plan that is approved by a licensed practitioner listed in Section 8.746.2.
Outpatient Fee-for-Service Substance Use Disorder Treatment services may only be rendered by providers outlined in Section 8.746.2, with an exception for certain providers of Medication Assisted Treatment described below.
Services are covered only when the client has been diagnosed with at least one of the following:

a. Alcohol use or induced disorder b. Amphetamine use or induced disorder c. Cannabis use or induced disorder d. Cocaine use or induced disorder e. Hallucinogen use or induced disorder f. Inhalant use or induced disorder g. Opioid use or induced disorder h. Phencyclidine use or induced disorder i. Sedative Hypnotic or Anxiolytic use or induced disorder j. Tobacco use disorder 8.746.6 COVERED SERVICES 8.746.6.A. Substance Use Disorder Assessment 1. A substance use disorder assessment is an evaluation designed to determine the most appropriate level of care based on criteria established by the American Society of Addiction Medicine (ASAM), the extent of drug or alcohol use, abuse, or dependence and related problems, and the comprehensive treatment needs of a client with a substance use disorder a. Course of treatment and changes in level of care must be based on best practices as defined by the current ASAM Patient Placement Criteria.

b. Re-assessments must be spaced appropriately throughout the course of treatment to ensure the treatment plan is effectively managing the client’s changing needs.

c. Each complete assessment corresponds to one unit of service.

d. An assessment may involve more than one session and may span multiple days. If the assessment spans multiple days, the final day of the assessment is reported as the date of service. 8.746.6.B. Individual and Family Therapy 1. Individual and family therapy is the planned treatment of a client’s problem(s) as identified by an assessment and listed in the treatment/service plan. The intended outcome is the management and reduction, or resolution of the identified problem(s).

Individual and family therapy is limited to one client per session.

Individual and family therapy are billed at 15 minutes per unit.

a. A session is considered a single encounter with the client that can encompass multiple timed units.

Family therapy must be directly related to the client’s treatment for substance use disorder or dependence.
Individual therapy and family therapy sessions are allowed on the same date of service. 8.746.6.C. Group Therapy 1. Group therapy refers to therapeutic substance use disorder counseling and treatment services, administered through groups of people who have similar needs, such as progression of disease, stage of recovery, and readiness for change.
Group therapy must include more than one patient.
A session of group therapy may last up to three hours and is billed in units of one hour each (e.g., a three hour group session would consist of three units).

a. A unit of service may be billed separately for each client participating in the group therapy session. 8.746.6.D. Alcohol / Drug Screening and Counseling 1. Alcohol / drug screening and counseling is the collection of urine followed by a counseling session with the client to review and discuss the results of the screening.

a. The analysis of the urine specimen (urinalysis) may only be billed by a provider with the appropriate CLIA certification for the test performed. Urinalysis is not part of the Outpatient Fee-For-Service SUD benefit.

b. Substance use disorder providers will only be reimbursed for collecting the urine specimen and providing a counseling session to review and discuss the results of the urinalysis. Claims submitted for the collection of the urine sample without the subsequent counseling of urinalysis results will not be reimbursed.

i. If the client does not return for the counseling of their urinalysis results, the collection of the sample cannot be claimed.

c. Substance use disorder counseling services to discuss and counsel the client on the test results must be provided by an eligible rendering provider, as outlined in Section 8.746.2.

d. The counseling portion of the service may be conducted during a session of individual or family therapy.

e. Multiple urine collections per date of service are not additionally reimbursed.

f. Alcohol / drug screening and counseling is limited to one unit per date of service.

i. A unit of service is the single collection and subsequent counseling session. 8.746.6.E. Targeted Case Management 1. Targeted case management refers to coordination and planning services provided with, or on behalf of, a client with a substance use disorder a. The client does not need to be physically present for this service to be performed if it is done on the client’s behalf.

Targeted case management services are limited to service planning, advocacy, and linkage to other appropriate medical services related to substance use disorder diagnosis, monitoring, and care coordination.
A unit of service equals one 15-minute increment of targeted case management, and consists of at least one documented contact with a client or person acting on behalf of a client, identified during the case planning process. 8.746.6.F. Social / Ambulatory Detoxification 1. Facilities licensed by the Office of Behavioral Health (OBH) to provide detoxification services are the only provider eligible to render social / ambulatory detoxification services.
Social / ambulatory detoxification services:

a. Include supervision, observation, and support from qualified personnel for clients exhibiting intoxication or withdrawal symptoms.

b. Are provided when there is minimal risk of severe withdrawal (including seizures and delirium tremens) and when any cooccurring mental health or medical conditions can be safely managed in an ambulatory setting.

A session is defined as the continuous treatment time from the first day to the last day of social/ambulatory detoxification.

a. Each session may last a maximum of three days.

Room and board is not a covered social / ambulatory detoxification service. Claims billed for room and board will not be reimbursed.

Social / ambulatory detoxification is divided into four distinct services— physical assessment of detoxification progress, evaluation of level of motivation, safety assessment, and provision of daily living needs—with corresponding procedure codes, which may be provided and billed on the same date of service if medically necessary, as defined in rule at 10 CCR 2505-10 Section 8.076.1.8. 8.746.6.G. Medication-Assisted Treatment (MAT)
Medication Assisted Treatment (MAT) is a benefit for opioid addiction that includes a medication approved by the U.S. Food and Drug Administration (FDA) for opioid addiction detoxification or maintenance treatment.
When methadone is administered for MAT, the reimbursement for the medication’s acquisition is bundled with the reimbursement for administration and dispensing under a single billing code. When other medications are used for MAT (e.g. Suboxone), the reimbursement for the medication is billed separately from the administration and dispensing using physician administered drug billing codes.

a. Only licensed physicians, physician assistants, or nurse practitioners are eligible to administer MAT. All providers must comply with the Office of Behavioral Health’s Opioid Medication Assisted Treatment program requirements set forth at 2 C.C.R. 502-1 21.320.

b. Take-home dosing is permitted in accordance with Office of Behavioral Health rules at 2 CCR 502-1 21.320.8. Therefore, one unit of MAT must be reported for each date of service the client ingests the dose of methadone.

c. If the client ingests their dose at the facility, the place of service must be reported as office. If the client ingests their dose at home, the place of service must be reported as home. Records must include documentation to substantiate claims for take-home doses.

8.746.7 PRIOR AUTHORIZATION REQUIREMENTS 8.746.7.A. There are no prior authorization requirements for the Outpatient Fee-for- Service Substance Use Disorder Treatment benefit.

8.746.8 NON-COVERED SERVICES 8.746.8.A. The following services are not covered under the Outpatient Fee-for- Service Substance Use Disorder Treatment benefit:

Day treatment program services.
Intensive outpatient psychiatric rehabilitation.
Peer advocate services.
Residential treatment services, with the exception of those provided in a Residential Child Care Facility, as set forth in Section 8.765.
Services provided by a third party that is under contract with the provider.
Any substance use disorder treatment service not specified as covered in

Section 8.746.6.

8.747 SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT

SERVICES

8.747.1 DEFINITIONS

Brief Intervention means a provider interaction with a client that is intended to induce a positive change in a health-related behavior. Brief intervention may include an initial intervention, a follow-up intervention and/or a referral.

Brief Screen or Pre-screen means several short questions related to the client’s substance use. A brief screen or pre-screen is designed to determine if a full screen is necessary.

Follow-up Intervention means services to reassess a client’s status, assess progress and promote or sustain a reduction in substance use. Follow-up services may also be used to assess a client’s need for additional services.

Full Screen means the use of a Colorado Medicaid approved evidence-based screening tool to identify clients at risk for substance abuse problems.

Screening, Brief Intervention and Referral to Treatment (SBIRT) means comprehensive, integrated public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.

8.747.2 CLIENT ELIGIBILITY 8.747.2.A. All clients 12 years of age and older are eligible to receive this service.

8.747.3 PROVIDER REQUIREMENTS 8.747.3.A. Screening, Brief Intervention and Referral to Treatment services must be provided by, or under the supervision of, a licensed health care professional. 8.747.3.B. The following licensed professionals are eligible to provide services or supervise staff that are providing services:

Licensed Physician 2. Physician Assistant 3. Nurse Practitioner 4. Dentist 5. Psychologist with PhD. or PsyD.
Licensed Clinical Social Worker (LCSW)
Marriage and Family Therapist 8. Licensed Professional Counselor (LPC)
Licensed Addiction Counselor (LAC)
Certified Addictions Counselor III 8.747.3.C. All licensed individuals must be trained in order to provide or supervise individuals providing Screening, Brief Intervention and Referral to Treatment 1. A minimum of four (4) hours Screening, Brief Intervention and Referral to Treatment training is required. 8.747.3.D. All non-licensed individuals must be trained in Screening, Brief Intervention and Referral to Treatment services in order to provide services; including the following requirements:
Be under the supervision of a licensed and trained Screening, Brief Intervention and Referral to Treatment services provider.
Complete a minimum of 60 hours professional experience such as coursework, internship, practicum, education or professional work within their respective field. This experience should include a minimum of 4 hours of training that is directly related to Screening, Brief Intervention and Referral to Treatment services.
Complete a minimum of 30 hours of face-to-face client contact within their respective field. This may include internships, on the job training, or professional experience. This contact may include, but does not have to be directly related to Screening, Brief Intervention and Referral to Treatment services training.

8.747.4 COVERED SERVICES 8.747.4.A Screening, Brief Intervention and Referral to Treatment services are covered for risky substance use or abuse including alcohol and drugs.

A full screen, using a Colorado Medicaid approved screening tool, shall be limited to two (2) per client per state fiscal year. 8.747.4.B. Brief intervention services may be provided on the same date of service as the full screen, or on subsequent days.
The Brief Intervention shall be limited to two (2) sessions per client per state fiscal year. Each session is limited to two (2) units per session, at 15 minutes per unit.

8.747.5 NON-COVERED SERVICES 8.747.5.A Non-covered services include:

Pre-screen or brief screen.

8.747.6 REIMBURSEMENT 8.747.6.A Providers may submit for reimbursement under either CPT or HCPC codes, but not both. 8.747.6.B Screening, Brief Intervention and Referral to Treatment services provided by Federally Qualified Health Centers under supervision, as defined in Section 8.700.1, will be reimbursed in the encounter rate. 8.747.6.C Screening, Brief Intervention and Referral to Treatment services may be provided on the same day as other Evaluation & Management services. 8.747.6.D Any claims reimbursed for more than the maximum units per year are subject to recovery by the Department.

8.748 PRENATAL PLUS PROGRAM

8.748.1 DEFINITIONS

Initial Assessment Form means the Prenatal Plus Program risk assessment tool that must be used by all Prenatal Plus Program Providers to further assess and document a client’s needs.

Program Eligibility Screening Form means the Prenatal Plus Program eligibility tool that must be used by all Prenatal Plus Program Providers to determine if a client is eligible for Prenatal Plus Program services.

Prenatal Plus Program Provider means an entity or agency that meets the qualifications described in Section 8.748.4 and has been accepted as such by the Department of Health Care Policy and Financing (the Department).

8.748.2 PROGRAM PURPOSE

The purpose of the Prenatal Plus Program is to improve the maternal and infant health outcomes of at-risk Medicaid clients by providing comprehensive and coordinated prenatal and early postpartum support services that complement traditional clinical prenatal care. The primary goal of the program is to reduce the incidence of low birth weight babies while also addressing other lifestyle, behavioral, and non-medical aspects of a woman’s life that may affect her and/or her baby’s health and well-being. By focusing on case management, nutrition counseling and support, psychosocial counseling and support, client education and health promotion, the Prenatal Plus Program seeks to ensure that women have access to the services and information needed to have healthy pregnancies and healthy babies.

8.748.3 CLIENT ELIGIBILITY 8.748.3.A To be eligible for services provided through the Prenatal Plus Program, a Colorado Medicaid client shall:

Be pregnant (self-declared or medically verified) or in the postpartum period (but participated in the Prenatal Plus Program during the prenatal period); and 2. Be determined by a Prenatal Plus Program Provider using the Program Eligibility Screening Form to be at risk of having a negative maternal and/or infant health outcome(s) due to identified risk factors which shall be further assessed and documented using the Initial Assessment Form.

8.748.4 PROVIDER ELIGIBILITY AND QUALIFICATIONS 8.748.4.A Providers wishing to render and be reimbursed for Prenatal Plus Program services, as a condition of being a Prenatal Plus Program Provider, shall:

Be a Colorado Medicaid provider enrolled as one of the following Colorado Medicaid Billing Provider Types: Clinic, Federally Qualified Health Center, Rural Health Center, Non-Physician Practitioner Group, Physician, Nurse Practitioner, Certified Nurse-Midwife, or Physician’s Assistant;
Execute and submit a Prenatal Plus Program addendum to the Colorado Medical Assistance Program Provider Participation Agreement for review and acceptance by the Department; and 3. Manage a Prenatal Plus Program multidisciplinary team(s) of personnel.

The multidisciplinary team shall include:

a. A care coordinator(s) who acts as the hub of the multidisciplinary team and is the person primarily responsible for organizing resources and assisting clients in accessing services to meet their individual needs. The care coordinator(s) shall, at minimum, hold a bachelor’s degree in a relevant human/social services discipline or be a registered nurse;

b. A registered dietitian(s) who is currently registered with the Commission on Dietetic Registration as a registered dietitian, or a dietetic intern(s) in an internship accredited by the American Dietetic Association and supervised by a registered dietitian who has agreed to serve as a preceptor for the dietetic intern;

c. A mental health professional(s) who, at minimum, is a master’s level professional in the field of social work, marriage and family therapy, professional counseling, or other mental health specialty, or an intern(s) in an accredited mental health internship and supervised by a master’s level mental health professional; or the Prenatal Plus Program Provider must have a consistent, documented referral relationship with a mental health provider(s) not part of the multidisciplinary team but participating with the Colorado Medicaid Community Mental Health Services Program.

Prenatal Plus Program Providers who do not include a mental health professional as part of their multidisciplinary team shall not be eligible for reimbursement of psychosocial counseling and support through the Prenatal Plus Program; and d. A Colorado Medicaid-enrolled physician, nurse practitioner, certified nurse-midwife, or physician’s assistant who is the rendering provider that delegates the provision of Prenatal Plus Program services to the multidisciplinary team.

Retain in the record of each client to whom Prenatal Plus Program services are rendered:

a. Identification of qualifying risk factors using the Program Eligibility Screening Form; and b. A client risk assessment using the Initial Assessment Form.

8.748.5 REIMBURSABLE SERVICES 8.748.5.A Services reimbursable through the Prenatal Plus Program include:

Nutrition counseling and support provided by the registered dietitian/dietetic intern consisting of the following components which may be provided on an individual basis or in a group setting based on client need:

a. Nutrition screening;

b. General nutrition education;

c. Comprehensive nutrition status assessment; and d. Nutrition counseling and targeted nutrition education based on client-specific need. Nutrition counseling shall be considered inclusive of nutrition care-planning, goal-setting, monitoring, followup, and nutrition care plan revision.

Psychosocial counseling and support provided by the mental health professional consisting of the following components which may be provided on an individual basis or in a group setting based on client need:

a. Psychosocial health screening;

b. Comprehensive psychosocial health assessment; and c. Psychosocial health counseling and support. Psychosocial counseling and support shall be considered inclusive of psychosocial care-planning, goal-setting, monitoring, follow-up, and psychosocial care plan revision.

i. Psychosocial counseling and support does not include clinical psychotherapy services, traditional medication management, or other clinical services specifically related to treatment of a diagnosed mental health disorder. When clinical mental health disorders are identified, including substance use disorders, clients shall be referred to a provider who participates in the Colorado Medicaid Community Mental Health Services Program or a Medicaidenrolled substance use disorder treatment provider.

General client education and health promotion provided by the care coordinator which may be provided on an individual basis or in a group setting based on client need, regarding topics that may include:

a. Basic understanding of the prenatal period i. Physical and emotional changes related to pregnancy including fetal development;

ii. Healthy and appropriate weight gain during pregnancy;

iii. Healthy prenatal diet and food precautions;

iv. Physical activity precautions and appropriate exercise;

v. Substance use and how it can affect maternal and infant health outcomes;

vi. Sexually transmitted diseases/infections and how they can affect maternal and infant health outcomes;

vii. Bonding with the baby before birth;

viii. Importance of oral hygiene;

ix. Warning signs of preterm labor; and x. Common terminology;

b. Common concerns related to childbirth and breastfeeding i. Birth planning, hospital packing/preparation, and attending birth classes;

ii. Pain management options during delivery; and iii. Benefits of breastfeeding, preparing for breastfeeding and breastfeeding basics;

c. The postpartum period and healthy infancy i. Postpartum mood disorders (“baby blues” and postpartum depression);

ii. Postpartum recovery issues and adjustment including body changes, self-esteem, and relationship stressors;

iii. Managing stress, day-to-day problem-solving, positive communication techniques, building and using support networks;

iv. Family planning and contraception;

v. Comforting and stimulating infants (including education on shaken baby syndrome risk reduction, recognizing an infant’s distress cues, and bonding/attachment postpartum);

vi. Appropriate expectations for infant behavior, sleeping patterns, teething and crying;

vii. Infant health including newborn feeding, immunizations, pediatrician visits, and car-seat safety; and viii. Environmental risk factors including violence in the home, smoke, substance use and how they can affect infant health;

Targeted case management provided by the care coordinator. Targeted case management is a service provided to assist clients in gaining access to needed medical, social, educational, and other services, and includes the following components:

a. Comprehensive assessment and periodic reassessment of the client’s needs to determine the necessity for any medical, educational, social, or other services;

b. Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that specifies the goals and actions to address the medical, social, educational, and other services needed and identifies a course of action to respond to the assessed needs;

c. Referral and related activities to help the client obtain needed services including activities that help link the client with medical, social, or educational providers, or other programs and services that are capable of providing needed services; and d. Monitoring and follow-up activities including activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the client’s needs, and which may be with the client, family members, providers, or other entities or individuals.

e. Targeted case management provided by the care coordinator may include, but is not limited to, screening for nutrition and psychosocial risk factors.

f. Note: Targeted case management does not include case management activities that are an integral component of another covered Medicaid service; the direct delivery of an underlying medical, educational, social, or other service to which a client has been referred; activities integral to the administration of foster care programs; or activities for which a client may be eligible that are integral to the administration of another non-medical program.

8.748.6 REIMBURSEMENT 8.748.6.A Reimbursement shall be the lower of:

Submitted charges; or 2. Fee schedule for Prenatal Plus Program services as determined by the Department.

8.749 NURSE HOME VISITOR PROGRAM

8.749.1 DEFINITIONS

Nurse means a person licensed as a professional nurse pursuant to §12-38-102,C.R.S., et seq., or accredited by another state or voluntary agency that the state board of nursing has identified by rule pursuant to §12-38-108(1)(a),C.R.S., as one whose accreditation may be accepted in lieu of board approval.

Nurse Home Visitors means registered nurses who provide targeted case management Provider Agency means an agency that has met the Nurse Home Visiting Program provider requirements and has been certified by the Department of Public Health and Environment.

Targeted Case Management means services which will assist individuals in gaining access to needed medical, social, education and other services to promote healthy first pregnancies, improve the health and development of a woman’s first child and to encourage self-sufficiency.

8.749.2 PROGRAM DESCRIPTION

Nurse Home Visitor Program (NHVP) means a program established pursuant to §25-31- 101,C.R.S. et seq., including the provision of targeted case management services to first-time pregnant women or whose first child is less than one month old and who are at or below 200% of the Federal Poverty Level. Services are offered through the child’s second birthday plus one month.

8.749.3 CLIENT ELIGIBILITY

First-time (defined as no previous live births), pregnant women or whose first child is less than one month old and who are at or below 200% of the Federal Poverty Level are eligible for the NHVP.

8.749.4 PROVIDER REQUIREMENTS 8.749.4.A. A participating provider shall be:

Certified by the Colorado Department of Public Health and Environment;
Allowed to bill as a clinic including, but not limited to Certified Public Health Clinics, Federally Qualified Health Centers and Rural Health Centers.

8.749.5 PROVIDER RESPONSIBILITIES 8.749.5.A. Targeted Case Management Services 1. Providers shall provide Targeted Case Management services including:

a. Assessment of the first time pregnant woman and her first child’s needs for health, mental health, social services, education, housing, childcare and related services.

b. Development of care plans to obtain the needed services.

c. Referral to resources to obtain the needed services including medical providers who provide care to a first time pregnant woman and her first child.

d. Routine monitoring and follow-up visits with the women where progress in obtaining the needed services is monitored, problemsolving assistance is provided and the care plans are revised to reflect the women and children’s current needs.

Providers shall document and chart Targeted Case Management activities and complete assessment and referral forms.

8.749.6 REIMBURSEMENT 8.749.6.A. Monthly payments for Targeted Case Management shall be made for each child/family visited under the program.

Services to the mother shall be limited to 3 units per month with a lifetime maximum limit of 30 units.
Services to the child shall be limited to 3 units per month with a lifetime maximum of 75 units.
A different rate shall be calculated for each provider agency based on their actual historical cost and their projected budget for the next fiscal year.
At the end of the fiscal year, payments will be reconciled with the actual costs for each agency based on agency cost reports, to assure that payment was not more than the actual cost of providing services.

Overages shall be recovered.

8.750 COMPREHENSIVE COMMUNITY BEHAVIORAL HEALTH PROVIDERS AND

ESSENTIAL BEHAVIORAL HEALTH SAFETY NET PROVIDERS

8.750.1 DEFINITIONS

"Comprehensive community behavioral health provider" means a licensed behavioral health entity or behavioral health provider approved by the Behavioral Health Administration (BHA) to provide care coordination and behavioral health safety net services, either directly or through formal agreements with behavioral health providers in the community or region.

“Essential Behavioral Health Safety Net Providers” means a licensed behavioral health entity or behavioral health provider approved by BHA to provide care coordination and at least one of the behavioral health safety net services listed in 27-50-101(11) C.R.S.

8.750.2 REQUIREMENTS FOR PARTICIPATION 8.750.2.A. The provider must be approved by the Behavioral Health Administration (BHA).

8.750.3 COVERED SERVICES 8.750.3.A. Comprehensive Community Behavioral Health providers shall provide the covered behavioral health safety net services listed in 27-50-101(11) C.R.S. 8.750.3.B Essential Behavioral Health Safety Net providers shall provide at least one of the covered behavioral health services listed in 27-50-101(13) C.R.S.

Case management services, including but not limited to:

a. Service planning and program linkage.

b. Referral recommendations.

c. Monitoring and follow up.

d. Client advocacy.

e. Crisis management.

8.750.4 REIMBURSEMENT 8.750.4.A. Comprehensive Community Behavioral Health providers and Essential Behavioral Health Safety Net providers must be reimbursed in accordance with 25.5-4-403 C.R.S.

8.754 MEMBER CO-PAYMENT

8.754.1 MEMBER RESPONSIBILITY

Members shall be responsible for the following co-payments: 8.754.1.A. Hospital outpatient, $0.00 per visit, effective July 1, 2023. 8.754.1.B. Physician (M.D. or D.O) office or home visit, $0.00 per visit, effective July 1, 2023. 8.754.1.C. Rural health clinic, $0.00 per visit, effective July 1, 2023. 8.754.1.D. Behavioral Health Provider visits, except services which fall under Home and Community Based Service programs, $0.00 per visit, effective July 1, 2023. 8.754.1.E. Pharmacy, $0.00 per prescription or refill, effective July 1, 2023. 8.754.1.F. Optometrist, $0.00 per visit, effective July 1, 2023. 8.754.1.G. Podiatrist, $0.00 per visit, effective July 1, 2023. 8.754.1.H. Inpatient hospital, $0.00 per admission, July 1, 2023. 8.754.1.I. Durable medical equipment/disposable supply services, $0.00 per date of service, effective July 1, 2023. 8.754.1.J. Laboratory services, $0.00 per date of service, July 1, 2023. 8.754.1.K. Radiology services, $0.00 per date of service, July 1, 2023. 8.754.1.L. Emergency services, $0.00 co-pay.

For services that continue to have a co-pay under Section 8.754.2, it is the provider’s responsibility to identify emergency on the claim form so that the fiscal agent can exempt the service from co-payment.

8.754.2 NON-EMERGENCY SERVICES

Effective July 1, 2022, non-emergency services rendered in the hospital outpatient emergency room are subject to a $8.00 co-payment, in compliance with 42 U.S.C. 1396o (2021), per visit. 8.754.2.A. Providers may not assess a $6.00 co-payment for non-emergency services provided in the emergency room unless they have first:

Determined that the medical condition does not meet the threshold for emergency care services, as defined at 10 C.C.R. 2505-10, Section 8.300.1.I;
Informed the client that the condition does not require emergency care services;
Informed the client of the amount of their cost sharing obligation for nonemergency services provided in the emergency room;
Provided the client with the name and location of an available and accessible alternative non-emergency services provider; and 5. Determine that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is otherwise exempt from cost sharing; and 6. Provide a referral to coordinate scheduling for treatment by the alternative provider.

8.754.3 EMERGENCY TREATMENT

Prescription drugs administered during emergency treatment shall be considered part of the treatment and are not subject to co-payment.

8.754.4 PRESCRIPTIONS

All prescriptions written in the emergency room or elsewhere are subject to the copayment set forth in Paragraph 8.754.1.E. above.

8.754.5 EXEMPTIONS

The following clients and services are exempt from co-payment requirements: 8.754.5.A. Children under the age of 19. 8.754.5.B. All services to women in the maternity cycle.

The maternity cycle means pregnancy, labor, birth and the immediate postpartum period not to exceed six weeks.
The client must inform the provider of her pregnancy or postpartum condition at the time of service, and all providers must indicate pregnancy on the claim form in order to claim this exemption.
In the case of prescription drugs, the prescribing physician should note pregnancy or postpartum on the prescription.
Providers may request oral or written verification of pregnancy or postpartum condition by contacting the physician.
If the provider questions the client’s statement that she is pregnant or postpartum and the provider is unable to obtain verification of the pregnancy or postpartum condition, then the provider may collect the copayment amount imposed by this regulation from the recipient.
If the recipient feels that she has been wrongly denied an exemption due to an unverified pregnancy or postpartum condition, she has the right of appeal through the recipient appeal process set forth at 10 C.C.R. 2505- 10, Section 8.057. 8.754.5.C. All services to institutionalized clients, including those in skilled nursing facilities, intermediate care facilities (ICF’s), ICF’s for the mentally retarded, recipients under age 21 in inpatient psychiatric hospitals, and recipients 65 and over in institutions for mental diseases. 8.754.5.D. Family planning services and supplies furnished to clients of child-bearing age. The fiscal agent shall identify the family planning services and supplies exempted on the Medicaid claim form. 8.754.5.E. All emergency care services.
Emergency care services is defined in Section 8.300.1.I.
Emergency treatment can be given in the emergency room, the outpatient department, or a physician’s office.
The attending medical personnel shall define the emergent nature of the recipient’s condition.
For cases where it is not clear if an emergency exists, a triage of the member will be conducted to determine if the member’s condition meets the threshold for emergency care services, as defined in Section 8.300.1.I.
There shall be no co-payment charge for the triage. 8.754.5.F. All services provided under the Community Mental Health Services program and Managed Care programs. 8.754.5.G All preventive and vaccine services as required by the Affordable Care Act (42 USC § 1396d(a)(13) (2010)) and described in the United States Preventive Services Task Force (USPSTF) A and B recommendations and the Advisory Committee for Immunization Practices (ACIP) recommended vaccines and their administration which are hereby incorporated by reference. The incorporation of the USPSTF A and B recommendations and the ACIP recommended vaccines excludes later amendments to, or editions of, the referenced material.

The USPSTF A and B recommendations is available from the US Preventive Services Task Force web page at http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm. The ACIP recommended vaccines is available at the Centers for Disease Control and Prevention webpage at http://www.cdc.gov/vaccines/hcp/acip-recs/. Pursuant to § 24-4-103 (12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at:

Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

8.754.6 PROVIDERS 8.754.6.A. The co-payment amount charged by a provider shall not vary depending on the cost of the specific service being rendered. 8.754.6.B. A provider may not deny services to an individual when such members are unable to immediately pay the co-payment amount. However, the member remains liable for the co-payment at a later date. 8.754.6.C. Providers shall bill their usual and customary charge. For any service for which a co-payment amount is imposed, the fiscal agent shall deduct the appropriate co-payment amount from the payment to the provider. 8.754.6.D. Physicians providing laboratory or radiology services in their office shall be responsible for collecting co-payments for the office visit and for the laboratory or radiology services provided.

8.760 TARGETED CASE MANAGEMENT SERVICES

8.760.1 DEFINITIONS .10 “Case Management Agency” (CMA) means a public or private not-for-profit or for-profit agency that meets all applicable state and federal requirements and is certified by the Department to provide case management service for Home and Community Based waivers pursuant to Section 25.5-10-209.5, C.R.S. and pursuant to a provider participation agreement with the state department. .11 “Child with a developmental delay” means: a person less than five years of age with delayed development or who is at risk of having a developmental disability. .12 Community Centered Board means a private corporation, for-profit or not-forprofit that is designated pursuant to Section 25.5-10-209, C.R.S., responsible for, but not limited to conducting Developmental Disability determinations, waiting list management Level of Care Evaluations for Home and Community Based Service waivers specific to individuals with intellectual and developmental disabilities, and management of State Funded programs for individuals with intellectual and developmental disabilities.

a. Persons receiving targeted case management services may not be restricted from requesting, on a statewide basis, which Community Centered Board or Case Management Agency will provide them with targeted case management services. .13 “Developmental disability” means a disability that is manifested before the person reaches twenty-two years of age; which constitutes a substantial disability to the affected individual; and is attributable to a developmental delay or intellectual disability or related conditions which include cerebral palsy, epilepsy, autism, or other neurological conditions when such conditions result in impairment of general intellectual functioning or adaptive behavior similar to that of a person with intellectual disability Unless otherwise specifically stated, the federal definition of “developmental disability” found in 42 U.S.C. sec. 15002, et seq., shall not apply.

8.761 TARGETED CASE MANAGEMENT (TCM) SERVICES FOR PERSONS WITH

DEVELOPMENTAL DISABILITITES .14 Targeted Case Management services for Persons with Developmental Disabilities consists of facilitating enrollment; locating, coordinating, and monitoring needed developmental disabilities services; and coordinating with other non-developmental disabilities funded services, such as medical, social, educational, and other services to ensure non-duplication of services and monitor the effective and efficient provision of services across multiple funding sources.

Targeted case management services includes the following activities:

a. Comprehensive assessment and periodic reassessment of individual needs to determine the need for any medical, educational, social or other services and completed annually or when the Client experiences significant change in need or in level of support. These assessment activities include:

Taking Client history; and 2. Identifying the Client's needs, completing related documentation, and gathering information from other sources such as family members, medical providers, social workers, and educators as necessary, to form a complete assessment of the Client.

b. Development and periodic revision of a specific care plan that:

Is based on the information collected through the assessment;
Specifies the goals and actions to address the medical, social, educational, and other services needed by the Client;
Includes activities such as ensuring the active participation of the Client, and working with the Client (or the Client representative as defined in Section 8.500.1) and others to develop those goals; and 4. Identifies a course of action to respond to the assessed needs of the Client.

c. Referral and related activities to help a Client obtain needed services including activities that help link a Client with:

Medical, social, educational providers; or 2. Other programs and services including making referrals to providers for needed services and scheduling appointments, as needed.

d. Monitoring and follow-up includes activities that are necessary to ensure the care plan is implemented and adequately addresses the Client’s needs. Monitoring and follow up actions shall:

Be performed when necessary to address health and safety and services in the care plan;
Include activities to ensure:

A. Services are being furnished in accordance with the Client’s care plan;

B. Services in the care plan are adequate; and C. Necessary adjustments in the care plan and service arrangements with providers are made if the needs of the Client have changed;

Include direct contact and observation with the Client in a place where services are delivered to a Client in accordance with the following frequency:

A. Face-to-face monitoring shall be completed for a Client enrolled in HCBS-DD at least once per quarter;

B. Face-to-face monitoring shall be completed for a Client enrolled in HCBS-SLS at least once per quarter;

C. Face-to-face monitoring shall be completed for a Client in HCBS-CES at least once per quarter; and D. Face-to-face monitoring shall be completed at least once every six months for children in Early Intervention Services.

E. Upon Department approval, contact may be completed by the case manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the case manager or client (e.g. natural disaster, pandemic, etc.). .15 All case documentation must be entered into the Department’s IMS within five (5) business days from the date of activity.

8.761.2 DETERMINATION OF CLIENT ELIGIBLITY .21 To receive targeted case management services individuals must meet the following criteria:

a. Be determined eligible for Medicaid by the County Department of Social/Human Services in the county in which the person resides;

b. Be determined by the designated Community Centered Board to have a developmental disability or developmental delay; and c. Be actively enrolled in one of the following programs:

Home and Community Based Services for Persons with Developmental Disabilities waiver (HCBS-DD);
Home and Community Based Services - Supported Living Services waiver (HCBS-SLS);
Home and Community Based Services- Children’s Habilitation Residential Program (HCBS-CHRP)
Home and Community Based Services - Children's Extensive Support waiver (HCBS-CES); or 4. Early Intervention Services (EI) . .22 The specific programs listed in Section 8.761.21.c.1 through 4 are the only programs which are eligible for targeted case management services.

8.761.3 PROVIDER ELIGIBILITY .31 Only certified Early Intervention Services may be reimbursed for targeted case management services for persons enrolled in Early Intervention Services pursuant to 12 CCR 2509-10, Section 7.913. .32 Only case management agencies certified by the Department pursuant to Sections 8.519 through 8.519.23 may provide case management for persons enrolled in the Home and Community Based Services outlined in Sections 8.503 Home and Community Based Services for Children’s Extensive Support (HCBS- CES) Waiver, 8.508 Home and Community Based Services for Children’s Residential Habilitation Program (HCBS-CRHP), 8.500 Home and Community Based Services for the Developmentally Disabled (HCBS-DD) Waiver, and 8.500.90 Home and Community Based Services for Supported Living Services (HCBS-SLS) Waiver et seq.

8.761.4 REIMBURSEMENT .41 Claims are reimbursable only when supported by the following documentation:

a. The name of the Client;

b. The date of the activity;

c. The nature of the activity including whether it is direct or indirect contact with the Client;

d. The content of the activity including the relevant observations, assessments, findings;

e. Outcomes achieved, and as appropriate, follow up action;

f. For EI services, the total number of units associated with the activity; and g. For HCBS waiver programs, documentation required under Sections 8.519 and 8.760. .42 TCM providers shall record what documentation exists in the log notes and enter it into the state data system as required by the Department. .43 Claims related to EI for travel time to and from a TCM activity are reimbursable at the same unit rate as TCM services. The time claimed for travel shall be documented separately from the time claimed for the TCM activity. .44 Reimbursement rates shall be published prior to their effective date in accordance with Federal requirements at 42 C.F.R. § 447.205 and shall be based upon a market-based. El shall continue to utilize the rate with a unit of service equal to fifteen (15) minutes according to the State’s approved fee schedule. EI TCM, which is limited to 240 units per Client per state fiscal year. .45 TCM services may not be claimed prior to the first day of enrollment into an eligible program nor prior to the actual date of eligibility for Medicaid benefits. .46 TCM for HCBS-DD, HCBS-CES, HCBS-CHRP and HCBS-SLS are to be reimbursed based on the Departments TCM Fee Schedule.

8.761.5 EXCLUSIONS .51 Case management services provided to any individuals enrolled in the following programs are not billable as Targeted Case Management services for persons with developmental disabilities as specified in Section 8.760:

a. Persons enrolled in a Home and Community Based Services waiver not included as an eligible HCBS service as described in Section 8.761.21.c.

b. Persons residing in a Class I nursing facility.

c. Persons residing in an Intermediate Care Facility for the Intellectually Disabled (ICF-ID).

8.762 CASE MANAGEMENT - BEHAVIORAL HEALTH .10 Case Management Services - Mental Health are a Medicaid benefit statewide when provided in accordance with the provisions of the following sections.

.20 DEFINITION

Case Management Services are defined as those services which will assist mentally ill individuals eligible under the state plan, in gaining access to needed medical, social educational, and other services. These services are separate from those services defined under the clinic options services in Section 8.750.

.30 DETERMINATION OF MEMBER ELIGIBILITY

In addition to Medicaid eligibility, members must have a behavioral health diagnosis or are being assessed for a behavioral health diagnosis and be in need of case management services as defined above.

.40 PROVIDER ELIGIBILITY

Only providers approved by the Behavioral Health Administration shall be reimbursed for case management services under these provisions.

.50 REIMBURSEMENT

Reimbursement shall be on a prospective fee for services basis in accordance with Federal requirements at 42 CFR 447.321 and Section 8.752.

8.763 TARGETED CASE MANAGEMENT - TRANSITION COORDINATION

Transition Coordination means support provided to a member who is moving from a congregate setting other than an assisted living facility or being diverted from possible institutionalization and includes the following activities: comprehensive assessment for transition, community risk assessment, development of a transition plan, referral and related activities, and monitoring and follow up activities as they relate to the transition or diversion. 8.763.A Eligibility 1. To be eligible for Transition Coordination, members must be adult Medicaid recipients, who reside in a congregate setting other than an assisted living facility and are willing to participate and have expressed interest in moving to a home and community-based setting or have been identified as being at risk for institutionalization by the Department.

Members may also be Medicaid recipients receiving Home and Community Based Services (HCBS) provided by the State operated Regional Centers (RC) who want to move to a private Home and Community Based Services Provider. Services are expected to begin while an individual is living in a facility and continue through integration into community living, based on the community risk assessment. Excluded are children under the age of 18. 8.763.B Services 1. Transition Coordination is provided pursuant to Section 8.519.27. 8.763.C Limitations on Service 1. Transition Coordination is limited to 360 units per member per transition or diversion. A unit of service is defined as each completed 15-minute increment that meets the description of a Transition Coordination activity.

When an individual has a documented need for additional units, the 360unit cap may be exceeded to ensure the health and welfare of the member. The Transition 1 Coordinator shall submit documentation to the Department including:

a. A copy of the community risk assessment describing the member’s current needs.

b. The number of additional units requested.

c. A history of Transition Coordination units provided to date and outcomes of those services d. An explanation of the additional Transition Coordination supports to be provided by the transition coordinator using any additional approved units.

8.765 SERVICES FOR MEMBERS IN RESIDENTIAL CHILD CARE FACILITIES AS

DEFINED BELOW

8.765.1 DEFINITIONS 8.765.1.A. Assessment means the process of continuously collecting and evaluating information to develop a member’s profile on which to base a Plan of Care, service planning, and referral. 8.765.1.B. Clinical Staff means medical staff that are at a minimum licensed at the level of registered nurse, performing within the authority of the applicable practice acts. 8.765.1.C. “Colorado Child and Adolescent Needs and Strengths Tool (CANS)” is an evidence-based, validated, decision-supported tool designed to identify the strengths and needs of children, youth, and their families and facilitate the linkage between the process and the design of individualized service plans including the application of evidence-based practices. The CANS supports levelof-care decision-making, facilitates quality improvement initiatives, and allows for the monitoring of service outcomes. 8.765.1.D. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the Colorado Medicaid program’s benefit under Section 8.280 for children and adolescents that provides a comprehensive array of prevention, diagnostic, and treatment services for infants, children and adolescents under age 21 who have low income. 8.765.1.E. Emergency Safety Intervention means the use of Restraint and Seclusion as an immediate response to an Emergency Safety Situation. 8.765.1.F. Emergency Safety Situation means unanticipated behavior of the member that places the member or others at serious threat of violence or injury if no intervention occurs and that calls for Emergency Safety Intervention. 8.765.1.G. Emergency Services means emergency medical and crisis management 8.765.1.H Enhanced Standardized Assessment (ESA) means a behavioral health encounter conducted by a nonphysician, licensed or licensure candidate behavioral health professional. The ESA is a comprehensive, clinical assessment completed by a behavioral health provider to assist in determining appropriate treatment/service recommendations for children, youth, and families. The ESA includes a collection of biopsychosocial information and the use of the CANS.

Treatment in a Qualified Residential Treatment Program (QRTP) or a Psychiatric Residential Treatment Facility (PRTF) can be the recommendation of the ESA. 8.765.1.I. Independent Team means a team certifying the need for Psychiatric Residential Treatment Facility (PRTF) services that is independent of the Referring Party and includes a physician who has competence in the diagnosis and treatment of behavioral illness and knowledge of the member’s condition. 8.765.1.J. Interdisciplinary Team means staff in a PRTF comprised of a physician, and a Licensed Behavioral Health Professional, registered nurse or occupational therapist responsible for the treatment of the member. 8.765.1.K. Licensed Behavioral Health Professional means a psychologist licensed pursuant to C.R.S. § 12-245-304, a psychiatrist licensed pursuant to C.R.S. § 12- 240-110 or C.R.S. § 12-240-114, a clinical social worker licensed pursuant to C.R.S. § 12-245-404, a marriage and family therapist licensed pursuant to C.R.S. § 12-245-504, a professional counselor licensed pursuant to C.R.S. § 12-245- 603, or a social worker licensed pursuant to C.R.S. § 12-245-404, that is supervised by a licensed clinical social worker. 8.765.1.L. Medication Management Services means review of medication by a physician at intervals consistent with generally accepted medical practice and documentation of informed consent for treatment. 8.765.1.M. Multidisciplinary Team means staff in a Residential Child Care Facility (RCCF) providing behavioral health services comprised of at least one Licensed Behavioral Health Professional and other staff responsible for the treatment of the member and may include a staff member from the Referral Agency. 8.765.1.N. Out-of-State High-Intensity Residential Treatment (OHIRT) means an outof-state residential provider who is not a Qualified Residential Treatment Program (QRTP). OHIRT is a facility that is not a hospital and provides inpatient psychiatric services under the direction of a physician for individuals under age 21. 8.765.1.O. Plan of Care means a treatment plan designed for each member and family, developed by an Interdisciplinary or Multidisciplinary Team. 8.765.1.P. Prone Position means a member lying in a face down or front down position. 8.765.1.Q. Psychiatric Residential Treatment Facility (PRTF) means a facility that is not a hospital and provides inpatient psychiatric services for individuals under age 21 under the direction of a physician, licensed pursuant to C.R.S. § 12-240- 110. 8.765.1.R. Qualified Residential Treatment Programs (QRTP) means a facility that provides residential trauma-informed treatment that is designed to address the needs, including clinical needs, of children with serious emotional or behavioral disorders or disturbances. 8.765.1.S. Referring Party means the Division of Youth Corrections, County Departments of Human/Social Services who have legal custody of a member, Behavioral Healthcare Organization, Managed Care Organization (MCO), Regional Accountable Entity (RAE), parent or legal guardian, or Comprehensive Community Behavioral Health Provider that refers the member to a PRTF, QRTP, OHIRT or RCCF for the purpose of placement through the Children and YouthMental Health Treatment Act. 8.765.1.T. Restraint includes Drug Used as a Restraint, Mechanical Restraint and Personal Restraint. 8.765.1.U. Drug Used as a Restraint means any drug that is administered to manage a member’s behavior in a way that reduces the safety risk to the member or to others; has the temporary effect of restricting the member’s freedom of movement and is not a standard treatment for the member’s medical or psychiatric condition. 8.765.1.V. Mechanical Restraint means any device attached or adjacent to the member’s body that the member cannot easily remove that restricts freedom of movement or normal access to the member’s body. 8.765.1.W. Personal Restraint means personal application of physical force without the use of any device, for the purpose of restraining the free movement of the member’s body. This does not include briefly holding a member without undue force in order to calm or comfort, or holding a member’s hand to safely escort the member from one area to another. This does not include the act of getting the member under control and into the required position for Restraint. 8.765.1.X. Residential Child Care Facility (RCCF) means any facility that provides out-of-home, 24-hour care, protection and supervision for children as defined at C.R.S. § 26-6-903(29) 8.765.1.Y. Seclusion means the involuntary confinement of a member alone in a room or an area from which the member is physically prohibited from leaving.

8.765.2 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF)

COVERED SERVICES 8.765.2.A. PRTF benefit shall include services as identified in the Plan of Care as well as other services necessary for the care of the member in the facility. These services include, but are not limited to:

Individual therapy.
Group therapy.
Family, or conjoint, therapy conducted with the member present, unless member contact with family members is contraindicated.
Emergency services.
Medication Management Services.
Room and Board.

8.765.3 PRTF NON-COVERED SERVICES 8.765.3.A. The following are not a benefit in a PRTF:

The day of discharge.
Leave days.
Days when the member is in detention.

8.765.4 DEPARTMENT-FUNDED PRTF MEMBER ELIGIBILITY 8.765.4.A. To receive benefits in a PRTF, the member shall:

Be between the ages of three and twenty-one.
Be certified to need PRTF level of care by an Independent Team. The Team shall certify that:

a. Ambulatory care resources available in the community do not meet the treatment needs of the member.

b. Proper treatment of the member’s behavioral condition requires services on an inpatient basis under the direction of a physician.

c. The services can reasonably be expected to improve the member’s behavioral health or prevent further regression so that the services shall no longer be needed.

Have an ESA supporting PRTF as the medically necessary level of care. 8.765.4.B. The member shall not be eligible to receive services when:
The member is no longer able to benefit from the service or is no longer progressing towards goals.
The member is absent without approved leave in excess of 24 consecutive hours or has been removed from the facility and placed in non-PRTF services.
The Interdisciplinary Team determines that the member has attained treatment goals.
An ESA determines PRTF is not, or is no longer, the medically necessary 5. Admission of minors not in the custody of a County Department of Human/Social Services or DHS as a result of commitment to the Division of Youth Corrections shall be subject to the requirements set forth at C.R.S. § 27-65-103. 8.765.4.C. Initial Authorization and Prior Authorization Requirement 1. For children receiving behavioral health services in a Psychiatric Residential Treatment Facility (PRTF) and funded by the Department, the ESA will determine behavioral health medical necessity for initial 2. Ongoing PRTF services may require Prior Authorization.

8.765.5 PRTF PROVIDER ELIGIBILITY 8.765.5.A. All PRTF Providers shall have an Interdisciplinary Team.

The Interdisciplinary Team shall include either a board-certified psychiatrist, or a clinical psychologist who has a doctoral degree, a physician licensed to practice medicine or osteopathy, and one of the a. A licensed clinical social worker, licensed marriage and family therapist or licensed professional counselor.

b. A registered nurse with specialized training or one year's experience in treating individuals with behavioral health conditions.

c. A certified occupational therapist with specialized training or one year’s experience in treating individuals with behavioral health conditions; or d. A licensed psychologist.

The Interdisciplinary team shall:

a. Assess the member's immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities.

b. Assess the potential resources of the member and member’s family.

c. Develop and implement a comprehensive, individualized written d. Set treatment objectives.

e. Prescribe therapeutic modalities to achieve the objectives of the 8.765.5.B. All PRTF providers shall implement a Plan of Care. 8.765.5.C. An initial Plan of Care shall be developed within 72 hours of the member’s admission and shall address the immediate and emergency needs of the member. 8.765.5.D. A comprehensive Plan of Care shall:

Be completed within 14 days of admission.
Be signed and dated by the member, the Referring Party or legal guardian/parent, and the Licensed Behavioral Health Professional.
Address clinical and other needs including the member's presenting problems, physical health, emotional status, behavior, support system in the community, available resources and discharge plan.
Include specific goals and measurable objectives, expected dates of 5. Specify the type, frequency and duration of all PRTF services necessary to meet the needs of the member and to treat the member’s current 6. Identify the provision of or the referral for services other than PRTF 7. Be readily identifiable and be maintained in the member’s record.
Document any court-ordered treatment including identifying the agency responsible for providing the court-ordered treatment.
Include revisions to the Plan of Care at least monthly, or sooner if appropriate. 8.765.5.E. The PRTF shall designate a Licensed Behavioral Health Professional to act as a case manager for each member to oversee the formulation, implementation, review and revision to the Plan of Care. 8.765.5.F. The Licensed Behavioral Health Professional shall sign and date the Plan 8.765.5.G. The PRTF shall ensure the member and/or legal guardian participate in the formulation, review and revision of the Plan of Care. If the member or legal guardian is unable to participate or when his or her participation is clinically contraindicated, the PRTF shall document the reasons in the member's record.

Any decision to not involve the family or guardian shall be approved by the Referring Party. In addition, other persons selected by the member, the family or guardian, the Referring Party or the Licensed Behavioral Health Professional may be included in the formulation, review and revision of the Plan of Care. 8.765.5.H Except in cases of emergency, all PRTF services in the Plan of Care shall be provided. 8.765.5.I. The PRTF shall ensure that physician prescribed information is used for the component of the Plan of Care requiring Medication Management Services. 8.765.5.J. The PRTF shall ensure all members and/or guardians are aware of the complaint and grievance procedures. 8.765.5.K. The PRTF shall ensure all members and/or guardians are aware of the PRTFs policies regarding Restraint and Seclusion as required in 42 C.F.R. §§ 483.350-376 (2024), which is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 303 E. 17 Avenue, Suite 1100, Denver, Colorado 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer starting at https://www.ecfr.gov/current/title-42/chapter- IV/subchapter-G/part-483/subpart-G/section-483.350. 8.765.5.L. The PRTF shall facilitate access to necessary medical care and shall be responsible for coordinating behavioral health treatment with medical treatment. 8.765.5.M. Member Transfers:

A member shall be transferred only to the care of another PRTF or placement facility when adequate arrangements for care have been made by the Referring Party.
The member and the legal guardian shall be given a minimum of 24 hours notice before the member is transferred unless this notice is waived by the Referring Party or legal guardian in writing or if an emergency condition exists.
Transfers shall be documented in the clinical record. 8.765.5.N. PRTF Licensure and Certification Requirements.
The PRTF shall:

a. Be certified by the Department of Human Services (DHS), to provide behavioral health services as a PRTF.

b. Be licensed by DHS, Division of Child Care Licensing, as a Residential Child Care Facility and a PRTF.

c. Be certified as a qualified residential provider by the Department of Public Health and Environment.

d. Be accredited by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children.

e. Provide an attestation to the Department that the PRTF is in compliance with the condition of participation for Restraint and Seclusion as described in Section 8.765.6.F and in federal law. .2. A PRTF that has more than one physical address shall have a separate Medicaid provider number for each facility. 8.765.5.O. PRTF Requirements to Notify and Involve the Regional Accountable Entity (RAE) or Managed Care Organization (MCO)

By close of business on the day following placement, the provider shall notify the member’s RAE or MCO of the placement.
The provider shall notify the RAE or MCO and the Department of emergent transfers or changes of placement, of any member, by close of business on the day following transfer.
The provider shall notify the RAE or MCO and the Department of any plans to transfer the member to another placement or facility as soon as possible.
The provider shall include the RAE or MCO, to the extent possible, in ongoing care planning and discharge planning for the duration of the member’s treatment at the provider’s facility.

8.765.6 PRTF PROVIDER RESPONSIBILITIES 8.765.6.A. A PRTF must maintain an organized, legible, chronological, current treatment record for each member. Treatment records shall include:

Admission information such as the member’s personal information and demographic data, source of referral, most current Diagnostic Statistical Manual diagnosis and substance abuse history.
Documentation of the member’s legal status, including but not limited to guardianship, conservatorship, court orders, custody, certifications, advisement and consent.
Copies of all Assessments.
All Plans of Care and revisions.
Documentation of member’s attendance at, participation in and outcomes of PRTF Services.
Documentation that the member and/or the legal guardian was provided with a copy of the Plan of Care.
Correspondence to and from agencies and individuals involved in the member’s treatment.
An explanation whenever any member of the Interdisciplinary Team, member, parent or guardian, when appropriate, does not sign a Plan of Care.
The name of the Licensed Behavioral Health Professional responsible for the formulation, implementation, review and revision of the member’s Plan 10. A discharge report, within 30 consecutive days of the discharge from the PRTF, summarizing treatment received and outcomes.
For transfers between facilities, documentation of appropriate clinical information and coordination of services between the two facilities.
Documentation of any unplanned discharges without advance notice and any discharges against the Licensed Behavioral Health Professional's advice.
Information regarding any serious injury sustained while in the PRTF to the member or by the member and details describing the circumstances by which the injury occurred.
Information regarding a member’s death and details of the circumstances by which the death occurred.
Dates, times and circumstances of unauthorized leave.
Documentation of detention dates.
Treatment entries that are signed and dated by the person providing treatment, including title or position of the person providing treatment. 8.765.6.B. All members of the Clinical Staff shall be trained annually in the development and review of Plans of Care and the details of this training shall be documented. 8.765.6.C. Records shall be kept in a secure location at the PRTF. 8.765.6.D. Data, including claims data, shall be retained for six years unless there is a written statutory requirement or regulation available from a county, state or federal agency requiring a longer retention period. 8.765.6.E. Clinical records shall be retained for six years after the member’s 21st birthday. 8.765.6.F. The PRTF shall comply with the following requirements for the use of Restraint and Seclusion:
Personal, Mechanical and Drugs Used as Restraint shall be ordered only by a physician, physician’s assistant or nurse practitioner.
An order for Restraint or Seclusion shall not be written as a standing order or on an as-needed basis.
Restraint and Seclusion shall not result in harm or injury to the member and shall be used only to ensure the safety of the member or others during an Emergency Safety Situation and only until the Emergency Safety Situation has ceased.
Restraint and Seclusion shall not be used simultaneously.
A Personal Restraint when a member is in a Prone Position is prohibited.
If the order for Restraint or Seclusion is verbal, it shall be received by a registered nurse, licensed practical nurse or physician’s assistant.
The Restraint or Seclusion shall be carried out by Clinical Staff who are trained in the use of emergency safety intervention.
Only a physician, registered nurse, licensed practical nurse or physician’s assistant shall administer a Drug Used as a Restraint.
Clinical Staff trained in the use of emergency safety interventions that are physically present during the Restraint or Seclusion shall monitor the member during the Restraint or Seclusion period.
Each order for Restraint or Seclusion shall never:

a. Exceed the duration of the emergency safety situation; and b. Exceed four hours in length for youth ages 18 to 21; two hours in length for members ages nine to 17; or one hour in length for members under the age of nine.

Within one hour of the initiation of the Emergency Safety Intervention a physician, registered nurse or physician’s assistant shall conduct a faceto-face assessment of the physical and psychological well-being of the member. A psychologist may conduct the face-to-face assessment if done in conjunction with a physician, registered nurse or physician’s assistant.
The PRTF shall notify the parent(s) or legal guardian(s) of a member who has been restrained or secluded as soon as possible, but not to exceed 24 hours, after the initiation of each emergency safety intervention and shall document the date and time of this notification in the member’s record.
Within 24 hours of the use of Restraint or Seclusion, staff involved in an Emergency Safety Intervention and the member shall have a face-to-face discussion. This discussion shall include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the well-being of the member. Other staff and the member’s parent or guardian may participate in the discussion, if appropriate.
Within 24 hours after the use of Restraint or Seclusion, all staff involved in the Emergency Safety Intervention, and appropriate supervisory and administrative staff, shall conduct a debriefing session that includes, at a minimum, a review and discussion of:

a. The situation that required the intervention, including a discussion of the precipitating factors that led up to the intervention.

b. Alternative techniques that may have prevented the use of the Restraint or Seclusion.

c. New procedures implemented to mitigate any recurrence of the use of Restraint or Seclusion.

d. The outcome of the intervention, including any injuries that may have resulted from the use of Restraint or Seclusion.

8.765.6.G CRITICAL INCIDENT & SERIOUS OCCURRENCE REPORTING

CRITICAL INCIDENT REPORTING

a. All critical incidents must be reported to the Department of Health Care Policy and Financing for Medicaid members only, with nonmember information being anonymized. Critical incidents are defined in accordance with 12 C.C.R. 2509-8: 7.701.2 (2025), which is incorporated herein by reference. The incorporation of this

Section excludes later amendments to, or editions of, the issuer at chromeextension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.sos.stat e.co.us/CCR/GenerateRulePdf.do?ruleVersionId=11977&fileName =12%20CCR%202509-8.

b. Providers must follow all critical incident reporting and timing requirements as set forth at 12 CCR 2509-8: 7.701.52 (2025), which is incorporated herein by reference. The incorporation of this

c. In the event of a conflict between the federal and state timing requirement for reporting, the earlier timeframe controls.

SERIOUS OCCURRENCE REPORTING

a. All serious occurrences, as defined under 42 C.F.R. § 483.374, must be reported to the Department of Health Care Policy and Financing regardless of the individual’s Medicaid status. 42 C.F.R.§ 483.374 is incorporated herein by reference. The incorporation of this Section excludes later amendments to, or editions of, the issuer at https://www.ecfr.gov/current/title-42/chapter- IV/subchapter-G/part-483/subpart-G/section-483.374.

b. Providers must also follow all serious occurrence reporting and timing requirements under 42 C.F.R. § 483.374, as well as all other reporting and timing requirements that may be applicable regarding restraint and seclusion under Colorado and federal law.

c. In the event of a conflict between the federal and state timing requirements for reporting, the earlier timeframe controls. 8.765.7 REIMBURSEMENT FOR PRTFs 8.765.7.A. A PRTF shall be reimbursed a per diem rate as determined and approved by the Department. 8.765.7.B. The Department shall recover the per diem reimbursement when:

Each service is not documented in the treatment record at the frequency specified in the Plan of Care.
There is no Plan of Care in the record, for the period of time claims were paid.
Records are requested but not provided with 21 calendar days. 8.765.7.C. A PRTF may appeal the Department’s recovery actions within 30 calendar days from the date on the notice. The appeal shall be submitted in accordance with Section 8.050. 8.765.7.D. Portions of the PRTF Rule pertaining to payment and approvals for treatment are applicable only when the Department is the funding source.

8.765.8 OUT-OF-STATE HIGH-INTENSITY RESIDENTIAL TREATMENT

(OHIRT) COVERED SERVICES 8.765.8.A. OHIRT benefit shall include services as identified in the Plan of Care as well as other services necessary for the care of the member in the facility. These services include, but are not limited to:

Individual therapy.
Group therapy.
Family, or conjoint, therapy conducted with the member present, unless member contact with family members is contraindicated.
Emergency services.
Medication Management Services.
Room and Board.

8.765.9 OHIRT NON-COVERED SERVICES 8.765.9.A. The following are not covered in an OHIRT:

The day of discharge.
Leave days.
Days when the member is in detention.

8.765.10 DEPARTMENT-FUNDED OHIRT: MEMBER ELIGIBILITY 8.765.10.A. To receive benefits in an OHIRT, the member shall:

Be between the ages of three and twenty-one.
Be certified to need OHIRT level of care by an Independent Team. The Team shall certify that:

a. Ambulatory care resources available in the community do not meet the treatment needs of the member.

b. Proper treatment of the member’s behavioral condition requires services on an inpatient basis under the direction of a physician.

c. The services can reasonably be expected to improve the member’s behavioral health or prevent further regression so that the services shall no longer be needed.

Have an ESA supporting OHIRT or PRTF as the medically necessary 8.765.10.B. The member shall not be eligible to receive services when:
The member is no longer able to benefit from the service or is no longer progressing towards goals.
The member is absent without leave in excess of 24 consecutive hours or has been removed from the facility and placed in non-OHIRT services.
The Interdisciplinary Team determines that the member has attained treatment goals.
An ESA determines OHIRT or PRTF is not, or is no longer, the proper 5. Admission of minors not in the custody of a County Department of Human/Social Services or DHS as a result of commitment to the Division of Youth Corrections shall be subject to the requirements set forth at C.R.S. § 27-65-103. 8.765.10.C. Initial Authorization and Prior Authorization Requirement 1. For children receiving behavioral health services in an Out-of-State High- Intensity Residential Treatment (OHIRT) and funded by the Department, the ESA will determine behavioral health medical necessity for initial 2. Ongoing OHIRT services may require Prior Authorization.

8.765.11 OHIRT PROVIDER ELIGIBILITY 8.765.11.A. All OHIRT Providers shall have an Interdisciplinary Team.

The Interdisciplinary Team shall include either a board-certified psychiatrist, or a clinical psychologist who has a doctoral degree, a physician licensed to practice medicine or osteopathy, and one of the a. A licensed clinical social worker, licensed marriage and family therapist or licensed professional counselor.

b. A registered nurse with specialized training or one year's experience in treating individuals with behavioral health conditions.

c. A certified occupational therapist with specialized training or one year’s experience in treating individuals with behavioral health conditions; or d. A licensed psychologist.

The Interdisciplinary team shall:

a. Assess the member's immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities.

b. Assess the potential resources of the member and member’s family.

c. Develop and implement a comprehensive, individualized written d. Set treatment objectives.

e. Prescribe therapeutic modalities to achieve the objectives of the 8.765.11.B. All OHIRT providers shall implement a Plan of Care. 8.765.11.C. An initial Plan of Care shall be developed within 72 hours of the member’s admission and shall address the immediate and emergency needs of the member. 8.765.11.D. A comprehensive Plan of Care shall:

Be completed within 14 days of admission.
Be signed and dated by the member, the Referring Party or the legal guardian/parent, and the Licensed Behavioral Health Professional.
Address clinical and other needs including the member's presenting problems, physical health, emotional status, behavior, support system in the community, available resources and discharge plan.
Include specific goals and measurable objectives, expected dates of 5. Specify the type, frequency and duration of all OHIRT services necessary to meet the needs of the member and to treat the member’s current 6. Identify the provision of or the referral for services other than OHIRT 7. Be readily identifiable and be maintained in the member’s record.
Document any court-ordered treatment including identifying the agency responsible for providing the court-ordered treatment.
Include revisions to the Plan of Care at least monthly, or sooner if appropriate. 8.765.11.E. The OHIRT shall designate a Licensed Behavioral Health Professional to act as a case manager for each member to oversee the formulation, implementation, review and revision to the Plan of Care. 8.765.11.F. The Licensed Behavioral Health Professional shall sign and date the Plan 8.765.11.G. The OHIRT shall ensure the member and/or legal guardian participate in the formulation, review and revision of the Plan of Care. If the member or legal guardian is unable to participate or when his or her participation is clinically contraindicated, the OHIRT shall document the reasons in the member's record.

Any decision to not involve the family or guardian shall be approved by the Referring Party. In addition, other persons selected by the member, the family or guardian, the Referring Party or the Licensed Behavioral Health Professional may be included in the formulation, review and revision of the Plan of Care. 8.765.11.H Except in cases of emergency, all OHIRT services in the Plan of Care shall be provided. 8.765.11.I. The OHIRT shall ensure that physician prescribed information is used for the component of the Plan of Care requiring Medication Management Services. 8.765.11.J. The OHIRT shall ensure all members and/or guardians are aware of the complaint and grievance procedures. 8.765.11.K. The OHIRT shall ensure all members and/or guardians are aware of the OHIRT policies regarding Restraint and Seclusion in accordance with 42 C.F.R. §§ 483.350-376 (2024), which is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 303 E. 17 Avenue, Suite 1100, Denver, Colorado 80203. Incorporated materials may also be obtained from the original issuer starting at https://www.ecfr.gov/current/title- 42/chapter-IV/subchapter-G/part-483/subpart-G/section-483.350. 8.765.11.L. The OHIRT shall facilitate access to necessary medical care and shall be responsible for coordinating behavioral health treatment with medical treatment. 8.765.11.M. Member Transfers:

A member shall be transferred only to the care of another OHIRT or placement facility when adequate arrangements for care have been made by the Referring Party.
The member and the legal guardian shall be given a minimum of 24 hours notice before the member is transferred unless this notice is waived by the Referring Party or legal guardian in writing or if an emergency condition exists.
Transfers shall be documented in the clinical record. 8.765.11.N. OHIRT Licensure and Certification Requirements.
The OHIRT shall:

a. Be accredited by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children.

b. Provide an attestation to the Department that the OHIRT is in compliance with the condition of participation for Restraint and Seclusion as described in Sections 8.765.12.F and 8.765.11.K.

c. Be licensed as a residential facility for persons under 21.

d. Shall meet all other license and certification requirements for a residential facility serving persons under 21 in the state in which it is located.

An OHIRT that has more than one physical address shall have a separate Medicaid provider number for each facility. 8.765.11.O. OHIRT Requirements to Notify and Involve the Regional Accountable Entity (RAE) or Managed Care Organization (MCO)
By close of business on the day following placement, the provider will notify the member’s RAE or MCO of the placement.
The provider will notify the RAE or MCO and the Department of emergent transfers or changes of placement of any member by close of business on the day following transfer.
The provider will notify the RAE or MCO and the Department of any plans to transfer the member to another placement or facility as soon as possible.
To the extent possible, the provider will include the RAE or MCO in ongoing care planning and discharge planning for the duration of the member’s treatment at the provider’s facility.

8.765.12 OHIRT PROVIDER RESPONSIBILITIES 8.765.12.A. An OHIRT must maintain an organized, legible, chronological, current treatment record for each member. Treatment records shall include:

Admission information such as the member’s personal information and demographic data, source of referral, most current Diagnostic Statistical Manual diagnosis and substance abuse history.
Documentation of the member’s legal status, including but not limited to guardianship, conservatorship, court orders, custody, certifications, advisement and consent.
Copies of all Assessments.
All Plans of Care and revisions.
Documentation of member’s attendance at, participation in, and outcomes of OHIRT Services.
Documentation that the member and/or the legal guardian was provided with a copy of the Plan of Care.
Correspondence to and from agencies and individuals involved in the member’s treatment.
An explanation whenever any member of the Interdisciplinary Team, member, parent or guardian, when appropriate, does not sign a Plan of Care.
The name of the Licensed Behavioral Health Professional responsible for the formulation, implementation, review, and revision of the member’s 10. Within 30 consecutive days of the discharge from the OHIRT, a discharge report summarizing treatment received and outcomes.
For transfers between facilities, documentation of appropriate clinical information and coordination of services between the two facilities.
Documentation of any unplanned discharges without advance notice and any discharges against the Licensed Behavioral Health Professional's advice.
Information regarding any serious injury sustained to the member or by the member while in the OHIRT and details describing the circumstances by which the injury occurred.
Information regarding a member’s death and details of the circumstances by which the death occurred.
Dates, times, and circumstances of unauthorized leave.
Documentation of detention dates.
Treatment entries that are signed and dated by the person providing treatment, including title or position of the person providing treatment. 8.765.12.B. All members of the Clinical Staff shall be trained annually in the development and review of Plans of Care and the details of this training shall be documented. 8.765.12.C. Records shall be kept in a secure location at the OHIRT. 8.765.12.D. Data, including claims data, shall be retained for six years unless there is a written statutory requirement or regulation available from a county, state or federal agency requiring a longer retention period. 8.765.12.E. Clinical records shall be retained for six years after the member’s 21st birthday. 8.765.12.F. The OHIRT shall comply with the following requirements for the use of Restraint and Seclusion:
Personal, Mechanical and Drugs Used as Restraint shall be ordered only by a physician, physician’s assistant or nurse practitioner.
An order for Restraint or Seclusion shall not be written as a standing order or on an as-needed basis.
Restraint and Seclusion shall not result in harm or injury to the member and shall be used only to ensure the safety of the member or others during an Emergency Safety Situation and only until the Emergency Safety Situation has ceased.
Restraint and Seclusion shall not be used simultaneously.
A Personal Restraint when a member is in a Prone Position is prohibited.
If the order for Restraint or Seclusion is verbal, it shall be received by a registered nurse, licensed practical nurse or physician’s assistant.
The Restraint or Seclusion shall be carried out by Clinical Staff who are trained in the use of emergency safety intervention.
Only a physician, registered nurse, licensed practical nurse, or physician’s assistant shall administer a Drug Used as a Restraint.
Clinical Staff trained in the use of emergency safety interventions that are physically present during the Restraint or Seclusion shall monitor the member during the Restraint or Seclusion period.
Each order for Restraint or Seclusion shall never:

Within one hour of the initiation of the Emergency Safety Intervention a physician, registered nurse, or physician’s assistant shall conduct a faceto-face assessment of the physical and psychological well-being of the member. A psychologist may conduct the face-to-face assessment if done in conjunction with a physician, registered nurse, or physician’s assistant.
The OHIRT shall notify the parent(s) or legal guardian(s) of a member who has been restrained or secluded as soon as possible, but no more than 24 hours after the initiation of each emergency safety intervention and shall document the date and time of this notification in the member’s record.
Within 24 hours of the use of Restraint or Seclusion, staff involved in an Emergency Safety Intervention and the member shall have a face-to-face discussion. This discussion shall include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the well-being of the member. Other staff and the member’s parent or guardian may participate in the discussion, if appropriate.
Within 24 hours after the use of Restraint or Seclusion, all staff involved in the Emergency Safety Intervention, and appropriate supervisory and administrative staff, shall conduct a debriefing session that includes, at a minimum, a review and discussion of:

a. The situation that required the intervention, including a discussion of the precipitating factors that led up to the intervention.

b. Alternative techniques that may have prevented the use of the Restraint or Seclusion.

c. New procedures implemented to mitigate any recurrence of the use of Restraint or Seclusion.

d. The outcome of the intervention, including any injuries that may have resulted from the use of Restraint or Seclusion.

8.765.13. CRITICAL INCIDENT & SERIOUS OCCURRENCE REPORTING

8.765.13.A. CRITICAL INCIDENT REPORTING

All critical incidents must be reported to the Department of Health Care Policy and Financing for Medicaid members only, with non-member information being anonymized. Critical incidents are defined in accordance with 12 C.C.R. 2509-8: 7.701.2 (2025), which is incorporated herein by reference. The incorporation of this Section excludes later amendments to, or editions of, the referenced material. Pursuant to C.R.S. § 24-4- 103(12.5), the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at:

Colorado Department of Health Care Policy and Financing, 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at chrome- 2. Providers must follow all critical incident reporting and timing requirements as set forth at 12 CCR 2509-8: 7.701.52 (2025), which is incorporated herein by reference. The incorporation of this Section excludes later amendments to, or editions of, the referenced material. Pursuant to C.R.S. § 24-4-103(12.5), the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at chrome- 3. In the event of a conflict between the federal and state timing requirement for reporting, the earlier timeframe controls.

8.765.13.B. SERIOUS OCCURRENCE REPORTING

All serious occurrences, as defined under 42 C.F.R. § 483.374, must be reported to the Department of Health Care Policy and Financing regardless of the individual’s Medicaid status.
Providers must also follow all serious occurrence reporting and timing requirements under 42 C.F.R. § 483.374, as well as all other reporting and timing requirements that may be applicable regarding restraint and seclusion under Colorado and federal law. .In the event of a conflict between the federal and state timing requirements for reporting, the earlier timeframe controls. 8.765.14 REIMBURSEMENT FOR DEPARTMENT-FUNDED OHIRTs 8.765.14.A. An OHIRT shall be reimbursed a per diem rate as determined approved by the Department. 8.765.14.B. The Department shall recover the per diem reimbursement when:
Each service is not documented in the treatment record at the frequency specified in the Plan of Care.
There is no Plan of Care in the record for the period of time claims were paid.
Records are requested but not provided with 21 calendar days, 4. For any other reason authorized by state and federal statutes and regulations. 8.765.14.C. An OHIRT may appeal the Department’s recovery actions within 30 calendar days from the date on the notice. The appeal shall be submitted in accordance with Section 8.050.

8.765.15 BEHAVIORAL HEALTH BENEFITS FOR MEMBERS IN AN RCCF 8.765.15.A. Family therapy shall not exceed maximum of one service unit per day.

Family therapy without the member present may be provided at a maximum of one service unit per week if treatment is documented in the Plan of Care that member contact with family members is contraindicated.

Family Therapy without the member present shall be for the specific benefit of the member. 8.765.15.B. Individual therapy shall not exceed two service units per day. 8.765.15.C. Group therapy shall not exceed eight service units per day. 8.765.15.D. A Licensed Behavioral Health Professional may authorize family, individual and group therapy in excess of maximum service units per day if the following is documented in the Plan of Care:

The reason for the additional therapy.
How many additional units are necessary.
How long the additional therapy is necessary. 8.765.15.E. The Licensed Behavioral Health Professional shall re-authorize therapy in excess of the maximum service units per day in the Plan of Care at least every 30 days. 8.765.15.F. Beginning July 1, 2022, only services rendered under Early and Periodic Screening, Diagnosis and Treatment in accordance with Section 8.280 are a covered RCCF benefit.

8.765.16 NON-COVERED BENEFITS FOR MEMBERS IN AN RCCF 8.765.16.A. The following benefits are not covered for members in an RCCF:

Court-ordered treatment that is not otherwise medically indicated;
Room and board services;
Educational, vocation and job training services;
Recreational or social activities;
Habilitative care for children who have intellectual or developmental disabilities; and 6. Services provided by public institutions or institutions for behavioral health conditions.

8.765.17 MEMBER ELIGIBILITY FOR BEHAVIORAL HEALTH SERVICES IN AN

RCCF 8.765.17.A. To be eligible for behavioral health services delivered in an RCCF the member shall:

Be between the ages of three and 21 years of age.
Have a current, and valid assessment or evaluation completed by a Licensed Behavioral Health Professional that supports medical necessity for behavioral health services, and demonstrates which services the member would benefit from.

8.765.18 ELIGIBILITY FOR PROVIDERS DELIVERING SERVICES IN AN RCCF 8.765.18.A Individual, group and family therapy provided in an RCCF shall be provided by a Licensed Behavioral Health Professional or a provisionallylicensed Behavioral Health Professional supervised by a Licensed Behavioral Health Professional, employed by or contracted with an RCCF that is licensed by the Colorado Department of Human Services. 8.765.18.B. Licensed Behavioral Health Professionals providing behavioral health services to members in an RCCF are exempt from the direct physician supervision requirement in Section 8.200.2.A through E. 8.765.18.C. Licensed Behavioral Health Professionals providing behavioral health services to members in the RCCF enroll as Medicaid rendering providers.

8.765.19 RCCF RESPONSIBLITIES 8.765.19.A. The RCCF shall include the following in the member’s record:

Any clinical Assessments;
Member’s Medicaid Eligibility Determination Form; and 3. Member’s diagnoses, characteristics and presenting problem. 8.765.19.B. The RCCF shall transmit the items listed in Section 8.765.19.A. to the Referring Party 8.765.19.C. The RCCF shall designate a Licensed Behavioral Health Professional to act as a case manager for behavioral health services for each member. 8.765.19.D. The Licensed Behavioral Health Professional shall maintain an organized, legible, chronological, current record on each member. 8.765.19.E. The member’s Plan of Treatment for behavioral health services shall be integrated into the agency’s comprehensive Plan of Care reviewed by the Multidisciplinary Team. The Plan of Care shall:
Be signed and dated by the member, the Referring Party and the Licensed Behavioral Health Professional and the parent/guardian.
Include an initial plan developed prior to the onset of behavioral health services that needs of the member.
Address behavioral health and other needs including the member's presenting problems, physical health, emotional status, behavior, support system in the community, available resources and discharge plan.
Include specific goals and measurable objectives, expected dates of 5. Specify all behavioral health services necessary to meet the needs of the member and to treat the member’s current diagnosis while the member is in the RCCF.
Identify the provision of or the referral for services other than behavioral health services.
Be readily identifiable and be maintained in the member’s record.
Document any court-ordered behavioral health services including identifying the agency responsible for providing the court-ordered 9. Be reviewed by the Multidisciplinary Team monthly and revised as needed. 8.765.19.F. Except in cases of emergency, all behavioral health services indicated in the Plan of Care shall be provided.

8.765.20 REIMBURSEMENT FOR BEHAVIORAL HEALTH SERVICES IN A

RCCF 8.765.20.A. Reimbursement for Behavioral Health Services in a RCCF shall be the lower of billed charges or the maximum unit rate of reimbursement. Beginning July 1, 2022, RCCF services will not be reimbursable unless provided under Early and Periodic Screening, Diagnosis and Treatment in accordance with

Section 8.280. 8.765.20.B. The RCCF shall enroll as a Medicaid provider for the purposes of acting as a billing entity for Licensed Behavioral Health Professionals providing behavioral health services in the RCCF.

8.765.21 QUALIFIED RESIDENTIAL TREATMENT PROGRAM (QRTP)

8.765.21.A DEPARTMENT-FUNDED QRTP: CLIENT ELIGIBILITY

Children up to age eighteen (18) years old and for those persons up to twenty-one (21) years old who consent to the placement or are placed by court order, for whom an Enhanced Standardized Assessment determines that the child’s needs cannot be met in a less restrictive, family- based setting because of their serious emotional or behavioral disorders or disturbances.
For children receiving behavioral health services in a Qualified Residential Treatment Program (QRTP) and funded by the Department, the ESA will determine behavioral health medical necessity for initial treatment.
Prior Authorization may be necessary for ongoing QRTP services.

8.765.21.B QRTP AND PROVIDER ELIGIBILITY

Beginning October 1, 2021, to be eligible for Colorado Medicaid reimbursement, a QRTP must:

a. Be enrolled with Colorado Medicaid;

b. Be licensed by the Colorado Department of Human Services (CDHS), Provider Services Unit (PSU), as a Child Care Facility with QRTP indicated as the Service Type in accordance with CDHS regulations;

c. Be accredited by:

i. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), ii. The Commission on Accreditation of Rehabilitation Facilities (CARF), iii. The Council on Accreditation of Services for Families and Children, or iv. Any other independent, not-for-profit accrediting organization approved by the Secretary of Health and Human Services.

d. Submit an attestation form to the Department with the facility’s Colorado Medicaid enrollment application with Colorado Medicaid that attests:

i. The facility has no more than sixteen (16) beds, including all beds at a single address or on adjoining properties regardless of program or facility type;

ii. The facility does not share a campus with a Psychiatric Residential Treatment Facility (PRTF);

iii. For facilities more than one (1) mile but less than ten (10) miles apart by road from another overnight facility controlled by the same ownership or governing body, the other overnight facility meets the following criteria:

The facility maintains its own license;
The facility has dedicated staff that ensures a stable treatment environment;
Residents do not move between the facility and another during the episode of care iv. For facilities less than one (1) mile apart, but not on the same campus or adjoining properties, the QRTP is in a home-like structure (cottage, house, apartment) located farther than 750 feet from another overnight facility within a community setting that includes publicly used infrastructure (roads, parks, shared spaces, etc.).
Provider Qualifications.

a. The rendering provider for the following services must be an enrolled Licensed Behavioral Health Professional in a QRTP:

i. Individual therapy, ii. Group therapy, and iii. Family therapy.

8.765.21.C PROVIDER RESPONSIBILITIES 1 All critical incidents must be reported to the Department of Health Care Policy and Financing (Department) for Medicaid members only, with nonmember information being anonymized. Critical incidents are defined in accordance with 12 C.C.R. 2509-8:7.701.2 which is incorporated herein by reference. The incorporation of this Section excludes later amendments to, or editions of, the referenced material. Pursuant to C.R.S. § 24-4- 103(12.5), the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at:

Colorado Department of Health Care Policy and Financing, 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at chrome- 2. Providers must follow all critical incident reporting and timing requirements when reporting to the Department, in accordance with 12 C.C.R. 2509-8: 7.701.52, which is incorporated herein by reference. The incorporation of this Section excludes later amendments to, or editions of, the referenced material. Pursuant to C.R.S. § 24-4-103(12.5), the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 303 E. 17th Avenue, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at chrome- 3. QRTP Requirements to Notify and Involve the Regional Accountable Entity (RAE) or Managed Care Organization (MCO)

a. By close of business on the day following placement, the provider will notify the member’s RAE or MCO of the placement.

b. The provider will notify the RAE or MCO and the Department of emergent transfers or changes of placement, of any member, by close of business on the day following transfer.

c. The provider will notify the RAE or MCO and the Department of any plans to transfer the member to another placement or facility as soon as possible.

d. To the extent possible, the provider will include the RAE or MCO in ongoing care planning and discharge planning for the duration of the member’s treatment at the provider’s facility.

8.765.21.D COVERED SERVICES

Medically necessary services pursuant to Section 8.076.1.8 that are not excluded in Section 8.765.21.D and are:

a. Included in the member’s stabilization plan created by the QRTP in accordance Colorado Department of Human Services (CDHS) regulations.

b. Included in the member’s individual child and family plan created by the QRTP in accordance with CDHS regulations.

c. Included in the member’s discharge and aftercare plan created by the QRTP in accordance with CDHS regulations.

All EPSDT services not specified in Sections 8.765.21.D.1 are covered under Section 8.280.

8.765.21.E NON-COVERED SERVICES

The following services are not covered for members in a QRTP:

a. Room and board;

b. Educational, vocational, and job training services;

c. Recreational or social activities; and d. Services provided to inmates of public institutions or residents of Institutions of Mental Disease (IMD).

8.765.21.F DEPARTMENT-FUNDED QRTP SERVICES: PRIOR AUTHORIZATION

REQUIREMENTS

An ESA affirming the need for QRTP level of care is required for initial 2. Prior authorization may be required for ongoing treatment at this level of care.

8.765.21.G REIMBURSEMENT

QRTPs are reimbursed a per diem rate, as determined by the Department, if the following conditions are fulfilled:

a. Rendered services are documented in the treatment record at the frequencies specified in the member’s care plan(s);

b. A care plan(s) is on record for the time period reported in the reimbursement claim; and c. The care meets professionally recognized standards for care in a QRTP.

QRTPs must enroll as a Colorado Medicaid provider to act as a billing entity for Licensed Behavioral Health Professionals rendering behavioral health services in the QRTP.
Portions of the QRTP rule pertaining to payment and approvals for treatment are applicable only when the Department is the funding source.

8.770 ABORTION SERVICES

Effective January 1, 2026: 8.770.1. Member Eligibility 8.770.2.A. All Health First Colorado enrolled members are eligible. 8.770.2. Provider Eligibility 8.770.3.A. All Health First Colorado enrolled providers are eligible to perform abortion services when it is within their scope of practice. 8.770.3. Covered Services 8.770.4.A. Abortion services, including but not limited to related surgical procedures and medications, are covered for all pregnant persons and service coverage is included as a family planning-related service in accordance with C.R.S. § 25.5-4- 412 and C.R.S. § 25.5-5-329. 8.770.4.B. A provider who is licensed by the state and acting within the scope of the provider’s license and in accordance with applicable law may be reimbursed for abortion services. 8.770.4. Prior Authorization Requirements (PAR) 8.770.4.A. Prior authorization is not required for this service. 8.799 Community Health Workers/Community Representatives 8.799.1. DEFINITIONS 8.799.1.A. Community Health Worker (CHW) means a frontline public health worker who serves as a liaison between health-care providers or social service providers and community members in order to facilitate access to physical, behavioral, or dental health-related services, or services to address social determinants of health, and who improves the quality and cultural responsiveness of healthrelated service delivery. Community Health Worker is meant to be an umbrella term for individuals who meet this definition but may go by many names, such as health promoters, community outreach workers, promotores de salud, health navigators, and patient navigators. 8.799.1.B. Community Health Representative (CHR) is an individual who holds a CHR credential issued by a tribe in accordance with the Indian Health Care Improvement Act at 25 U.S.C. § 1616.

8.799.2. PURPOSE 8.799.2.A. Community Health Worker/Community Health Representative (CHW/CHR) services are provided as preventative health services to prevent disease, disability, and other health conditions or their progression, to prolong life, and to promote physical and behavioral health and efficiency.

8.799.3. MEMBER ELIGIBILITY 8.799.3.A. All Colorado Medicaid members are eligible for CHW/CHR services.

Community Health Worker services must be recommended by a physician or other licensed practitioner of the healing arts acting within their scope of authorized practice under State law.

8.799.4. PROVIDER REQUIREMENTS 8.799.4.A. Enrolled providers who provide CHW services must be on the Colorado Department of Public Health and Environment (CDPHE) CHW/CHR registry and complete one of the following four pathways:

Colorado Training Pathway a. Participate in and successfully complete a CDPHE recognized Community Health Worker Training Program; and b. Complete and pass the state Community Health Worker Assessment.
Work Experience Pathway a. Must have 2,000 hours (one year of Full Time Equivalency of Community Health Worker experience) within the past 5 years;

i. Requirements for work experience documentation include:

Complete documentation showing examples of work experience aligning with each of Colorado’s Core Community Health Worker Competencies as defined by CDPHE;
Signature or attestation from at least one supervisor on this documentation;
Signature attesting the individual meets and will continue to comply with National CHW Ethical Standards.

b. After review and approval of work experience by CDPHE, the individual must complete and pass the state Community Health Worker Assessment.

Community Heath Representative Pathway a. Community Health Representatives (CHRs) in tribal communities that are placed on the Community Health Worker registry, based on their current training; and b. Current and future CHRs that complete the application to be on Colorado’s Community Health Worker registry via the appropriate online platform and have had the relevant CHR training reviewed by CDPHE, will be eligible for reimbursement.
Reciprocity Pathway a. If credentialed in another state that has reciprocity with Colorado and placed on the CDPHE Community Health Worker registry, the CHW/CHR is eligible for reimbursement.

8.799.5. COVERED SERVICES 8.799.5.A. Health Promotion and Coaching:

Provides information and training to members that enables them to make positive contributions to their health status.
Health Promotion and Coaching includes:

a. Screening for health-related social needs;

b. Setting goals;

c. Creating an action plan; and d. Providing information and/or coaching. 8.799.5.B. Health Education and Training:

Trains and/or increases the member’s awareness of methods and measures that have been proven effective in avoiding illness and/or lessening its effects.
The content of education must be consistent with established or recognized health care standards. 8.799.5.C. Health System Navigation and Resource Coordination:
Includes:

a. Helping to engage, or re-engage, in routine preventive care, or ensure member-led follow-up in primary care;

b. Adherence to treatment plans; and/or c. Assist in self-management of chronic conditions, including assisting members to access covered services and other community resources necessary to promote health, address health care carriers, and health related social needs.

8.799.6. SERVICE LIMITATIONS 8.799.6.A. One unit is equal to 30 minutes. Members are eligible for up to 4 units per day and 16 units per month.

8.799.7. PRIOR AUTHORIZATION 8.799.7.A. There are no prior authorization requirements for CHW/CHR services. ______________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.800 MEDICAL ASSISTANCE - SECTION 8.800 Pharmaceuticals, Podiatry Services, Immunization Services {#sec-10-ccr-2505-10-8.800 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.800}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE - SECTION 8.800 PHARMACEUTICALS, PODIATRY SERVICES, IMMUNIZATION SERVICES 10 CCR 2505-10 8.800 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

8.800 PHARMACEUTICALS

8.800.A DEFINITIONS

340B Pharmacy means any pharmacy that participates in the Federal Public Health Service Act section 340B Drug Pricing Program as described in 42 U.S.C. § 256b (2023), which is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This statute is available for public inspection at the provide certified copies of the material incorporated at cost upon request or shall state, another state, or the organization or association originally issuing the code, 2. Average Acquisition Cost (AAC) means the average acquisition cost for like drugs grouped by Generic Sequence Number (GSN). For GSNs with both generic and brand drugs, the Department shall determine two separate AAC rates for the GSN. One AAC rate shall be based on the average acquisition cost for all generic drugs while the other shall be based on the average acquisition cost for all brand drugs.
Clotting Factor Maximum Allowable Cost (CFMAC) means the rate for a clotting factor drug for which no Average Acquisition Cost (AAC) rate is established. The CFMAC rate is determined based on available acquisition cost data and publicly available data unique to each clotting factor drug.
Conflict of Interest means having conflicting professional or personal obligations or personal or financial interests that would make it difficult, or appear to make it difficult to fulfill duties in an unbiased manner.
Department means the Colorado Department of Health Care Policy and Financing.
Dispensing Fee means the reimbursement amount for costs associated with filling a prescription. Costs include salary costs, pharmacy department costs, facility costs, and other costs.
Dispensing Prescriber means a health care professional who, as licensed by Colorado state law, prepares, dispenses, and instructs members to selfadminister medication.
Drug Class means drugs that are grouped together due to a common mechanism of action, or to treat a particular disease, symptom, or indication.
Emergency Situation means any condition that is life threatening or requires immediate medical intervention as determined in good faith by the pharmacist.
E-prescription means the transmission of a prescription through an electronic application.
Fiscal agent means a contractor that supports and operates the pharmacy benefit management system on behalf of the Medical Assistance Program.
Federal Upper Limit (FUL) means the upper limit for multiple source drugs as set by the Centers for Medicare and Medicaid Services pursuant to 42 C.F.R. § 447.512-515 (2023), which is hereby incorporated by reference into this rule.

Such incorporation, however, excludes later amendments to or editions of the referenced material. This statute is available for public inspection at the provide certified copies of the material incorporated at cost upon request or shall state, another state, or the organization or association originally issuing the code, 13. Generic Sequence Number (GSN) means a standard number to group together drugs that have the same ingredients, route of administration, drug strength, and dosage form.

Good Cause for purposes of terminating the appointment of any P&T Committee member means failing to disclose a Conflict of Interest; participating in wrongdoing or misconduct in the case of serving as a member of a committee or other advisory body for the Department; failing to perform required duties; or missing two scheduled meetings per calendar year.
Government Pharmacy means any pharmacy whose primary function is to provide drugs and services to members of a facility whose operating funds are appropriated directly from the State of Colorado or the federal government excluding pharmacies funded through Indian Health Services.
Institutional Pharmacy means any pharmacy whose primary function is to provide drugs and services to hospitalized patients and others receiving health care provided by the facility with which the pharmacy is associated.
Mail Order Pharmacy means any pharmacy that delivers drugs primarily by mail.
Maintenance Medication means any drug, as determined by the Department, which is used to treat a chronic illness or symptoms of a chronic illness.
Maximum Allowable Cost (MAC) means a rate that is calculated using an adjustment of the national pricing benchmark Wholesale Acquisition Cost (WAC).
Medical Assistance Program is a program of Medical Assistance as defined in § 25.5-1-103(5), C.R.S. (2023).
Medical Assistance Program Allowable Charge means the allowed ingredient cost plus a dispensing fee or the provider’s Usual and Customary Charge, whichever is less, minus the member’s copayment as determined according to

Section 8.754.

Medical Director means the physician or physicians who are employed by the Department to provide medical direction.
Medicare Part D means the prescription drug benefit provided to Part D-eligible individuals pursuant to the Medicare Prescription Drug, Improvement and Modernization Act of 2003, as codified at 42 U.S.C. § 1395w-101, et seq.
Medicare Part D Drugs means drugs defined at 42 U.S.C. § 1395w-102(e) (2023) and 42 C.F.R. § 423.100 (2023), which are hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This statute is available for public inspection at the provide certified copies of the material incorporated at cost upon request or shall state, another state, or the organization or association originally issuing the code, 25. National Average Drug Acquisition Cost (NADAC) is a Centers for Medicare and Medicaid Services published rate which represents the national average of the drug acquisition costs submitted by retail community pharmacies.
Non-preferred Drug means a drug that is designated as non-preferred by the Medical Director pursuant to Section 8.800.16.A and which requires prior authorization to be payable by the Medical Assistance Program.
Old Age Pension Health Care Program and Old Age Pension Health Care Supplemental Program (OAP State Only) means the program established pursuant to § 25.5-2-101 to provide necessary medical care for clients that qualify for Old Age Pension but do not qualify for the Medical Assistance Program pursuant to Title XIX of the Social Security Act and Colorado statutes.
Over-the-Counter (OTC) means a drug that is appropriate for use without the supervision of a health care professional such as a physician, and which can be purchased by a consumer without a prescription.
Part D eligible individual has the same meaning as defined in Section 8.1000.1.
Pharmacy and Therapeutics Committee (P&T Committee) means an advisory board that shall perform reviews and make recommendations which facilitate the development and maintenance of the Preferred Drug List as described in Section 8.800.17.
Preferred Drug means a drug that is designated preferred by the Medical Director pursuant to Section 8.800.16.A, that is payable by the Medical Assistance Program without first obtaining a prior authorization unless otherwise required to protect the health and safety of specific members.
Preferred Drug List (PDL) means a list which identifies the Preferred Drugs and Non-preferred Drugs within a drug class that is applicable only to fee-for-service and primary care physician Medical Assistance Program members.
Prescriber means a healthcare professional licensed pursuant to Colorado state law who may prescribe and authorize the use of medicine or treatment to a member. Prescribers must be enrolled in the Medical Assistance Program to receive reimbursement.
Provider Bulletin means a document published and distributed by the Department program and policy staff to communicate information to providers related to the Medical Assistance Program.
Retail Pharmacy means any pharmacy that is not a 340B Pharmacy, Government Pharmacy, Institutional Pharmacy, Mail Order Pharmacy, or Rural 36. Rural Pharmacy means any pharmacy that is the only pharmacy within a twentymile radius.
Serious Mental Illness means the following psychiatric illnesses: bipolar disorders (hypomanic, manic, depressive, and mixed), depression in childhood and adolescence, major depressive disorders (single episode or recurrent), obsessive-compulsive disorders (single or recurrent), paranoid and other psychotic disorders, schizoaffective disorders (bipolar or depressive), and schizophrenia.
Serious or Complex Medical Condition is defined as one of the following medical conditions: Serious Mental Illness, cancer, epilepsy, multiple sclerosis, or HIV/AIDS, or a condition requiring medical treatment to avoid death, hospitalization, or a worsening or advancing of disease progression resulting in significant harm or disability.
Step Therapy means a protocol that requires a member to use a prescription drug or sequence of prescription drugs, other than the drug that the member’s Prescriber recommends for the member’s treatment, before the Department provides coverage for the recommended prescription drug.
Submitted Ingredient Cost means a pharmacy’s calculated ingredient cost. For drugs purchased through the Federal Public Health Service’s 340B Drug Pricing Program, the Submitted Ingredient Cost means the 340B purchase price.
Total Prescription Volume means all new and refill prescriptions dispensed for all payer types. Payer types include but are not limited to Medicaid, Medicare, commercial, third-party, and uninsured.
Usual and Customary Charge means the reimbursement amount the provider charges the general public to pay for a drug.
Wholesale Acquisition Cost (WAC) means with respect to a drug or biological, the manufacturer’s list price for the drug or biological to wholesalers or direct purchasers in the United States, not including prompt pay or other discounts, rebates, or reductions in price, for the most recent month for which the information is available, as reported in wholesale price guides or other publications of drug or biological pricing data.

8.800.2 CONDITIONS OF PARTICIPATION 8.800.2.A. A pharmacy must be licensed or certified by the appropriate regulatory body in the state in which it is located. Pharmacies located outside of Colorado must also be registered in Colorado if required by the Colorado Board of 8.800.2.B. Any pharmacy or Dispensing Prescriber, whether in-state or out-of-state, that submits claims for reimbursement must be enrolled in the Medical Assistance program in accordance with Sections 8.040.1 and 8.013.1. The Department may deny a provider application, and the Department may terminate or not renew a provider agreement in accordance with Sections 8.076, 8.125, and 8.130. 8.800.2.C. An out-of-state pharmacy may enroll as a Medical Assistance Program provider subject to the same conditions of participation as an in-state pharmacy.

8.800.3 MAIL ORDER 8.800.3.A. Only Maintenance Medications may be delivered through the mail.

8.800.4 DRUG BENEFITS 8.800.4.A. Only those drugs designated by companies participating in the federally approved Medical Assistance Program drug rebate program and not otherwise excluded according to these rules are regular drug benefits. Notwithstanding the foregoing, drugs not covered by rebate agreements may be reimbursed if the Department has made a determination that the availability of the drug is essential, such drug has been given an “A” rating by the U. S. Food and Drug Administration (FDA), and a prior authorization has been approved. Prescribed drugs not covered by rebate agreements may also be reimbursed if approved for importation by the FDA when medically necessary for drug shortages, if approved by the FDA under emergency use authorization, if available over-thecounter (OTC), or if non-traditional prescribed products such as insect repellant.

Reimbursement of any drugs that are regular drug benefits may be restricted as set forth in these rules. 8.800.4.B. Pursuant to 42 U.S.C. 1396r-8 (d)(2), certain drugs or classes of drugs may be excluded from coverage or may be subject to restrictions.

The following are covered with restrictions:

a. Agents when used for weight gain;

b. Agents when used for the symptomatic relief of cough and colds;

c. Prescription vitamin and mineral products, except prenatal vitamins and fluoride, for documented deficiency, d. Non-prescription Drugs; and e. Selected prescribed drugs that are not covered outpatient drugs.

Such prescribed drugs may include OTC nutritional supplements, drugs approved by the FDA under emergency use authorization (EUA), FDA-approved imported drugs, and non-traditional prescribed products such as insect repellant.

The following are excluded from coverage:

a. Agents when used for anorexia or weight loss; b Agents when used to promote fertility;

c. Covered outpatient drugs that the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee; and d. Agents used for the treatment of sexual or erectile dysfunction unless such agents are used to treat a condition, other than a sexual or erectile dysfunction, for which the agents have been approved by the FDA. 8.800.4.C. The following are not pharmacy benefits of the Medical Assistance Program:

Spirituous liquors of any kind;
Dietary needs or food supplements;
Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap of any kind, dentifrices, etc.;
Medical supplies;
Drugs classified by the FDA as "investigational" or "experimental”.
Less-than-effective drugs identified by the Drug Efficacy Study Implementation (DESI) program; and 7. Medicare Part D Drugs for Part D eligible individuals.
Agents when used for cosmetic purposes or hair growth. 8.800.4.D. Aspirin, OTC insulin and medications that are available OTC and that have been designated as Preferred Drugs on the PDL are the only OTC drugs that are regular benefits without restrictions. Nonprescription drugs prescribed for a medically accepted indication in the following classes may be covered: aspirin; cough and cold or allergy preparations consisting of antihistamines, analgesics/antipyretics, cough suppressants, decongestants, and expectorants or combinations thereof; doxylamine; emergency contraceptives; contraceptives; intranasal corticosteroids; ; laxatives; opioid antagonists; pain relievers; proton pump inhibitors; select vitamin and mineral products; smoking cessation preparations. 8.800.4.E. Restrictions may be placed on drugs in accordance with Title 42 of the United States Code, Section 1396r-8(d)(2020). Title 42 of the United States Code, Section 1396r-8(d)(2020) is hereby incorporated by reference into this

rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This statute is available for public inspection at the Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Pursuant to C.R.S. §24-4-103(12.5)(V)(b), the agency shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, 1. Without limiting the foregoing, restrictions may be placed on drugs for which it has been deemed necessary to address instances of fraud or abuse, potential for, and history of, drug diversion and other illegal utilization, overutilization, other inappropriate utilization or the availability of more cost-effective comparable alternatives. 8.800.4.F. To the extent the drug categories listed in Section 8.800.4.B are not Medicare Part D Drugs, they shall be covered for Part D eligible individuals in the same manner as they are covered for all other eligible Medical Assistance Program members. 8.800.4.G. Generic drugs shall be dispensed to members in fee-for-service programs unless:

Only a brand name drug is manufactured.
A generic drug is not therapeutically equivalent to the brand name drug.
The final cost of the brand name drug is less expensive to the Department.
The drug is in one of the following exempted classes for the treatment of:

a. Mental Illness;

b. Cancer;

c. Epilepsy; or d. Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome.

The Department shall grant an exception to this requirement if:

a. The member has been stabilized on a medication and the treating physician, or a pharmacist with the concurrence of the treating physician, is of the opinion that a transition to the generic equivalent of the brand name drug would be unacceptably disruptive; or b. The member is started on a generic drug but is unable to continue treatment on the generic drug.

c. Such exceptions shall be granted in accordance with procedures established by the Department.

8.800.5 DRUGS ADMINISTERED OR PROVIDED IN PHYSICIAN OFFICES OR

CLINICS 8.800.5.A. Extended-release injectable drugs which treat mental health or substance use disorders, and are administered in a pharmacy, physician’s office, or clinic, may be considered part of the physician services benefit and billed on the physician claim form; such drugs may also be considered a pharmacy benefit and billed by a pharmacy. Any other drugs administered in a physician's office or clinic are considered part of the physician's services benefit only and are not a pharmacy benefit. 8.800.5.B. Dispensing Prescribers whose offices or sites of practice are located within 25 miles from the nearest participating pharmacy shall not be reimbursed for drugs or services that are dispensed from their offices.

8.800.6 COMPOUNDED PRESCRIPTIONS 8.800.6.A. Compounded prescriptions shall be billed by submitting all ingredients in the prescription as one multiple-line claim. The provider will be reimbursed for each ingredient of the prescription according to Section 8.800.13.A-G, and will also be reimbursed for the dispensing fee according to Section 8.800.13.H-I. A compounding fee, over and above the stated dispensing fee, will not be paid.

8.800.7 PRIOR AUTHORIZATION REQUIREMENTS 8.800.7.A. Prior authorization shall be obtained before drugs that are subject to prior authorization restrictions may be provided as a benefit. Prior authorization requests may be made by the member’s physician, any other health care provider who has authority under Colorado law to prescribe the medication being requested, or any long-term-care pharmacy or infusion pharmacy that fills prescriptions on behalf of the member and is acting as the agent of the prescriber. The prior authorization request shall be made to the Fiscal Agent. The prescriber shall provide any information requested by the Fiscal Agent including, but not limited to, the following:

Member name, Medical Assistance Program state identification number, and birth date;
Name of the drug(s) requested;
Strength and quantity of drug(s) requested; and 4. Prescriber’s name and medical license number, Drug Enforcement Administration number, or National Provider Identifier. 8.800.7.B. When the prior authorization request is received, it shall be reviewed to determine if the request is complete. If it is complete, the requesting provider shall be notified of the approval or denial of the prior authorization request via telephone and/or facsimile at the time the request is made, if possible, but in no case later than 24 hours after the request is made. If the prior authorization request is incomplete or additional information is needed, an inquiry to the party requesting the prior authorization shall be initiated within one working day from the day the request was received. If no response is received from that party within 72 hours of the Department’s inquiry, the prior authorization shall be denied. 8.800.7.C. In an emergency situation, the pharmacy may dispense up to a 72-hour supply of a covered drug that requires a prior authorization if it is not reasonably possible to request a prior authorization for the drug before it must be dispensed to the member for proper treatment. The pharmacist may call the prior authorization help desk to receive override approval. Prescriptions dispensed under the override approval are eligible for reimbursement.

8.800.7.D. PRIOR AUTHORIZATION FOR NEW DRUGS

If a new drug entity, including new generic drugs and new drug product dosage forms of existing drug entities, is approved by the FDA and is in a Drug Class already subject to prior authorization, the new drug entity may be subject to prior authorization without any comment period.

a. If it is a new drug entity that is subject to the PDL, the prior authorization criteria for that new drug entity shall remain in effect until the applicable Drug Class is reviewed by the Drug Utilization Review (DUR) Board.

b. If it is a new drug entity that is not subject to the PDL, the prior authorization criteria shall remain in effect until the new drug entity is reviewed by the DUR Board, which shall be completed within six months.

If a new drug entity, including new generic drugs and new drug product dosage forms of existing drug entities, is approved by the FDA and is not in a Drug Class already subject to prior authorization, the new drug entity may be subject to prior authorization and will be reviewed by the DUR board within six months.
The Department shall conduct preliminary coverage reviews for a new drug entity indicated for the treatment of Serious Mental Illness within 90 days of FDA approval. 8.800.7.E. Any changes to the drugs that are subject to prior authorization, or any documentation required to obtain a prior authorization shall be published in the Provider Bulletin, Appendix P or PDL. Notification in the Provider Bulletin,

Appendix P or PDL shall satisfy any notification requirements of any such changes. The Appendix P and PDL documents may be accessed on the Department’s website at www.colorado.gov/hcpf. 8.800.7.F The Department shall review a request and determine if an exception to Step Therapy is granted if the Prescriber submits a prior authorization request with justification and supporting clinical documentation for the treatment of a Serious or Complex Medical Condition that meets the criteria set forth in § 25.5- 4- 428.

8.800.8 LIMIT REQUIREMENTS 8.800.8.A. Limits shall include a limit on the number of units of a drug that a member may receive in a 30-day or 100-day period, as applicable. Limits placed on the coverage of any drugs under the Medical Assistance Program shall result in pharmaceutical services still being sufficient in the amount, duration and scope to meet all applicable federal laws and regulations. 8.800.8.B. The Department shall solicit and maintain a list of any interested parties who wish to comment on any proposed limits on drugs. The list of interested parties shall be notified of any proposal and shall be given reasonable time, not to exceed 30 days, to comment or recommend changes before any such drugs are limited. Notwithstanding the foregoing, if a new drug is approved by the FDA and that drug is in a class of drugs already subject to limits, the new drug shall also be subject to limits without any comment period. 8.800.8.C. Any limits on drugs or changes to the drugs that are subject to limits shall be published in the Provider Bulletin. Notification in the Provider Bulletin shall satisfy any notification requirements of any such limits or changes to the limits.

8.800.9 DRUG UTILIZATION REVIEW

8.800.9.A. PROSPECTIVE DRUG UTILIZATION REVIEW

A pharmacist shall review the available member record information with each drug order presented for dispensing for purposes of promoting therapeutic appropriateness by considering the following:

a. Over-utilization or under-utilization;

b. Therapeutic duplication;

c. Drug-disease contraindications;

d. Drug-drug interactions;

e. Incorrect drug dosage or duration of drug treatment;

f. Drug-allergy interactions; and g. Clinical abuse/misuse.

When in the pharmacist's professional judgment a potential problem is identified, the pharmacist shall take appropriate steps to avoid or resolve the problem, which may, if necessary, include consultation with the prescriber.

8.800.9.B. MEMBER COUNSELING

A pharmacist or pharmacist designee shall offer drug therapy counseling to each Medical Assistance Program member or the caregiver of such member with a new prescription or with a refill prescription if the pharmacist or pharmacist designee believes that it is in the best interest of the member. The offer to counsel shall be face-to-face communication whenever practicable or by telephone.
If the offer to counsel is accepted, a pharmacist or pharmacist designee shall review the member’s record and then discuss with the member or the member’s caregiver those matters that, in the exercise of his or her professional judgment, the pharmacist or pharmacist designee considers significant including the following:

a. The name and description of the drug;

b. The dosage form, dose, route of administration, and duration of drug therapy;

c. Intended use of the drug and expected action;

d. Special directions and precautions for preparation, administration, and use by the member;

e. Common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, including their avoidance, and the action required if they occur;

f. Techniques for self-monitoring drug therapy;

g. Proper storage;

h. Prescription refill information; and i. Action to be taken in the event of a missed dose.

Alternative forms of member information shall not be used in lieu of the personal discussion requirement for member counseling but may be used to supplement this discussion when appropriate. Examples of such alternative forms of member information include written information leaflets, auxiliary or pictogram labels, and video programs.
Member counseling by a pharmacist or pharmacist designee as described in this section shall not be required for members of a hospital or institution where other licensed health care professionals administer the prescribed drugs pursuant to a chart order.
A pharmacist or pharmacist designee shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided.

8.800.9.C. RETROSPECTIVE DRUG UTILIZATION REVIEW

The Department shall periodically review claims data in order to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among physicians, pharmacists and members receiving drug benefits or associated with specific drugs or categories of drugs.
Such reviews shall be based on predetermined criteria that monitor for therapeutic problems including but not limited to therapeutic appropriateness, over-utilization, under-utilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, and clinical abuse/misuse.

8.800.9.D. DRUG UTILIZATION REVIEW (DUR) BOARD

The DUR Board shall serve in an advisory capacity to the Department.

The DUR Board’s activities shall include but are not limited to the following:

a. Approving the application of standards;

b. Conducting retrospective DUR;

c. Conducting ongoing interventions with pharmacists and physicians concerning therapy problems identified in the course of the DUR program;

d. Making recommendations regarding certain Department policy issues as determined by the Department; however, the Department shall consider all such recommendations but shall not be bound by them; and e. Engaging in any other activities as designated by the Department.

The DUR Board shall meet at least quarterly.
The DUR Board shall consist of eight members appointed by the Executive Director of the Department based upon recommendations of relevant professional associations. Membership on the Board shall consist of four physicians and four pharmacists, all of whom are licensed and actively practicing in Colorado. The physicians and pharmacists shall serve two-year terms and may be reappointed to additional terms at the discretion of the Executive Director. The terms shall be staggered so that in each year, there are two physician members and two pharmacist positions that are reappointed.
The membership of the DUR Board shall include health care professionals who have recognized knowledge and expertise in one or more of the following:

a. The clinically appropriate prescribing of covered outpatient drugs;

b. The clinically appropriate dispensing and monitoring of outpatient drugs;

c. Drug utilization review, evaluation and intervention; or d. Medical quality assurance.

The DUR Board shall have those responsibilities as set forth in Title 42 of the Code of Federal Regulations, Section 456.716(d)(2024). Title 42 of the Code of Federal Regulations, Section 456.716(d)(2024) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This statute is available for public inspection at the Department of Health Care Policy and Financing, 303 E. 17th Ave.,, Denver, CO 80203. Pursuant to C.R.S. §24-4-103(12.5)(V)(b), the agency shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule.
The DUR Board is also responsible for preparing and submitting a report to the Department on an annual basis which shall include the following information:

a. A description of the activities of the DUR Board, including the nature and scope of the prospective and retrospective drug utilization review programs;

b. A summary of the interventions used;

c. An assessment of the impact of these educational interventions on quality of care; and d. An estimate of the cost savings generated as the result of the program.

The DUR Board under the direction of the Department may delegate to a retrospective DUR contractor the responsibility of preparation of continuing education programs, the conduct of interventions and the preparation of any reports.

8.800.10 BILLING PROCEDURES 8.800.10.A. Charges for prescribed drugs shall be submitted on an appropriate pharmacy claim form or electronically in a Department approved format. All entries shall be legible. 8.800.10.B. Each claim must identify the member, Prescriber, date of service, National Drug Code number of the drug actually dispensed, prescription number, quantity dispensed, days’ supply, the Usual and Customary Charge and any other information required by the Department.

8.800.11 PRESCRIPTION RECORD REQUIREMENTS 8.800.11.A. The original prescription shall be a hard copy written, faxed or electronically mailed or otherwise transmitted by the prescriber or reduced to writing by pharmacy staff when received by telephone. All information required by the Colorado State Board of Pharmacy shall appear on each prescription including any information required if a substitution for a drug is made. All refill information shall be recorded in accordance with the Colorado State Board of Pharmacy requirements. 8.800.11.B. All records for new prescriptions and refills for which payment from the Medical Assistance Program is requested shall be maintained in accordance with Colorado State Board of Pharmacy requirements except that such records must be retained for the length of time set forth in Section 8.040.2. 8.800.11.C. The pharmacist shall be responsible for assuring that reasonable efforts have been made to obtain, record, and maintain the following member information from the member or his/her apparent agent for each new prescription:

Name, address, telephone number, date of birth or age, and gender;
Individual history where significant, including disease state or states, known allergies and drug reactions, and a comprehensive, chronological list of medications and prescribed relevant devices; and 3. Additional comments relevant to the member's pharmaceutical care as described in the Prospective Drug Review and Member Counseling sections set forth in Section 8.800.9.

8.800.11.D. TAMPER-RESISTANT PRESCRIPTION DRUG PADS OR PAPER

The use of tamper-resistant prescription drug pads or paper is required for all written or electronically printed prescriptions for all Medical Assistance Program members when:

a. Prescriptions are issued for outpatient drugs, including controlled and uncontrolled substances, or OTC drugs that are reimbursable through the Medical Assistance Program and dispensed by a pharmacy; and b. The Medical Assistance Program is the primary or secondary payer of the prescription being filled.

To be considered tamper-resistant, the pad/paper used for a written or electronically printed prescription shall integrate three distinct characteristics. The three characteristics and the specific features required are as follows:

a. Characteristic #1: One or more industry-recognized features designed to prevent unauthorized copying of completed or blank prescription form. A prescription shall contain at least one of the following features:

i) Void/Illegal/Copy Pantograph with or with the Reverse Rx feature. The word “Void”, “Illegal”, or “Copy” appears when the prescription is photocopied. If the paper has the Reverse Rx feature, the Rx symbol must disappear when photocopied at light setting. The Reverse Rx feature is not allowed as a feature by itself.

ii) Micro-fine printed security message generated by a computer, electronic medical records system or other electronic means. The message may serve as a signature line or border. This must be printed in 0.5 font or smaller and readable when viewed at 5x magnification or greater and illegible when copied.

iii) Coin-reactive ink or security mark. The pad or paper identifies an area on the pad/paper where the ink changes color or reveals wording or a picture when that area is rubbed by a coin. This must be accompanied by a message describing what is necessary to demonstrate authenticity.

iv) Security print watermark. Specific wording is printed on the front or back of the prescription paper and can only be seen when viewed at an angle.

v) Paper with a watermark. This is paper that contains a watermark that can be seen when backlit.

b. Characteristic #2: One or more industry recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber. A prescription shall contain at least one of the following features:

i) An erasure-revealing background. This is a background that consists of a non-white solid color or consistent pattern that has been printed onto the paper. If an erasure or modification is attempted, the background will show marks or the color of the underlying paper where the alterations were made.

ii) Toner fusing technology for laser-printed prescriptions. This is a treatment that is added to the surface of the paper to create a strong bond between the laser-printed text and the paper. The computer-printed information cannot be lifted from the surface of the paper without damaging the paper.

iii) Chemical-reactive paper. This is paper that contains features that show discoloration or reveals a hidden message if solvents are used to attempt to wash the ink from its surface.

iv) Plain bond paper combined with inkjet-printing. The inkjet printing is absorbed into the high grade paper stock.

Erasures and modifications cannot be made without damaging the paper.

v) Pre-printed quantity check-off boxes indicated in ranges of no more than 25 per range combined with a written quantity.

The range box corresponding to the quantity prescribed must be checked by the prescriber for the prescription to be valid.

vi) Pre-printed refill indicator where the number of refills allowed is marked or no refills or “NR” is marked when no refills are authorized. Refill information must be completed by the prescriber for the prescription to be valid.

vii) Characters surrounding the authorized dispensing quantity and the number of refills. Special characters such as a series of asterisks must be repeated on both sides of the numbers indicating the quantity and the number of refills authorized (e.g., Quantity 50 Refill 3). This is acceptable only for prescriptions that are generated by a computer, electronic medical records system or other electronic means.

c. Characteristic #3: One or more industry recognized features designed to prevent the use of counterfeit forms. A prescription must contain at least one of the following features:

i) Security features listed visibly in a box, band or border on the prescription. This must be a complete listing of all of the security features incorporated into the prescription pad/paper in order to minimize tampering.

ii) Security threads. Metal, fluorescent or plastic security threads are embedded into the prescription pad/paper.

iii) Thermochromic ink. All or some of the pad or paper is preprinted with ink that changes color when exposed to heat and then changes back to its original color when cooled.

This must be accompanied by a message describing what is necessary to demonstrate authenticity.

The use of tamper-resistant prescription pads or paper is not required when:

a. Prescriptions are transmitted by telephone, fax or E-prescription directly to the pharmacy by the prescriber or prescriber’s staff that is authorized to act on the prescriber’s behalf; or b. A prescriber administers or provides the drug directly to the member; or c. A prescriber in an institutional setting writes the order into the medical record and then the order is given by medical staff directly to the pharmacy; or d. A Medical Assistance Program managed care entity pays for or dispenses the prescription; or e. A prescription is written for any medical item, service or equipment that is not considered an outpatient drug; or f. A drug that is provided as part of, or as incident to and in the same setting as, any of the following (and for which payment may be made as part of payment for the following and not as direct reimbursement for the drug):

i) Inpatient hospital services;

ii) Hospice services;

iii) Dental services (except when a State Plan authorizes direct reimbursement to the dispensing dentist);

iv) Physician services;

v) Outpatient hospital services;

vi) Nursing facilities and intermediate care facilities for the mentally retarded;

vii) Other laboratory and x-ray services; or viii) Renal dialysis.

The pharmacy may dispense up to a 72-hour supply of a covered outpatient prescription drug in an emergency situation, provided that the pharmacy obtains a compliant prescription in writing, or by telephone, facsimile, or E-prescription, within 72 hours of filling the prescription.
When a Medical Assistance Program member is determined retroactively eligible after a pharmacy has filled the recipient’s prescription, the prescription shall be deemed to comply with the tamper-resistant pad/paper requirements. This presumption applies only to prescriptions that were filled before the member was determined eligible. Prescriptions that are filled or refilled after the member is determined eligible require a new, tamper-resistant prescription or the pharmacy may obtain verbal confirmation of the prescription from the prescriber or may obtain the prescription from the prescriber by facsimile or E-prescription.

8.800.11.E. PRESCRIPTION TRACKING AND CLAIM REVERSALS

The pharmacy shall keep:

a. A chronological log that contains the member’s name, his or her signature or agent’s signature and date of the receipt of the prescription; or b. An electronic prescription tracking system that records the status of prescriptions through the fill process including the date and time that the prescription was transferred to a person whom pharmacy personnel verified was the member or agent of the member.

c. The requirements in subsections (a) and (b) are waived for the duration of a public health emergency as declared by the Governor.

Pharmacies using a chronological log shall review all Medical Assistance Program prescriptions in shall-call status (filled but not released to the member or the member’s agent) at least weekly and enter a reversal of prescriptions not picked up within 14 days of billing. In no case shall prescriptions be kept in shall-call status for more than 21 days. The pharmacy shall maintain a record of each reversal for audit purposes.
Pharmacies using an electronic prescription tracking system shall review all Medical Assistance Program prescriptions in shall-call status on a daily

basis and enter a reversal of prescriptions not picked up within 10 days of billing. In no case shall prescriptions be kept in shall-call status for more than 14 days. The pharmacy shall maintain a record of each reversal for audit purposes.

Upon receipt of a written request from the Department or the Medicaid Fraud Unit for a record of Medical Assistance Program claims and reversals, the pharmacy has up to 72 hours or three working days to provide the requested information or to enter into an agreement with the Department or Unit stating the specific time within which the data shall be produced. 8.800.11.F. Any information, documents or records required to be retained under

Section 8.800.11 shall be made available for inspection to authorized personnel of the Department, U.S. Department of Health and Human Services or the Medicaid Fraud Control Unit.

8.800.12 BASIS FOR REIMBURSEMENT 8.800.12.A. Reimbursement shall be made for prescribed drugs provided to members when all of the following conditions are met:

The item dispensed is a covered benefit under the Medical Assistance Program and meets any and all restriction requirements as set forth in

Section 8.800 or any policies thereunder;

The person prescribing the item is licensed to do so under applicable law;

a. A pharmacist licensed in the state of Colorado may prescribe the over-the-counter (OTC) medications listed on the Department’s Pharmacist OTC Prescriptive Authority List which shall be posted on the Department’s website.

b. A pharmacist prescribing and dispensing OTC medications shall comply with the rules set forth by the Colorado State Board of 3. The item is dispensed pursuant to a valid prescription order;

The prescription is dispensed in accordance with applicable federal and state laws, rules, and regulations, including those regulations governing the Medical Assistance Program; and 5. The prescription is written on a tamper-resistant prescription drug pad or paper or is excluded from the tamper-resistant prescription drug pad or paper requirements set forth in Section 8.800.11.D.

8.800.13 REIMBURSEMENT CALCULATION 8.800.13.A. Covered drugs for all members except for OAP State Only clients shall be reimbursed the lesser of:

The Usual and Customary Charge minus the member’s copayment, as determined according to Section 8.754; or 2. The allowed ingredient cost plus a Dispensing Fee minus the member’s copayment, as determined according to Section 8.754.
Covered drugs for the OAP State Only Program shall be reimbursed according to Section 8.941.9. 8.800.13.B. The allowed ingredient cost for Retail Pharmacies, Rural Pharmacies, 340B Pharmacies, Institutional Pharmacies, Government Pharmacies and Mail Order Pharmacies shall be the lesser of AAC, NADAC, MAC, or Submitted Ingredient Cost.
The Department shall grant an exception to the allowed ingredient cost for clotting factor which shall be the lesser of AAC or Submitted Ingredient Cost. If AAC is not available, the allowed ingredient cost shall be the lesser of Clotting Factor Maximum Allowable Cost (CFMAC) or Submitted Ingredient Cost. 8.800.13.C. MAC rates shall be calculated as follows:
The generic drug MAC rate shall be WAC minus 22 percent.
The brand name drug MAC rate shall be WAC minus 4 percent. 8.800.13.D. AAC rates shall be rebased monthly using invoices and/or purchase records provided to the Department through a representative group of pharmacies. If the Department cannot establish a process to obtain invoices and/or purchase records on a monthly basis, the Department shall survey onefourth (1/4) of all Medicaid enrolled pharmacies every quarter to rebase AAC rates.
Notwithstanding Section 8.800.13.D, AAC rates for clotting factor drugs shall be rebased at least biannually. 8.800.13.E. A pharmacy wanting to inquire about a listed AAC rate shall complete the Average Acquisition Cost Inquiry Worksheet posted on the Department’s website. The pharmacy shall email the completed worksheet with a copy of the receipt invoice to the Department or designated vendor as indicated on the Average Acquisition Cost Inquiry Worksheet. The Department shall have five (5) days to provide an inquiry response to the pharmacy. If the AAC rate requires revision, the Department shall then have 5 additional days to update the AAC rate. 8.800.13.F. To address weekly fluctuations in drug prices, the Department shall apply a percent adjustment to existing AAC rates for drugs experiencing significant changes in price. The percent adjustment shall be determined using weekly changes in price based on national pricing benchmarks. Every week, the Department shall post an updated AAC price list, with the adjusted AAC rates, on the Department’s website (www.colorado.gov/hcpf). A percent adjustment shall only be applied to an AAC rate until the Department can rebase the rate through the process discussed in Section 8.800.13.D. 8.800.13.G. Any pharmacy, except a Mail Order Pharmacy, that is the only pharmacy within a twenty- mile radius may submit a letter to the Department requesting the designation as a Rural Pharmacy. 8.800.13.H. Dispensing Fees shall be determined based upon reported dispensing costs provided through a Cost of Dispensing (COD) survey. The Dispensing Fees for Retail Pharmacies, 340B Pharmacies, Institutional Pharmacies and Mail Order Pharmacies shall be tiered based upon annual Total Prescription Volume.

The Dispensing Fees shall be tiered at:

Less than 60,000 total prescriptions filled per year = $13.40 2. Between 60,000 and 90,000 total prescriptions filled per year = $11.49 3. Between 90,000 and 110,000 total prescriptions filled per year = $9.93 4. Greater than 110,000 total prescriptions filled per year = $8.72 8.800.13.I. The designation of a pharmacy’s Dispensing Fee shall be updated annually. Every October, the Department shall contact a pharmacy requesting the completion of an attestation letter stating the pharmacy’s Total Prescription Volume for the period September 1 to August 31. A pharmacy shall have until October 31 to provide the completed attestation letter to the Department. Using the attestation letter, the Department shall update a pharmacy’s Dispensing Fee effective January 1. A pharmacy failing to provide the Department an attestation letter on or before October 31, regardless of their previous Dispensing Fee, shall be reimbursed the $8.72 Dispensing Fee. 8.800.13.J. The Department shall determine the Dispensing Fee for a pharmacy enrolling as a Medicaid provider based on the pharmacy’s Total Prescription Volume. During the enrollment process, a pharmacy shall provide the Department an attestation letter stating their Total Prescription Volume for the previous twelve (12) months. Using the attestation letter, the Department shall determine the pharmacy’s Dispensing Fee effective upon approval of enrollment.

A pharmacy failing to provide the Department an attestation letter during the enrollment process shall be reimbursed the $8.72 Dispensing Fee. The Dispensing Fee shall be used until it can be updated the following year in accordance with Section 8.800.13.I.

If a pharmacy has been open for less than 12 months, the Department shall annualize the Total Prescription Volume to determine the pharmacy’s 2. If a pharmacy is new and possesses no Total Prescription Volume history to annualize, then the pharmacy shall provide a good faith estimate of their expected Total Prescription Volume. 8.800.13.K. In November of each year, the Department shall compare a pharmacy’s Total Prescription Volume and Medicaid percent provided with the attestation letter to their Medicaid claims data. If the Department identifies any inconsistencies, the Department shall request a pharmacy to provide documentation that substantiates their Total Prescription Volume for the period September 1 to August 31 within thirty (30) days. If the Department determines that the pharmacy incorrectly reported their Total Prescription Volume, the pharmacy shall be reimbursed at the correct tier based on their actual Total Prescription Volume. If a pharmacy does not provide the documentation to the Department within the 30 days, the pharmacy shall be reimbursed the $8.72 8.800.13.L. The tiered Dispensing Fee shall not apply to Government Pharmacies which shall instead be reimbursed a $0.00 Dispensing Fee. 8.800.13.M. The tiered Dispensing Fee shall not apply to Rural Pharmacies which shall instead be reimbursed a $14.14 Dispensing Fee. 8.800.13.N. Dispensing Prescribers who dispense medications that are reimbursed as a pharmacy benefit pursuant to Section 8.800 shall be reimbursed a $1.89 8.800.13.O. Reimbursement for clotting factor drugs that are reimbursed at AAC or Submitted Ingredient Cost shall include an enhanced professional dispensing fee, in addition to the usual professional dispensing fee as defined in Section 8.800.13.H.
The enhanced professional dispensing fee for clotting factor drugs shall be $0.03 per drug unit. 8.800.13.P. Effective January 1, 2026, reimbursement for Parenteral Nutrition that is reimbursed at the allowed ingredient cost as described in Section 8.800.13.B must include an enhanced professional dispensing fee, in addition to the usual professional dispensing fee as defined in Section 8.800.13.H 1. The enhanced professional dispensing fee for parenteral nutrition is $73.21 per claim.

8.800.14 PRESCRIPTION QUANTITIES 8.800.14.A. For chronic conditions requiring maintenance drugs, the maximum dispensing quantities for new and refill prescriptions shall be a 100-day supply.

For all other drugs, the maximum dispensing quantities for new and refill prescriptions shall be a 30-day supply. The Department may set or change minimum or maximum dispensing quantities of certain drugs.

8.800.15 REIMBURSEMENT FROM PHARMACIES REDISPENSING UNUSED

MEDICATION 8.800.15.A. A pharmacy participating in the Medical Assistance Program may accept unused medication from a hospital, hospital unit, hospice, nursing care facility, or assisted living residence that is required to be licensed pursuant to Section 25-3- 101, C.R.S. (2016), or a licensed health care provider for the purpose of dispensing the medication to another person. 8.800.15.B. A pharmacy shall reimburse the Department for the Medical Assistance Program Allowable Charge that the Department has paid to the pharmacy if medications are returned to a pharmacy and the medications are available to be dispensed to another person.

8.800.16 PREFERRED DRUG LIST

8.800.16.A. ESTABLISHING THE PREFERRED DRUG LIST

To develop and maintain the PDL, the Department shall take the following steps:

a. Determine which drugs and Drug Classes shall be reviewed for inclusion on the PDL.

b. Refer selected drugs and Drug Classes to the P&T Committee for clinical reviews performed without consideration of drug costeffectiveness. The P&T Committee shall make recommendations pursuant to 10 C.C.R. 2505-10, Section 8.800.17.C.

c. Make recommendations to the Medical Director based on evaluations of relevant criteria, including but not limited to:

i) Drug safety;

ii) Drug efficacy;

iii) The recommendations of the P&T Committee;

iv) Public comments received by the Department before a drug or Drug Class is reviewed at the relevant P&T Committee meeting;

v) Cost-effectiveness; and vi) Scientific evidence, standards of practice and other relevant drug information for such evaluation.

After the P&T Committee meets, the Medical Director shall review the recommendations of the P&T Committee and the Department and determine whether a reviewed drug is designated a Preferred Drug or a Non-preferred Drug.
After the Medical Director has designated a reviewed drug as Preferred or Non-preferred, the Department shall refer that drug to the DUR Board for recommendations on prior authorization criteria.
After the DUR Board meets, the Medical Director shall review the recommendations of the P&T Committee, the DUR Board and the Department and determine the efficacy, safety and appropriate prior authorization criteria for Preferred and Non-preferred Drugs to ensure the health and safety of members.
The Department shall provide public notice of PDL updates at least ten days before such changes take effect.
Drug Classes included on the PDL shall be reviewed at least annually.

8.800.16.B. NEW DRUGS

Notwithstanding any other provision of this section, a new drug entity, including new generic drugs and new drug product dosage forms of existing drug entities, in a Drug Class already included on the PDL.

a. Shall be subject to a preliminary evaluation by the Department within 30 days from when the drug is available on the market; and b. The Department shall designate the new drug as Preferred or Nonpreferred upon completion of the preliminary evaluation.

The Preferred or Non-preferred designation for a new drug shall continue until the relevant Drug Class is reviewed and the designation is changed pursuant to Section 8.800.16.A.
New drug prior authorization information is addressed in Section 8.800.7.D.

8.800.16.C. EXCLUSION OF DRUGS, DRUG CLASSES OR INDIVIDUALS FROM

THE PDL

The following exclusions are intended to promote good health outcomes and clinically appropriate drug utilization and to protect the most vulnerable Medical Assistance Program members.
After reviewing the recommendations of the P&T Committee and the Department, the Medical Director may, notwithstanding any other provision of this section and to the extent allowed by federal and state law:

a. Exclude drugs or Drug Classes from consideration for inclusion on the PDL.

b. Determine continuity of care protocols that exempt Medical Assistance Program members stabilized on specified Non-preferred Drugs from prior authorization requirements.

c. Exclude specific Medical Assistance Program populations from prior authorization requirements for all Non-preferred Drugs.

Individual Medical Assistance Program members shall be exempted, on an annual basis, from prior authorization requirements for all Nonpreferred Drugs if:

a. A member meets clinical criteria recommended by the Department and P&T Committee and approved by the Medical Director; and b. A member’s physician submits a request for exemption and meets the criteria for approval.

8.800.16.D. AUTHORITY OF THE EXECUTIVE DIRECTOR

The decisions of the Medical Director, made under the authority of this

section, shall be implemented by the Department at the sole discretion of the Executive Director.

If the Medical Director position is unfilled, the duties and obligations of that position, as described in this section, shall be performed by the Executive Director.

8.800.16.E. SUPPLEMENTAL REBATES

The Department may enter into supplemental rebate agreements with drug manufacturers for Preferred Drugs. The Department may contract with a vendor and/or join a purchasing pool to obtain and manage the supplemental rebates.

8.800.17 PHARMACY AND THERAPEUTICS COMMITTEE

8.800.17.A. MEMBERSHIP

The P&T Committee shall consist of at least five members, but not more than nine members, appointed by the Executive Director.

a. The P&T Committee membership shall include:

i) Four pharmacists;

ii) One member representative; and iii) Four physicians.

b. Physicians and pharmacists must be licensed and actively practicing in the State of Colorado while a member of the P&T Committee.

c. The Department shall solicit recommendations for P&T Committee members from professional associations, member advocacy groups and other Medical Assistance Program stakeholders.

d. The P&T Committee may meet and conduct business when at least any five members are appointed to the P&T Committee. A majority of the appointed P&T Committee members constitutes a quorum for the transaction of business at any P&T Committee meeting.

e. All P&T Committee members may vote on P&T Committee business when a vote is required. The affirmative vote of the majority of the appointed P&T Committee members is required to take action.

f. P&T Committee members shall serve two-year terms and may be reappointed to additional terms at the discretion of the Executive Director.

g. The terms shall be staggered so that in each year at least two pharmacists and any two physicians are reappointed.

h. The Executive Director may terminate the appointment of any P&T Committee member for Good Cause.

i. The Executive Director shall fill a vacancy occurring in the membership of the P&T Committee for the remainder of the unexpired term. Such replacement shall meet all applicable requirements as set forth in this section.

Physicians and pharmacists on the P&T Committee shall have knowledge and expertise in one or more of the following:

a. The clinically appropriate prescribing of covered outpatient drugs;

b. The clinically appropriate dispensing of outpatient drugs;

c. Drug use review, evaluation and intervention;

d. Medical quality assurance; or e. The treatment of Medical Assistance Program members.

8.800.17.B. CONFLICT OF INTEREST

P&T Committee members must complete and sign a conflict of interest disclosure form, prior to their appointment to the P&T Committee, which discloses any financial or other affiliation with organizations that may have a direct or indirect interest in business before the P&T Committee.
At any meeting, a P&T Committee member must recuse himself or herself from discussion and decision making for an entire Drug Class if he or she has a Conflict of Interest with any drug in that Drug Class.
At any meeting, if a P&T Committee member does no recuse themselves after the disclosure of a potential conflict, the P&T Committee will vote as to whether or not the member has a Conflict of Interest. The Department then makes the final determination if the member has a Conflict of Interest.

8.800.17.C. DUTIES

Among other duties, the P&T Committee shall:

a. Review drugs or Drug Classes selected by the Department.

b. Utilize scientific evidence, standards of practice and drug information.

c. Consider drug safety and efficacy and other review criteria requested by the Department.

d. Request information, recommendations or testimony from any health care professional or other person with relevant knowledge concerning a drug or Drug Class subject to P&T Committee review, at their discretion during the P&T Committee meeting.

e. Make clinical recommendations on drugs or Drug Classes. Such recommendations shall be considered by the Medical Director, when making final determinations on PDL implementation and maintenance.

f. Perform any other act requested by the Department necessary for the development and maintenance of the PDL as described in

Section 8.800.16.A.

g. A Department approved policy and procedures manual shall be followed by the P&T Committee.

h. Meet at least quarterly and other times at the discretion of the Department or the P&T Committee.

8.800.17.D. NOTICE/OPEN MEETINGS

P&T Committee meetings and the proposed agenda shall be posted publicly at least thirty days before the meeting.
The P&T Committee meetings shall be open to the public. If a P&T Committee meeting is required to be held in executive session pursuant to state or federal law, the executive session shall be convened after conclusion of the open meeting.

8.800.18 PRESCRIPTION DRUG CONSUMER INFORMATION AND TECHNICAL

ASSISTANCE PROGRAM 8.800.18.A. The Prescription Drug Consumer Information and Technical Assistance Program provides Medical Assistance Program members the opportunity to speak with a licensed pharmacist, or a licensed pharmacy intern under the supervision of a licensed pharmacist, to review the member’s medications, receive information on the prudent use of prescription drugs, explore how to avoid dangerous drug interactions, and improve member outcomes.

8.800.18.B. REQUIREMENTS FOR PARTICIPATION IN THE PROGRAM

Licensed pharmacists must have graduated from an accredited college of pharmacy on or after May 1996, or completed a structured and comprehensive education program by the Accreditation Council for Pharmacy Education, and must maintain an unrestricted license in good standing to practice pharmacy in Colorado to participate.
Licensed pharmacy interns must have and maintain an unrestricted license in good standing in Colorado.
Members may participate in the program if they are a fee-for-service member who receives prescription drug benefits and is at high risk of complications from drug interactions.

8.800.18.C. SERVICES

Medication therapy counseling services may be conducted face-to-face, over the telephone, or through a virtual meeting and the pharmacist or licensed intern shall:

a. Review the member’s profile with the member for accuracy and inquire as to any additional medications, providers or disease states;

b. Perform a medication review to identify, resolve and prevent medication related problems;

c. Provide education and training designed to enhance the member’s understanding and appropriate use of medications, and encourage member compliance with their therapeutic regimen;

d. Draft and submit a report which documents the counseling session and includes recommended changes to the member’s medication therapy and any other information providers may find relevant to the appropriate treatment of the member’s health.

8.810 PODIATRY SERVICES 8.810.1 Definitions Foot hygiene means the cleaning and soaking of the feet to maintain a clean condition.

Mid-calf means 50% of the total distance between the talus and tibial plateau.

Podiatry includes the suggesting, recommending, prescribing, or administering of any podiatric form of treatment, operation, or healing for the intended palliation, relief, or cure of any disease, ailment, injury, condition, or defect of the human toe, foot, ankle, tendons that insert into the foot, and soft tissue wounds below the mid-calf, including complications thereof consistent with such scope of practice. It may include partial amputation of the foot, but it does not involve the complete amputation, or disarticulation between the talus and the tibia, or the administration of an anesthetic, other than a local anesthetic.

Routine Foot Care means the cutting or removal of corns and calluses; trimming, cutting, or debriding of nails; and other hygienic care due to a physical or clinical finding that is consistent with a metabolic, neurological, or peripheral vascular disease diagnosis and indicative of significant peripheral involvement.

Soft tissue wound means a lesion to the musculoskeletal junction that includes dermal and sub-dermal tissue that does not involve bone removal or repair or muscle transfer.

8.810.2 CLIENT ELIGIBILITY 8.810.2.A. All Colorado Medicaid-enrolled Clients are eligible for Podiatry services.

8.810.3 PROVIDER ELIGIBILITY 8.810.3.A. All Colorado Providers enrolled in Medicaid are eligible to perform Podiatry services when it is within the scope of the Provider’s practice.

8.810.4 COVERED SERVICES 8.810.4.A. Colorado Medicaid covers the examination, diagnosis, and treatment of the foot and ankle up to the mid-calf when medically necessary as described in

Section 8.076.1.8. 8.810.4.B. Providers may provide avulsions involving the removal of the entire nail or a portion thereof without destruction of the nail matrix. Documentation substantiating services received more frequently than once every four months shall be detailed in the Client’s medical record.

8.810.4.C. LIMITATIONS

Routine Foot Care services are covered only when:

a. The Client or caregiver is not capable of performing routine foot care without risk of injury; and b. The procedure does not duplicate another Provider’s procedure during a 60 day period, which starts from the date of service of the first procedure; and c. One of the following:

i) The services are an integral part of otherwise covered services; or, ii) Documentation illustrates the presence of metabolic, neurological, or peripheral vascular disease or provides evidence of specific active complications resulting from prior insults due to systemic conditions; or, iii) There is evidence of pathologic nail infection that, in the absence of a systemic condition, results in intolerable pain or secondary infection.

Coverage for the debridement and reduction of nails, corns, and calluses is limited to once every 60 days. A Provider may provide both debridement and reduction of nails at the same visit. Once a Client has received either a debridement or reduction of nails or both, neither service is available for 60 days after the treatment.
When a Client requires excision procedures to be performed more than once, the medical record shall reflect the reason for persistent or recurrent infections and a plan for future preventative measures being taken.
Services that occur in a long term care (LTC) facility shall only be covered when:

a. The Client residing in the LTC facility, an RN, or LPN employed by the facility, the Client’s family, guardian, or attending physician requests the Service;

b. The LTC facility arranges for the podiatric services; and, c. The request and arrangement is documented in the medical record.

Excision of nail and matrix for permanent removal shall only be covered once per toe.
For established Clients, an evaluation and management visit service shall not be covered if the evaluation and management visit occurs on the same day as a debridement or reduction of nails, corns, and calluses, unless there is another separately identifiable service or procedure documented in the medical record.

8.810.5 NON-COVERED SERVICES 8.810.5.A. The following Podiatry services are not covered by Colorado Medicaid:

Surgical assistant services (differing from assisting surgeons).
Local anesthetics that are billed as a separate procedure.
Operating room facility charges for in-office procedures.
Treatment of subluxation of the foot.
Treatment of flat feet.
Routine supplies provided in the office.

8.815 IMMUNIZATION SERVICES 8.815.1 Definitions 8.815.1.A. Advisory Committee on Immunization Practices (ACIP) means the group of medical and public health experts that develops recommendations on how to use vaccines to control diseases in the United States. ACIP was established under Section 222 of the Public Health Service Act (42 U.S.C. § 2l7a). 8.815.1.B. Immunization means the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. 8.815.1.C. School District means any board of cooperative services established pursuant to article 5 of title 22, C.R.S., any state educational institution that serves students in kindergarten through twelfth grade including, but not limited to, the Colorado School for the Deaf and Blind, created in article 80 of title 22, C.R.S., and any public School District organized under the laws of Colorado except a junior college district. 8.815.1.D. Vaccine means a biological preparation that improves immunity to a particular disease. 8.815.1.E. Vaccine Administration Services means the provision of an injection, nasal absorption, or oral administration of a vaccine product. 8.815.1.F. Vaccines for Children (VFC) means the federally funded program administered through the Centers for Disease Control for the purchase and distribution of pediatric vaccines to program-registered providers for the Immunization of vaccine-eligible children 18 years of age and younger. 8.815.2 Client Eligibility 8.815.2.A. All Colorado Medicaid clients are eligible for Immunization and Vaccine Administration Services. 8.815.3 Provider Eligibility 8.815.3.A. Rendering Providers 1. Colorado Medicaid enrolled providers are eligible to administer Vaccines and Vaccine Administration Services as follows:

a. If it is within the scope of the provider’s practice;

b. In accordance with the requirements at Section 8.200.2.; and c. If the provider is administering Vaccines and Vaccine Administration Services to a client 18 years of age or younger, the provider is using Vaccines provided free of cost by the federal government, including through the VFC program. 8.815.3.B. Prescribing Providers 1. Colorado Medicaid enrolled providers are eligible to prescribe Vaccines and Vaccine Administration Services in accordance with Section 8.815.3.A.1.a.-b. 8.815.4 Covered Services 8.815.4.A. Vaccines identified in the ACIP Vaccine Recommendations and Guidelines are updated routinely and are covered as follows:

For clients 18 years of age and younger, Vaccines are either provided through the VFC program or are otherwise provided without cost by the federal government.
For clients 19 years of age and older, Vaccines are covered by Colorado Medicaid. 8.815.4.B. Administration of Vaccines identified in the ACIP Vaccine Recommendations and Guidelines is a covered service for all clients. 8.815.4.C. Immunization and Vaccine Administration Services that are provided by home health agencies, physicians, or other non-physician practitioners to clients at nursing facilities, group homes, or residential treatment centers are covered only as follows:
Immunization services for clients who are residents of nursing facilities and clients receiving home health services are covered only if ordered by their physician. The skilled nursing component for Immunization administration provided at a nursing facility is included in the facility’s rate or part of a regularly scheduled home health service for clients receiving home health services.
Clients who are residents of an Alternative Care Facility, as defined at

Section 8.495.1, may receive Immunization services from their own physician. They may also receive Immunization services as part of a home health service in accordance with Section 8.815.4.C.1. 8.815.5 Prior Authorization Requirements 8.815.5.A. Prior authorization is not required for this benefit. 8.815.6 Non-covered Services 8.815.6.A. The following services are not covered by Colorado Medicaid:

For clients 18 years of age and younger, Vaccines that have been obtained from a source other than the federal government;
Immunization and Vaccine Administration Services provided by a School District provider; and 3. Travel-related Immunization and Vaccine Administration Services.

Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.900 MEDICAL ASSISTANCE - SECTION 8.900 OAP, Primary Care Fund, Dental Health Care {#sec-10-ccr-2505-10-8.900 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.900}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE – SECTION 8.900 OAP, PRIMARY CARE FUND, DENTAL HEALTH CARE 10 CCR 2505-10 8.900 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] 8.900 [Repealed effective 7/1/2025] 8.920 Hospital Discounted Care The Health Care Billing for Indigent Patients Act of 2021, C.R.S. § 25.5-3-501, et. seq., referred to as Hospital Discounted Care, establishes the maximum rate a Health Care Facility and Licensed Health Care Professional may bill low-income patients for Discounted Care provided in the hospital, requires written description of patient’s rights, establishes patient appeals and complaint processes, and imposes requirements on hospitals before assigning or selling patient debt to a medical creditor or before pursuing collection action. Senate Bill 24-116 added an increase in payment plan amounts for Health Care Facilities who bill for their own professionals, requires professionals who bill separately from the Health Care Facility to report their own data to the Department, and excludes primary care provided at rural or frontier clinics who have an approved sliding fee scale.

8.921 DEFINITIONS

A. Billing Statement means any patient-facing communication, whether electronic or in writing, that specifies an amount due for services and instructions for making payment.

B. Children’s Basic Health Plan or the Child Health Plan Plus (CHP+) means the Children’s Basic Health Plan as defined in Title 25.5, Article 8, C.R.S.

C. Department means the Department of Health Care Policy and Financing established pursuant to section 25.5-1-104, C.R.S.

D. Discounted Care means the amount a Provider may charge a Qualified Patient for Medically Necessary Health Care Services rendered.

E. Emergency Medicaid means short-term Medicaid coverage for eligible people who do not meet immigration or citizenship requirements for Medicaid and need treatment for life- and/or limb-threatening emergencies.

F. Emergency Hospital Services means treatment for conditions of an acute, severe nature which are life, limb, or disability threats requiring immediate attention, where any delay in treatment would, in the judgment of the responsible physician, threaten life or loss of function of a patient or viable fetus.

G. Federal Poverty Guidelines or FPG means a measure of income level issued annually by the United States Department of Health and Human Services. For Hospital Discounted Care, the FPG is updated annually every April 1.

H. Health Care Facility means a hospital licensed as a general hospital pursuant to Title 25, Article 3, Part 1, C.R.S., a hospital established pursuant to section 23- 21-503, C.R.S. or section 25-29-103, C.R.S., any freestanding emergency department licensed pursuant to section 25-1.5-114, C.R.S., or any outpatient health care facility that is licensed as an on-campus department or service of a hospital or that is listed as an off-campus location under a hospital’s license.

Health Care Facility does not include a federally qualified health center as defined in the federal “Social Security Act”, 42 U.S.C. sec. 1395x(aa)(4), or a student-learning medical or dental clinic that is established for the purpose of student learning, offering Discounted Care as part of a program of student learning that is physically situated within a health sciences school, Health Care Facility does not apply to primary care services provided in a clinic located in a designated rural or frontier county that offers a sliding-fee scale equal to the Medicare rural health clinic all inclusive rate payment established in accordance with 42 U.S.C. 1395l(f)(3)(B) or payment rate that is lower than usual and customary charges and considers a patient’s household size and income size as approved by the Department.

I. Health Care Services has the same meaning as set forth in section 10-16- 102(33), C.R.S.

J. Impermissible Extraordinary Collection Action means initiating foreclosure on an individual’s primary residence or homestead, including a mobile home, as defined in section 38-12-201.5(5), C.R.S.

K. Inpatient Hospital Service has the same meaning as set forth in 42 C.F.R. § 440.10. 42 C.F.R. § 440.10 (2024) is hereby incorporated by reference into this

rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This regulation is available for public inspection at the Department of Health Care Policy and Financing, 303 E. 17th Ave, Denver, CO 80203. Pursuant to C.R.S § 24-4-410(12.5)(V)(b), the Department shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule.

L. Licensed Health Care Professional or Professional means any health care professional who is registered, certified, or licensed pursuant to Title 12, C.R.S. or who provides services under the supervision of a health care professional who is registered, certified, or licensed pursuant to Title 12, C.R.S. and who provides Health Care Services in a Health Care Facility.

M. Medicaid means the Colorado Medical Assistance Act set forth in Title 25.5, Articles 4, 5, and 6, C.R.S.

N. Medical Creditor means any entity that attempts to collect on a medical debt, including a Provider or Provider’s billing office, a collection agency as defined in

section 5-16-103(3), a debt buyer as defined in section 5-16-103(8.5), C.R.S. and a debt collector as defined in 15 U.S.C. sec. 1692a(6).

O. Outpatient Hospital Service has the same meaning as set forth in 42 C.F.R. § 440.20. 42 C.F.R. § 440.20 (2024) is hereby incorporated by reference into this

P. Patient Contact Best Efforts means the process of communication efforts completed by the Provider to contact a patient. This includes phone calls, SMS messages, emails, and portal messages.

Q. Permissible Extraordinary Collection Action means an action other than an Impermissible Extraordinary Collection Action that requires a legal or judicial process, including but not limited to placing a lien on an individual’s real property, attaching or seizing an individual’s bank account or any other personal property, or garnishing an individual’s wages. A Permissible Extraordinary Collection Action does not include the attachment of a hospital lien pursuant to section 38-27-101, C.R.S.

R. Provider means any Health Care Facility or Licensed Health Care Professional subject to Title 25.5, Article 3, Part 5, C.R.S.

S. Qualified Patient means an individual who attests to residing in Colorado, whose household income is not more than two hundred fifty percent of the Federal Poverty Guidelines and who received an Inpatient Hospital Service or Outpatient Hospital Service at a Health Care Facility.

T. Screen or Screening means a process identified in rule by the Department whereby Health Care Facilities assess a patient’s circumstances related to eligibility criteria and determine whether the patient is likely to qualify for public health care coverage or Discounted Care, inform the patient of the Health Care Facility’s determination, and provide information to the patient about how the patient can enroll in public health care coverage.

U. SMS means short messaging service messages, commonly referred to as text messages.

V. Uninsured means an uninsured individual, as defined in section 10-22-113(5)(d), C.R.S.

8.922 SCREENING AND APPLICATION

A. Screening, Application, and Determination Notice 1. Beginning September 1, 2022, using the single uniform application developed and distributed by the Department, a Health Care Facility shall screen each uninsured patient and any insured patients who request to be screened for:

a. Public health insurance programs including but not limited to Medicare, Medicaid, Emergency Medicaid, and the Children’s Basic Health Plan.

b. Discounted Care, as described in section 25.5-3-503, C.R.S.

Uninsured Patients a. Health Care Facilities must complete the screening process using the uniform application within 45 days from the uninsured patient’s date of service or date of discharge, whichever is later.

b. The screening process consists of completing the first page of the uniform application using self-attested information provided by the patient or their guardian.

c. If the self-attested screening process results in a determination that the patient may be eligible for Discounted Care, then, at the time of the screening, the Health Care Facility must provide the patient or their guardian with a list of information and documents required to complete the application process. The patient is permitted 45 days to provide the documentation required to complete the application.

When all necessary documentation has been received from the patient, the Health Care Facility must determine the patient’s eligibility for Discounted Care and send written notice of the determination to the patient or guardian within 21 days.

d. If the self-attested screening process results in a determination that a patient likely is ineligible for Discounted Care, the patient must be informed that the screening results are not an official determination and that they have the right to complete the application and receive an official determination of eligibility for Discounted Care if they choose. If the patient requests to complete the application process for Discounted Care, the Health Care Facility must complete the application process and provide an official determination of eligibility for Discounted Care.

e. If the self-attested screening process results in a determination that the patient may be eligible for one or more public health coverage options, the Health Care Facility must inform the patient of those options and provide information on how the patient may apply for them, including any application deadlines the patient should be aware of.

Insured Patients a. If the insured patient or their guardian requests to be screened for public health insurance programs and Discounted Care, Health Care Facilities must screen insured patients within 45 days of their date of service or date of discharge, or within 45 days of the date of their first bill after their insurance adjustment, whichever is later.

b. The request to be screened may be made in person, by telephone, email, or by using the portal, if available. Health Care Facilities must contact the insured patient or their guardian to schedule the screening within three business days after receiving the insured patient’s request.

c. Patients believed to have health insurance coverage when services were rendered and who are subsequently determined to be uninsured on their date of service are considered Uninsured. Within 45 days from the date of the notification that the patient was not insured on the date of service, the Health Care Facility must complete the screening.

Presumptive Eligibility for State Medical Assistance Program a. Hospitals may not complete a presumptive eligibility screening for a patient in lieu of completing a screening as required in this section.

b. A hospital that is not a Qualified Hospital Presumptive Eligibility Site as defined in 10 CCR 2505-10 Section 8.100.1 may not use presumptive eligibility to deny discounted care to any patient.

Health Care Facility Determination Notice a. The Health Care Facility must provide the patient written notice of the determination within 21 days of receiving all required documentation to complete the patient’s application for Discounted Care. A copy of the determination must be sent to any and all applicable Licensed Health Care Professionals.

b. The determination shall be written in plain language and in the patient or their guardian’s preferred language.

c. If a Health Care Facility fails to issue written notice of the determination to the patient within 21 days of receiving all required documentation to complete the patient’s application, the patient may file an appeal. If the appeal is filed within 60 calendar days of the patient submitting all required documentation, the Health Care Facility must review the appeal and respond to the patient or their guardian and the Department within 15 calendar days of the date of the appeal.

d. For patients determined to be eligible for Discounted Care, the determination notice must include but is not limited to:

The programs and discounts for which the patient was determined likely eligible for, including but not limited to Medicaid, Emergency Medicaid, CHP+, Medicare, and Hospital Discounted Care, and the availability of subsidies through Connect for Health Colorado. This must also include where to find additional information and how to apply for each program the patient was determined potentially eligible for.

i. If the patient appears likely eligible for a program, and there is a deadline by which the patient must apply for that program for their services to be covered, that date must be included in the determination notice.

The dates for which the Discounted Care determination is valid.
The household size and income used to determine eligibility and the household calculated FPG.
The patient’s monthly installment amounts calculated on their gross household income pursuant to Section 8.923.A.2.
Information on how to file a complaint and how to file an appeal with the Health Care Facility and the Department.

e. The determination notice for patients determined not eligible for Discounted Care must include but is not limited to:

The basis for denial of Discounted Care.
The programs and discounts for which the patient was determined likely eligible for, including but not limited to Medicaid, Emergency Medicaid, CHP+, Medicare, and the availability of subsidies through Connect for Health Colorado. This must also include where to find additional information and how to apply for each program the patient was determined potentially eligible for.

i. If the patient appears likely eligible for a program, and there is a deadline by which the patient must apply to that program for their services to be covered, that date must be included in the determination notice.

The service date the Discounted Care denial covers and an explanation that the household may qualify for coverage of future services if there is a change in household size or income.
The household size and income used to determine eligibility and the household calculated FPG.
Information on how to file a complaint and how to file an appeal with the Health Care Facility and the Department.
A Health Care Facility is no longer obligated to screen an uninsured patient for past dates of service if the patient or their guardian signs the decline screening form developed by the Department that notes those specific dates of service or a past date range that includes those specific dates of service except when a patient or guardian who opted out of screening subsequently requests to complete the screening, if the subsequent request is made prior to starting Permissible Extraordinary Collections Actions.

a. The Health Care Facility must keep on file a decline screening form signed by the patient, or their guardian until June 30 of the seventh state fiscal year after the patient’s date of service or date of discharge, whichever is later.

For patients who are discharged without being screened or signing the decline screening form, the Health Care Facility must attempt to contact the patient by at least one method of contact that the patient indicates is their preferred method, which can include phone call, SMS message, email, and portal message at least once a month for six months after the patient’s date of discharge with the first contact sent prior to the expiration of 45 days after screening. The Health Care Facility may commence billing 46 days after the patient’s date of service or date of discharge, whichever is later. If the patient requests that the Health Care Facility cease contacting them by phone, SMS message, or email, the provider may consider those requirements as fulfilled. The Health Care Facility must document the patient’s request and maintain the request as part of the patient record.
If a Health Care Facility has attempted to contact the patient in accordance with Patient Contact Best Efforts, and the patient does not respond within 182 days of their date of service or date of discharge, whichever is later, the Facility may conclude that the patient has made an informed decision to decline screening. Patient Contact Best Efforts, at a minimum, must include:

a. Notice that the failure to respond may result in the loss of their right to be screened for cost saving options.

b. Calling any phone numbers provided by the patient and leaving voice messages with allowable information under the Health Insurance Portability and Accountability Act as defined at 45 C.F.R.

sec. 164.502 and the Telephone Consumer Protection Act as defined at 47 U.S.C. sec. 227 if the calls are unanswered, 1. 45 C.F.R. § 164.502 (2024) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This regulation is available for public inspection at the Department of Health Care Policy and Financing, 303 E. 17th Ave, Denver, CO 80203. Pursuant to C.R.S § 24-4- 410(12.5)(V)(b), the Department shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule.

c. SMS messages to any of the patient’s phone numbers identified by the patient as a mobile number if the Health Care Facility has the ability to send SMS messages, d. Sending emails to any email address provided by the patient, and e. Sending messages through any appropriate patient portal.

If a patient does not indicate their preferred method of contact, the Provider shall contact patients in accordance with their internal patient communication policies. Documentation of the communication attempts for patients must be kept in their patient records and the communication policy must be kept on file until the June 30 of the seventh state fiscal year past the patient’s date of service.
Documentation of the attempts to contact the patient or guardian to complete the screening must be maintained as part of the patient record.

This may include call logs, message logs, copies of sent emails, portal messages sent, and copies of bills.

Providers shall maintain all Discounted Care-related records, including but not limited to, documentation to support screenings and determinations, service data including dates of service for Qualified Patients and services provided to them on those dates, and expenditures until June 30 of the seventh state fiscal year following the creation of the documentation.

B. Patients 1. Any patient or patient’s guardian aged 18 and older may apply to receive Discounted Care.

The decision regarding eligibility for Discounted Care applies to both the patient and the members of the patient’s household.
If a patient is deceased, the personal representative of the estate or a family member may complete the screening and application on behalf of the patient.
The application to receive Discounted Care shall include the names, birth dates, and relationship to the patient of all members of the patient’s household who are included on the application.

a. A patient must include their spouse or civil union partner in their household for the application.

b. Any additional person living at the same address as the patient may also be included in the household.

c. A patient may include household members who live in other states or countries if the patient attests to the fact that they provide at least 50% of the household member’s support.

A minor shall not be screened separately from his or her parents or guardians unless they are emancipated or there exists a special circumstance. A minor is an individual under the age of 18.

C. Household Income 1. Using the information submitted by a patient or patient’s guardian, the Health Care Facility shall determine whether the patient meets all requirements to receive Discounted Care. Health Care Facilities must follow the income counting methodology determined by the Department.

Health Care Facilities shall determine Qualified Patient financial eligibility based on income from each household member 18 and older and household size. The Health Care Facility may not consider assets in determining eligibility.

Eligibility shall be determined at the time of application, unless required documentation is not available, in which case the patient or patient’s guardian will be notified of the missing documentation within three business days after receipt of the application. An eligibility determination shall be made within 21 calendar days after the application is complete.
Patients may establish household income by providing documents that satisfy documentation guidelines established by the Department.

Acceptable forms of documentation may include but is not limited to pay stubs, employer letter, tax returns, and business financial statements. The Health Care Facility may not require more than the minimum amount of documentation to substantiate declared income.

a. Patients who are experiencing homelessness are exempt from the documentation requirements related to establishing income and may self-attest to their household income.

8.923 HEALTH CARE SERVICE DISCOUNTS

A. Beginning September 1, 2022, if a patient screened pursuant to Section 8.922 is determined to be a Qualified Patient, a Health Care Facility and a Licensed Health Care Professional shall for Emergency Hospital and other Health Care Services:

Limit the amounts billed for Health Care Services to no more than the rate established in Department rule pursuant to Section 8.928.
Enter into a payment plan with the Qualified Patient in which the Qualified Patient pays for care in monthly installments. For services provided by a Health Care Facility, monthly installments shall not exceed four percent of the patient’s gross monthly household income on a bill from a Health Care Facility that contains only facility charges and shall not exceed six percent of the patient’s gross monthly household income on a bill from a Health Care Facility containing both facility and Licensed Health Care Professional charges. For services provided by each Licensed Health Care Professional who bills separately from the Health Care Facility, monthly installments shall not exceed two percent of the patient’s gross monthly household income; and 3. After a cumulative thirty-six months of payments, the Health Care Facility shall treat the Qualified Patient’s bill as paid in full and must permanently cease collection activities on any balance that remains unpaid.
Providers shall not suggest or require that patients obtain loans that include fees, interest, or payment plans that exceed 36 payments to pay for services in lieu of setting up a payment plan directly with the Health Care Facility or Licensed Health Care Professional.

a. If a patient defaults on a loan from the Provider, the same rules apply related to any collection actions taken by the Provider as apply for payment plans under this section. If a patient defaults on a loan from the Provider, the same rules apply related to any collection actions taken by the Provider as apply for payment plans under this section..

B. A Health Care Facility shall not:

Deny Discounted Care on the basis that the patient has not applied for any public benefits program, unless during the initial screening the patient is determined to be presumptively eligible for the state medical assistance program; or 2. Adopt or maintain any policies that result in the denial of admission or treatment of a patient because the patient may qualify for Discounted Care.

8.924 PATIENT RIGHTS

A. Beginning September 1, 2022, a Health Care Facility shall make available to the public and to each patient information developed by the Department about patient’s rights pursuant to Part 5 of Article 3 of Title 25.5 C.R.S. (2021) and the uniform application developed by the Department pursuant to section 25.5-3- 505(2)(i), C.R.S.

B. At a minimum, the Health Care Facility shall:

Post the information in all languages spoken by ten percent or more of the population in any Colorado county conspicuously on the Health Care Facility’s website, including a link to the information on the Health Care Facility’s main landing page;
Make the information available in patient waiting areas;
Make the information available to each patient, or the patient’s legal guardian, before the patient is discharged from the Health Care Facility, verbally or in writing in the patient’s or legal guardian’s preferred language, which may include using professional interpretation and/or translation services; and 4. Inform each patient on the patient’s Billing Statement of the patient’s rights pursuant to Part 5 of Article 3 of Title 25.5, C.R.S. (2021) including the right to apply for Discounted Care, and provide the website, email address, and telephone number where the information may be obtained in the patient’s preferred language.

C. Providers shall not present the patient’s rights in a format that differs from the format in which the material is distributed by the Department without Department approval.

Providers may not make any part of the patient’s rights information part of a footnote or use any other format that may minimize its importance.

8.925 REPORTING REQUIREMENTS

A. Beginning September 1, 2023 for Health Care Facilities and beginning September 1, 2025 for Licensed Health Care Professionals, and each September 1 thereafter, each Health Care Facility and Licensed Health Care Professional shall report to the Department data that the Department determines is necessary to evaluate compliance across race, ethnicity, age, and primary-language-spoken patient groups with the screening, Discounted Care, payment plan, and collections practices required by Title 25.5, Article 3, Part 5, C.R.S. . The Department shall distribute a compliance data reporting template to each Health Care Facility.

If a Health Care Facility or Licensed Health Care Professional is not capable of disaggregating the required data by race, ethnicity, age, and primary language spoken, the Health Care Facility or Licensed Health Care Professional shall report to the Department the steps the Health Care Facility or Licensed Health Care Professional is taking to improve race, ethnicity, age, and primary language spoken data collection and the date by which the facility or Licensed Health Care Professional will be able to disaggregate the reported data.

B. Beginning September 1, 2023 for Health Care Facilities and beginning September 1, 2025 for Licensed Health Care Professionals, and each September 1 thereafter, each Health Care Facility and Licensed Health Care Professional shall submit Discounted Care utilization and charge data in a format and timeline determined by the Department.

8.926 COLLECTIONS

A. Beginning September 1, 2022, before assigning or selling patient debt to a collection agency or a debt buyer, or before pursuing, either directly or indirectly, any Permissible Extraordinary Collection Action:

A Health Care Facility shall meet the screening requirements in Section 8.922;
A Provider shall provide Discounted Care to a Qualified Patient pursuant to Section 8.920;
A Provider shall provide a plain language explanation of the health care services and fees and notify the patient or their guardian of potential collection actions in their preferred language on the timeline developed by the Department; and 4. A Provider shall bill any third-party payer that is responsible for providing health care coverage to the patient. If a Licensed Health Care Professional is an out-of-network provider under a Qualified Patient’s health insurance plan, the Licensed Health Care Professional and health insurance carrier shall comply with the out-of-network billing requirements described in sections 10-16-704 (3) and 12-30-113, C.R.S.

B. A Health Care Facility must complete the Patient Contact Best Efforts in their attempts to contact a patient who has not signed a Decline Screening Form or who has not been screened as described in Section 8.922 prior to starting Permissible Extraordinary Collections Actions.

C. Documentation of Patient Contact Best Efforts communication attempts with the patient as outlined in Section 8.922 satisfies the screening requirements for Health Care Facilities.

D. For a Qualified Patient with an established payment plan, Permissible Extraordinary Collections Actions may not be started until the patient has failed to remit three consecutive payments and has not communicated with the Provider asking for a deferment or to be redetermined prior to or during those three months of missed payments. Providers must notify Qualified Patients with established payment plans at least 30 days prior to the commencement of Permissible Extraordinary Collections Actions.

E. Providers shall not commence collection proceedings against a patient for any amount in excess of the rates established at Section 8.923.A.2, and must reduce the amount owed by the amount of any payments received from the patient or a third-party payer.

8.927 APPEALS AND COMPLAINTS

A. If a patient is determined ineligible for Discounted Care after the uniform application has been completed, the patient may appeal the decision as follows:

No later than 30 calendar days from the date on the Health Care Facility’s eligibility determination letter, the patient or their guardian may submit an appeal in writing via U.S. Mail, email, or patient portal message if available to the Health Care Facility that made the determination.
Within 15 calendar days from the date of the appeal, the Health Care Facility shall complete a redetermination of eligibility and respond to the patient or guardian and the Department.
If the Health Care Facility upholds its initial eligibility determination, the patient or guardian may proceed to the next step of the appeals process as described in Section 8.927.A.4.
No later than 15 calendar days from the date of the Health Care Facility’s initial appeal decision, the patient shall submit a written appeal to the Department. Email submissions must be addressed to hcpf_HospDiscountCare@state.co.us. Letters must be mailed to:

Department of Health Care Policy and Financing Attention: State Programs Unit, Special Financing Division c/o Hospital Discounted Care 303 E. 17th Avenue Suite 1100 Denver, CO 80203 5. Within 15 calendar days from date of receipt of the appeal, the Department shall issue a final determination letter to both the patient and the Health Care Facility. If the Department deems that the redetermination was inaccurate, the Health Care Facility must resend a determination letter to the patient and the Department stating the patient is/was eligible for Discounted Care on the date of service.

B. A patient or guardian who believes a Health Care Facility has improperly calculated a payment plan based on inaccurate income information may appeal the payment plan offered by the Facility to the Department using the process described in Section 8.927.A.

C. The Department shall maintain records of all appeals and its final determinations for each Health Care Facility. If the Department determines a Health Care Facility has a repeated pattern of errors in patient eligibility determinations, the Department will require the Health Care Facility to attend training with the Department. The Health Care Facility may be subject to random application checks for 12 months following the training to ensure that the errors have been corrected.

D. Patients and their guardians may file complaints against Providers directly with the Department. Patients are not required to file a complaint with the Provider prior to filing a complaint with the Department.

Patients may submit complaints via U.S. Mail, email, or phone as follows:

Phone: 303-866-2580 Email: hcpf_HospDiscountCare@state.co.us U.S. Mail: Department of Health Care Policy and Financing Attention: State Programs Unit, Special Financing Division c/o Hospital Discounted Care 303 E. 17th Avenue Suite 1100 Denver, CO 80203 2. The Department shall review complaints within 30 calendar days of receipt.

The Department shall maintain records of all complaints for each Provider.

If the Department determines there is a repeated pattern in the complaints filed against the Provider, the Provider may be subject to a corrective action plan.

a. Providers will have 90 days to submit a corrective action plan.

Extensions may be made at the Department’s discretion up to no more than 120 days.

8.928 HOSPITAL DISCOUNTED CARE PROGRAM STRUCTURE

8.928.1 REVIEW OF PROVIDERS FOR NONCOMPLIANCE

A. The Department will periodically review Providers to ensure compliance with Part 5 of Article 3 of Title 25.5, C.R.S. (2024) and these rules. If the Department finds that a Provider is not in compliance with these rules, the Department will notify the Provider.

B. The Provider will have 90 days to file a corrective action plan with the Department that must include measures to inform impacted patients about the noncompliance and provide financial corrections consistent with these rules.

At the Department’s discretion, a Provider may be permitted up to 120 days to submit a corrective action plan upon request.
The Department may require a Provider that is not in compliance with Title 25.5, Article 3, Part 5, C.R.S. or these rules to develop and operate under a corrective action plan until the Department determines the Provider is in compliance.

C. If a Provider’s noncompliance with these rules is determined by the Department to be knowing or willful or there is a repeated pattern of noncompliance, the Department may fine the Provider no more than $5,000. If the Provider fails to take corrective action or fails to file a corrective action plan with the Department pursuant to this section, the Department may fine the Provider no more than $5,000 per week until the Provider takes corrective action. The Department will consider the size of the Health Care Facility and the seriousness of the violation in setting the fine amount.

D. The Department will make the information reported pursuant to this section and any corrective action plans for which fines were imposed pursuant to this section available to the public and shall annually report the information as part of its presentation to its committees of reference at a hearing held pursuant to section 2-7-203 (2)(a), C.R.S. of the “State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act.”

E. For audit purposes, Providers shall maintain all Discounted Care related records, including but not limited to, documentation to support screenings and determinations, service data including dates of service for Qualified Patients and services provided to them on those dates, and expenditures until June 30 of the seventh state fiscal year following the screening or determination.

8.928.2 RATES

The Department will annually establish rates for Discounted Care. The rates will approximate and not be less than one hundred percent of the Medicare rate or one hundred percent of the Medicaid rate, whichever is greater. The Department will publicly post the established rates on the Department’s website pursuant to section 25.5-3- 505(2)(j), C.R.S.

8.928.3 ADVISORY COMMITTEE

A. Committee Makeup. The Department will create a Hospital Discounted Care Advisory Committee, effective July 1, 2025. The Executive Director of the Department will appoint 11 members to the Hospital Discounted Care Advisory Committee. Committee members will include:

A member representing the Department;
Three members who are health care consumers, of whom no more than two members may be employed by a health care consumer advocacy organization;
A member who is a representative of a safety net hospital for which the percent of Medicaid-eligible inpatient days relative to the hospital’s total inpatient days is equal to or greater than one standard deviation above the mean;
A member who is a representative of a hospital in a rural area;
A member who is a representative of a hospital in an urban area;
A member who is a representative of a statewide organization of hospitals;
A member who is a representative of licensed health care professionals who provide services to patients in a hospital setting;
A member who is a representative of an organization of Colorado community health centers or a representative of a Colorado community health center, as defined in 42 U.S.C. § 254b;
A member who is a representative of an organization of safety net health providers or a safety net health provider that is not a community health center.

Members shall serve without compensation or reimbursement of expenses. The Executive Director of the Department will designate a member to serve as chair of the committee and the appointment will be valid until the seat is vacated, the chair steps down, or a new chair is selected by the Executive Director. The council shall convene at least twice every state fiscal year according to a schedule set by the chair. Members of the council shall serve three-year terms. Of the members initially appointed to the advisory committee, the Executive Director will appoint six members for two-year terms and five members for three-year terms. In the event of a vacancy on the advisory committee, the Executive Director will appoint a successor to fill the unexpired portion of the term for the member.

B. Committee Duties. The advisory committee shall:

Advise the Department on the operations and policies for Hospital Discounted Care, and 2. Make recommendations to the Medical Services Board regarding rules for Hospital Discounted Care. 8.930 [Repealed effective 8/12/2011.]

8.940 OLD AGE PENSION HEALTH CARE PROGRAM

8.941 EXTENT AND LIMITATIONS OF MEDICAL CARE

8.941.1 GENERAL DESCRIPTION - OLD AGE PENSION HEALTH CARE

PROGRAM

In accordance with the Constitution of Colorado, Article XXIV, Section 7, and the Colorado Public Assistance Act, an Old Age Pension Health Care Program is established to provide necessary medical care for the Old Age Pension (OAP) recipients who do not qualify for Medicaid under Title XIX of the Social Security Act and Colorado statutes. The State Department is designated as the single State agency to administer the program.

A. The Old Age Pension Health Care Program provides optional benefits to clients who qualify for (State only) OAP pensions who do not qualify for Federal Financial Participation (FFP) in the Colorado Medicaid Program. These cases are coded with Supplemental Income Status Code (SISC) C.

B. Under the Old Age Pension Health Care Program, only the following State funded benefits are provided:

Physician and practitioner services 2. Inpatient hospital 3. Outpatient services 4. Lab and x-ray 5. Emergency transportation 6. Emergency services 7. Dental 8. Pharmacy i. Medicare Part D prescription drugs provided pursuant to the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (defined at 42 U.S.C. sections 1395w-102 and 141 and 42 C.F.R. Part 423, et seq.) are not a benefit for those individuals who are eligible for both Medicare and the Old Age Pension Health Care Program. The pharmacy drug benefit under the Old Age Pension Health Care Program is subject to the requirements set forth at s

Section 8.800.

Home health services and supplies 10. Medicare cost sharing i. If Medicare pays for a medical service that is a non-benefit under the Old Age Pension Health Care Program, the co-insurance and deductible will not be paid by the Old Age Pension Health Care Program.

C. For the benefits listed above, the Old Age Pension Health Care Program shall only be used to provide clients with health care services determined to be medically necessary by a qualified health care provider.

D. All other medical benefits not listed in paragraph B are excluded under the Old Age Pension Health Care Program. Inpatient care in an institution for tuberculosis or mental diseases, skilled and intermediate nursing facility services, and home and community-based services are also excluded.

E. Eligibility shall not be retroactive and shall begin on the date of application or date eligibility is established, whichever is later.

F. Counties shall provide information to Old Age Pension Health Care Program clients regarding the disposal of excess resources in order to qualify for the Medicaid program. Such information shall include advisements concerning the prohibition of transfer of assets without fair consideration.

8.941.2 DEFINITIONS

A. Aid to the Needy Disabled-Colorado Supplement (AND-CS) – Program that provides a supplemental payment for individuals age zero (0) to fifty-nine (59) who are receiving Social Security Income (SSI) due to a disability or blindness, but are not receiving the full SSI benefit standard, as defined in 9 CCR 2503-5 3.510.

B. Aid to the Needy Disabled-State Only (AND-SO) – Program that provides interim assistance to individuals age eighteen (18) through fifty-nine (59) years of age (unless diagnosed with blindness, then age zero [0] through fifty-nine [59] years of age) who are disabled or blind but have not been approved for SSI or Social Security Disability Insurance (SSDI). Individuals are required to meet the total disability requirements of the program in addition to the non-financial and financial eligibility requirements. Individuals who are partially disabled or have a short-term disability are not eligible.

C. Federal Financial Participation (FFP) – The portion paid by the federal government to states for their share of expenditures for providing Medicaid services and for administering the Medicaid program and certain other human services programs.

D. Medical ID Card – The card issued to members and used by providers to verify member eligibility.

E. Old Age Pension (OAP) – Program that provides financial assistance for lowincome Colorado residents who are sixty (60) years of age or older who meet all financial and non-financial eligibility requirements.

F. Old Age Pension-C (OAP-C) – Program for individuals who are sixty (60) years of age or older who have been committed to the Colorado Mental Health Institute or to a Regional Center by order of the district or probate court.

G. State Department or Department – The Colorado Department of Health Care Policy and Financing.

H. Supplemental Income Status Code (SISC) – System codes used to distinguish the different types of state supplementary benefits (such as OAP) a recipient may receive. Supplemental Income Status Codes determine the FFP for benefits paid on behalf of groups covered under the Medical Assistance program.

I. Supplemental Security Income (SSI) – A Federal income supplement program funded by general tax revenues (not Social Security taxes) that provides income to aged, blind, or disabled individuals with little or no income and resources.

8.941.3 GROUPS ASSISTED UNDER THE OLD AGE PENSION HEALTH CARE

PROGRAM

Old Age Pension Health Care Program benefits are provided to persons receiving OAP who do not meet SSI eligibility criteria but do meet the State eligibility criteria for the Old Age Pension Health Care Program. These persons qualify for a SISC C..

A. SISC C – this code is for persons eligible to receive financial assistance under OAP who do not receive an SSI payment, and do not otherwise qualify for the Colorado Medicaid Program. SISC C signifies that no FFP is available in medical assistance program expenditures.

B. Recipients of financial assistance under AND-CS, AND-SO, or OAP-C are not eligible for assistance under the Old Age Pension Health Care Program.

8.941.4 FINANCIAL ASSISTANCE

All rules applicable to Old Age Pension financial assistance program payments (as set forth in the Department of Human Services rules at 9 CCR 2503-5) shall apply to the Old Age Pension Health Care Program.

8.941.5 CERTIFICATION OF PAYMENT FOR PROVIDERS

When submitting a claim for medical services to the Old Age Pension Health Care Program providers must submit a certification that states the following: “ I will accept as payment in full, payment made under the Old Age Pension Health Care Program, and certify that no supplemental charges have been, or will be, billed to the patient, except for those non-covered items, or services, if any, which are not reimbursable under the Old Age Pension Health Care Program.”

8.941.6 OUT-OF-STATE MEDICAL CARE

All requirements for out-of-state medical care as defined by Section 8.013 apply to the Old Age Pension Health Care Program for covered services with the exception that any reduction, suspension or elimination of benefits must be applied.

8.941.7 SUBMISSION OF CLAIMS

Rules governing the submission or payment of claims, provider or recipient appeals, third party liability, overpayment, fraud and abuse, and State identification numbers as defined in Section 8.100, apply to the Old Age Pension Health Care Program for covered services with the exception that any reduction, suspension or elimination of benefits provided must also be applied.

8.941.8 REIMBURSEMENT TO PROVIDERS

When reimbursement rates are modified, notifications shall be published on the Department’s website and will be published in the Provider Bulletin.

8.941.9 CLIENT CO-PAYMENT

Clients are responsible for paying directly to providers a co-payment according to the regulations and fee schedule as set forth under Section 8.754.1.

Clients whose co-payments reach a limit of $300 within a January 1 through December 31 calendar year will be exempted from further co-payments during that year. The exemption will begin on the date of payment that the $300 limit cumulative maximum has been reached.

A client must present the Medical ID Card to the provider at the time a service is rendered in order to claim exemption from copayment for that service.

8.942 CHANGE OF SUPPLEMENTAL INCOME STATUS CODE (SISC) TO

MEDICAID

8.942.1 MEDICAID QUALIFICATION

When a recipient of the Old Age Pension Health Care Program subsequently qualifies for Medicaid, their SISC must be changed to indicate Medicaid benefits. Additionally, the county must backdate the Medicaid benefits to the date the individual became eligible for Medicaid even if the recipient was eligible for the Old Age Pension Health Care Program at the time.

8.950 PRIMARY CARE FUND

8.950.1 GENERAL DESCRIPTION 8.950.1.A. In accordance with Section 21 of Article X (Tobacco Taxes for Health Related Purposes) of the State Constitution, an increase in Colorado’s tax on cigarettes and tobacco products became effective January 1, 2005, and created a cash fund that was designated for health related purposes. House Bill 05-1262 divided the tobacco tax cash fund into separate funds, assigning 19% of the moneys to establish the Primary Care Fund, set forth how the funds will be allocated and designated the Department of Health Care Policy and Financing (the Department) as the administrator of the Primary Care Fund. In addition to the moneys transferred from the tobacco tax cash fund, the Primary Care Fund may also include monetary gifts, grants, and donations received pursuant to House Bill 25-1288. 8.950.1.B. The Primary Care Fund provides an allocation of Moneys to health care providers that make basic health care services available in an outpatient setting to residents of Colorado who are considered low-income and uninsured. Moneys shall be allocated based on the number of eligible patients in an amount proportionate to the total number of eligible patients served by all health care providers who qualify for Moneys from this fund.

8.950.2 DEFINITIONS 8.950.2.A. Arranges For - Demonstrating Established Referral Relationships with health care providers for any of the Comprehensive Primary Care services not directly provided by the provider. 8.950.2.B. Children’s Basic Health Plan also known as Child Health Plan Plus (CHP+) - As specified in Article 8 of Title 25.5, C.R.S. 8.950.2.C. Comprehensive Primary Care - Basic, entry-level health care provided by health care practitioners or non-physician health care practitioners that is generally provided in an outpatient setting. At a minimum, this includes providing or arranging for the provision of the following services on a Year-Round Basis: primary health care; maternity care, including prenatal care; preventive, developmental, and diagnostic services for infants and children; adult preventive services, diagnostic laboratory and radiology services; emergency care for minor trauma; Pharmaceutical Services; and coordination and follow-up for hospital care. It may also include optional services based on a patient’s needs such as dental, behavioral health and eyeglasses. 8.950.2.D. Cost-Effective Care - Provides or Arranges for Comprehensive Primary Care that is appropriate and at a reasonable average cost per patient Visit and/or Encounter. 8.950.2.E. Eligible Patient is a patient receiving medical services from a Qualified Provider:

Whose yearly family income is at or below two hundred percent (200%) of the Federal Poverty Guideline (FPG);
Who is not eligible for the Medical Assistance Program, the Children’s Basic Health Plan, Medicare or any other governmental health care coverage such as through Social Security, the Veterans Administration, Military Dependency (TRICARE or CHAMPUS), or the United States Public Health Service; and 3. There is no Third Party Payer. 8.950.2.F Eligible Qualified Provider - A Qualified Provider who is identified by the Department to receive funding from the Primary Care Fund. 8.950.2.G. Established Referral Relationship - A formal, written agreement in the form of a letter, a memorandum of agreement or a contract between two entities which includes:
The Comprehensive Primary Care and/or products (e.g., pharmaceuticals, radiology) to be provided by one entity on behalf of the other entity;
Any applicable policies, processes or procedures;
The guarantee that referred Eligible Patients shall receive services on a Sliding Fee Schedule or at no charge; and 4. Signatures by representatives of both entities. 8.950.2.H. Moneys – The money the state can use for payment to providers which includes: ● Designated 19% of the tobacco tax revenue ● Monetary gifts, grants, and donations 8950.2 I Medical Assistance Program (Medicaid) - As specified in Article 4 of Title 25.5, C.R.S. 8.950.2.J. Medically Underserved Area - A federal government designation given to a geographical area based on the ratio of medical personnel (physicians, dentists, behavioral health workers, etc.) to the population. These areas have fewer than a generally accepted minimum number of medical personnel per thousand population resulting in insufficient health resources (personnel and/or facilities) to meet the medical needs of the resident population. Such areas are also defined by measuring the health status of the resident population; an area with an unhealthy population being considered underserved. 8.950.2.K. Medically Underserved Population - A federal government designation given to a human population that does not receive adequate medical attention or have access to health care facilities. 8.950.2.L. Outside Entity - A business or professional that is not classified as an employee of the provider or the Department and does not have a direct or indirect financial interest with the provider, but has auditing experience or experience working directly with the Medical Assistance Program or similar services or grants for Eligible Patients. 8.950.2.M. Pharmaceutical Services - Services that provide prescription drugs, or coordinate access to or Arranges for Eligible Patients to receive prescription drugs prescribed by the Qualified Provider on a Sliding Fee Schedule or at no charge. 8.950.2.N. Qualified Provider - An entity that provides Comprehensive Primary Care in Colorado and that:
Accepts all patients regardless of their ability to pay and uses a Sliding Fee Schedule for payments or does not charge Eligible Patients for services;
Serves a designated Medically Underserved Area or Medically Underserved Population as provided in section 330(b) of the federal “Public Health Service Act”, 42 U.S.C. sec. 254b, or demonstrates to the Department that the entity serves a population or area that lacks adequate health care services for low-income, uninsured persons;
Has a demonstrated Track Record of providing Cost-Effective Care;
Provides or Arranges For the provision of Comprehensive Primary Care to persons of all ages. An entity in a rural area may be exempt from this requirement if they can demonstrate that there are no providers in the community to provide one or more of the Comprehensive Primary Care services;
Completes a screening that evaluates eligibility for the Medical Assistance Program and the Children’s Basic Health Plan and refers patients potentially eligible for one of the programs to the appropriate agency (e.g., county departments of human/social services) for eligibility determination if they are not qualified to make eligibility determinations; and 6. Is a community health center, as defined in Section 330 of the federal “Public Health Services Act”, 42 U.S.C. Section 254b; or at least 50% of the patients served by the provider are Eligible Patients or patients who are enrolled in the Medical Assistance Program, the Children’s Basic Health Plan, or any combination thereof. 8.950.2.O. Quality Assurance Program - Formalized plan and processes designed to ensure the delivery of quality and appropriate Comprehensive Primary Care in a defined medical setting. This can be demonstrated by obtaining a certification or accreditation through the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC). If such certification or accreditation is not available, then at a minimum, the Quality Assurance Program shall be comprised of elements that meet or exceed the following components:
Establishment of credentialing/re-credentialing requirements for medical personnel;
Surveying and monitoring of patient satisfaction;
Establishment of a grievance process for patients, including documentation of grievances and resolutions;
Development of clinic operating policies and scheduled performance monitoring;
Review of medical records to check for compliance with established policies and to monitor quality of care;
Assessment of state and federal regulations to ensure compliance;
Establishment of patient safety procedures; and 8. Establishment of infection control practices. 8.950.2.P. Sliding Fee Schedule - A tiered co-payment system that determines the level of patient’s financial participation and guarantees that the patient financial participation is below usual and customary charges. Factors considered in establishing the tiered co-payment system shall only be financial status and the number of members in the patient’s family unit. 8.950.2.Q. Third Party Payments or Third Party Payer - Any individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient. Examples include the Medical Assistance Program; the Children’s Basic Health Plan; Medicare; commercial, individual or employmentrelated health insurance; court-ordered health insurance (such as that required by non-custodial parents); workers' compensation; automobile insurance; and long-term care insurance. 8.950.2.R. Track Record - Evidence of providing Comprehensive Primary Care covering at least a consecutive 52-week period prior to the submission of the application. 8.950.2.S. Unduplicated User/Patient Count - The sum of patients who have had at least one Visit/Encounter and received at least one of the services under the Comprehensive Primary Care definition during the applicable calendar year, but does not include the same patient more than once. The sum shall be calculated on a specific point-in-time occurring between the end of the applicable calendar year and prior to the submission of the application. Each patient shall be counted once under only one payment source designation (Third Party Payer or Eligible Patient). The patient’s payment source designation shall be the payment source designation listed for the patient at the specific point-in-time in which the calculation is made. The sum shall not include:
Counting a patient more than once if the same patient returns for additional services (e.g., medical or dental) and/or products (e.g., pharmaceuticals) during the applicable calendar year;
Counting a patient more than once if the payment source designation changed during the applicable calendar year;
Persons who have only received services through an outreach event, community education program, nurse hotline, or other types of communitybased events or programs and were not documented on an individual

basis;

Persons who have only received services from large-scale efforts such as mass immunization programs, screening programs, and health fairs; or 5. Persons whose only contact with the provider is to receive Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program) counseling and vouchers are not users and the contact does not generate an encounter. 8.950.2.T. Visit/Encounter - An appointment with medical personnel (physicians, physician assistants, dentists, behavioral health workers, etc.) in which the patient received health related services and/or products (e.g., pharmaceuticals or radiology) and the appointment is customarily billable to a Third Party Payer. 8.950.2.U. Year-Round Basis - Comprehensive Primary Care provided in a consecutive 52-week period directly by the provider and/or through an established referral relationship with other providers. If an organization is closed for four consecutive weeks or longer in a calendar year on a regularly scheduled

basis, it is not considered to directly provide services on a year-round basis.

8.950.3 PROVIDER ELIGIBILITY 8.950.3.A. Providers who provide Comprehensive Primary Care to Eligible Patients and who meet all of the requirements established for the Primary Care Fund as of the date the application form is submitted to the Department shall receive moneys appropriated to the Primary Care Fund. Specifically, the provider shall:

Meet all of the requirements of a Qualified Provider as specified in Section 8.950.2.N;
Have a Quality Assurance Program in place as specified in Section 8.950.2.O; and 3. Submit a completed application form according to stated guidelines as specified under Section 8.950.4.

8.950.4 APPLICATION 8.950.4.A. The application form shall be available to providers annually and posted for public access on the Department's website at least 30 calendar days prior to the response due date. 8.950.4.B. At a minimum, the application form shall require responses that:

Demonstrate how the provider meets the criteria of a Qualified Provider as defined in Section 8.950.2.N;
Provide an Unduplicated User/Patient Count covering the applicable calendar year which, at a minimum, shall include the number of patients eligible for the Medical Assistance Program and the Children’s Basic Health Plan and the number of patients considered to be Eligible Patients;
Provide certification that the Unduplicated User/Patient Count identified in

Section 8.950.4.B.2 has been verified by an Outside Entity; and 4. Provide documentation that the provider has a Quality Assurance Program as defined in Section 8.950.2.O. 8.950.4.C. Providers shall complete and provide a response annually. The response shall be made in compliance with all specifications in the application form, including format, data and documentation. Responses to the application form shall be submitted directly to the Department by the required response deadline. 8.950.4.D. All providers who submit a response to the application form shall be notified within 45 days of the response deadline if the provider met or did not meet the requirements to become an Eligible Qualified Provider.

8.950.5 DISBURSEMENT 8.950.5.A. Eligible Qualified Providers are determined on a state fiscal year basis and shall receive only those Moneys appropriated to the Primary Care Fund for that same state fiscal year, subject to the tax amount actually collected for that state fiscal year and all monetary gifts, grants and donations received during the state fiscal year. 8.950.5.B. Payments shall be based on the number of Eligible Patients in each Eligible Qualified Provider’s Unduplicated User/Patient Count in an amount proportionate to the total number of Eligible Patients from all Eligible Qualified Providers’ Unduplicated User/Patient Counts. 8.950.5.C. The schedule for the disbursement of Moneys to all Eligible Qualified Providers shall be dependent on actual tax collections allocated to the Primary Care Fund such that:

Tax collections for sales and monetary gifts, grants and donations received in July, August, and September shall be distributed to Eligible Qualified Providers prior to the end of October.
Tax collections for sales and monetary gifts, grants and donations received in October, November, and December shall be distributed to Eligible Qualified Providers prior to the end of January.
Tax collections for sales and monetary gifts, grants and donations received in January, February, and March shall be distributed to Eligible Qualified Providers prior to the end of April.
Tax collections for sales and monetary gifts, grants and donations received in April, May, and June shall be distributed to Eligible Qualified Providers prior to the end of July.
For State Fiscal Year 2005-06 only, tax collections for sales in January 2005 through December 2005, shall be distributed to Eligible Qualified Providers prior to the end of February 2006.

8.960 COLORADO DENTAL HEALTH CARE PROGRAM FOR LOW-INCOME

SENIORS 8.960.A Definitions 1. Arrange For or Arranging For means demonstrating established relations with Qualified Providers for any of the Covered Dental Care Services not directly provided by the applicant.

Covered Dental Care Services include Diagnostic Imaging, Emergency Services, Endodontic Services, Evaluation, Oral and Maxillofacial Surgery, Palliative Treatment, Periodontal Treatment, Preventive Services, Prophylaxis, Removable Prosthesis, and Restorative Services as listed by alphanumeric procedure code in Schedule A.
C.R.S. means the Colorado Revised Statutes.
Dental Health Professional Shortage Area or Dental HPSA means a geographic area, population group, or facility so designated by the Health Resources and Services Administration of the U.S. Department of Health and Human Services.
Dental Prosthesis means any device or appliance replacing one or more missing teeth and associated structures if required.
Department means the Colorado Department of Health Care Policy and Financing established pursuant to title 25.5, C.R.S.
Diagnostic Imaging means a visual display of structural or functional patterns for the purpose of diagnostic evaluation.
Economically Disadvantaged means a person whose Income is at or below 250% of the most recently published federal poverty level for a household of that size.
Eligible Senior or patient means an adult who is 60 years of age or older, who is Economically Disadvantaged, who is not eligible for dental services under Medicaid or the Old Age Pension Health and Medical Care Program, and who does not have private dental insurance. An Eligible Senior or patient is not ineligible solely because he/she is receiving dental benefits under Medicare or Medicare Advantage Plans.
Emergency Services means the need for immediate intervention by a Qualified Provider to stabilize an oral cavity condition.
Endodontic Services means services which are concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues, including pulpectomy.
Evaluation means an assessment that may include gathering of information through interview, observation, examination, and use of specific tests that allows a dentist to diagnose existing conditions.
Federally Qualified Health Center means a federally funded nonprofit health center or clinic that serves medically underserved areas and populations as defined in 42 U.S.C. section 1395x (aa)(4).
Income means any cash, payments, wages, in-kind receipt, inheritance, gift, prize, rents, dividends, or interest that are received by an individual or family.

Income may be self-declared. Resources are not included in Income.

Max Allowable Fee means the total reimbursement listed by procedure for Covered Dental Care Services under the Colorado Dental Health Care Program for Low-Income Seniors in Schedule A. The Max Allowable Fee is the sum of the Program Payment and the Max Patient Co-Pay.
Max Patient Co-Pay means the maximum amount that a Qualified Provider may collect from an Eligible Senior listed by procedure in Schedule A for Covered Dental Services under the Colorado Dental Health Care Program for Low-Income Seniors.
Medicaid means the Colorado medical assistance program as defined in article 4 of title 25.5, C.R.S.
Medicare means the federal health insurance program for people who are 65 or older; certain younger people with disabilities; or people with End-Stage Renal Disease.
Medicare Advantage Plans mean the plans offered by Medicare-approved private companies that must follow rules set by Medicare and may provide benefits for services Medicare does not, such as vision, hearing, and dental care.
Old Age Pension Health and Medical Care Program means the program described at Section 8.940 et. seq. and as defined in sections 25.5-2-101 and 26-2-111(2), C.R.S.
Oral and Maxillofacial Surgery means the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.
Palliative Treatment for dental pain means emergency treatment to relieve the patient of pain; it is not a mechanism for addressing chronic pain.
Periodontal Treatment means the therapeutic plan intended to stop or slow periodontal disease progression.
Preventive Services means services concerned with promoting good oral health and function by preventing or reducing the onset and/or development of oral diseases or deformities and the occurrence of oro-facial injuries.
Program Payment means the maximum amount by procedure listed in Schedule A for Covered Dental Care Services for which a Qualified Grantee may invoice the Department under the Colorado Dental Health Care Program for Low-Income Seniors. Program Payment must not be less than the reimbursement schedule for fee-for-service dental fees under the medical assistance program established in Articles 4, 5, and 6 of 10 CCR 2505-10.
Prophylaxis means the removal of dental plaque and calculus from teeth, in order to prevent dental caries, gingivitis and periodontitis.
Qualified Grantee means an entity that can demonstrate that it can provide or Arrange For the provision of Covered Dental Care Services and may include but is not limited to:

a. An Area Agency on Aging, as defined in section 26-11-201, C.R.S.;

b. A community-based organization or foundation;

c. A Federally Qualified Health Center, safety-net clinic, or health district;

d. A local public health agency; or e. A private dental practice.

Qualified Provider means a licensed dentist or dental hygienist in good standing in Colorado or a person who employs a licensed dentist or dental hygienist in good standing in Colorado and who is willing to accept reimbursement for Covered Dental Services. A Qualified Provider may also be a Qualified Grantee if the person meets the qualifications of a Qualified Grantee.
Removable Prosthesis means complete or partial Dental Prosthesis, which after an initial fitting by a dentist, can be removed and reinserted by the eligible senior.
Restorative Services means services rendered for the purpose of rehabilitation of dentition to functional or aesthetic needs of the patient.
Senior Dental Advisory Committee means the advisory committee established pursuant to section 25.5-3-406, C.R.S.. 8.960.B Legal Basis 8.960.B.1 The Colorado Dental Health Care Program for Low-Income Seniors is authorized by state law at part 4 of article 3 of title 25.5, C.R.S.. 8.960.C Request of Grant Proposals and Grant Award Procedures 8.960.C.1. Request for Grant Proposals 8.960.C.1.a Grant awards shall be made through an application process. The request for grant proposals form shall be issued by the Department and posted for public access on the Department’s website at https://www.colorado.gov/hcpf/researchdata-and-grants at least 30 days prior to the due date. 8.960.C.2 Evaluation of Grant Proposals 8.960.C.2.a Proposals submitted for the Colorado Dental Health Care Program for Low-Income Seniors will be evaluated by a review panel in accordance with the following criteria developed under the advice of the Senior Dental Advisory Committee.

The review panel will be comprised of individuals who are deemed qualified by reason of training and/or experience and who have no personal or financial interest in the selection of any particular applicant.
The sole objective of the review panel is to recommend to the Department’s executive director those proposals which most accurately and effectively meet the goals of the program within the available funding.
Preference will be given to grant proposals that clearly demonstrate the applicant’s ability to:

a) Outreach to and identify Eligible Seniors;

b) Collaborate with community-based organizations; and c) Serve a greater number of Eligible Seniors or serve Eligible Seniors who reside in a geographic area designated as a Dental HPSA.

The review panel shall consider the distribution of funds across the state in recommending grant proposals for awards. The distribution of funds should be based on the estimated percentage of Eligible Seniors in the state by Area Agency on Aging region as provided by the Department. 8.960.C.3 Grant Awards 8.960.C.3.a The Department’s executive director, or his or her designee, shall make the final grant awards to selected Qualified Grantees for the Colorado Dental Health Care Program for Low-Income Seniors. 8.960.C.4 Qualified Grantee Responsibilities 8.960.C.4.a A Qualified Grantee that is awarded a grant under the Colorado Dental Health Care Program for Low-Income Seniors is required to:
Identify and outreach to Eligible Seniors and Qualified Providers;
Demonstrate collaboration with community-based organizations;
Ensure that Eligible Seniors receive Covered Dental Care Services efficiently without duplication of services;
Maintain records of Eligible Seniors serviced, Covered Dental Care Services provided, and moneys spent for a minimum of six (6) years;
For Eligible Seniors with dental coverage through a Medicare Advantage Plan, bill the Medicare Advantage Plan for dental procedures covered by the Medicare Advantage Plan prior to seeking payment from the Department. The Colorado Dental Health Care Program is secondary to the Medicare Advantage Plan dental coverage;
Distribute grant funds to Qualified Providers in its service area or directly provide Covered Dental Care Services to Eligible Seniors;
Expend no more than seven (7) percent of the amount of its grant award for administrative purposes; and 8) Submit an annual report as specified under section 8.960.3.F. 8.960.C.5 Invoicing 8.960.C.5.a A Qualified Grantee that is awarded a grant under the Colorado Dental Health Care Program for Low-Income Seniors shall submit invoices on a form and schedule specified by the Department. Covered Dental Care Services shall be provided before a Qualified Grantee may submit an invoice to the Department.
Invoices shall include the number of Eligible Seniors served, the alphanumeric code and procedure description as listed in Schedule A, and any other information required by the Department.
The Department will pay no more than the established Program Payment per procedure rendered, as listed in Schedule A.
Eligible Seniors shall not be charged more than the Max Patient Co-Pay as listed in Schedule A.
Qualified Grantees shall not bill the Department for any procedures covered by Medicare Advantage Plans that have been billed and paid by the Medicare Advantage Plans;
Qualified Grantees shall indicate on the invoice if the Eligible Senior has dental coverage through a Medicare Advantage Plan and any claim to the Medicare Advantage Plan was adjudicated prior to billing the Department;
Qualified Grantees may invoice for no more than seven (7) percent of the Program Payment for administrative costs. 8.960.C.6 Annual Report 8.960.C.6.a On or before September 1, 2016, and each September 1 thereafter, each Qualified Grantee receiving funds from the Colorado Dental Health Care Program for Low-Income Seniors shall submit a report to the Department following the state fiscal year contract period. 8.960.C.6.b The annual report shall be completed in a format specified by the Department and shall include:
The number of Eligible Seniors served;
The types of Covered Dental Care Services provided;
An itemization of administrative expenditures;
The procedures and amounts billed to Medicare Advantage Plans for Eligible Seniors; and 5) Any other information deemed relevant by the Department.

10 CCR 2505-10 § 8.960 SCHEDULE A: COLORADO DENTAL HEALTH CARE

PROGRAM FOR LOW-INCOME SENIORS COVERED SERVICES AND PROCEDURE

CODES

Capitalized terms within this schedule shall have the meaning specified in the Definitions section.

Periodic oral D0120 $32.41 $32.41 $0.00 Evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation, periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures.

The findings are discussed with the patient. Report additional diagnostic procedures separately. Frequency: Two of D0120, D0150, D0180 per 12 Limited oral problem focused D0140 $54.90 $44.90 $10.00 An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Definitive procedures may be required on the same date as the evaluation. Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infections, etc. Frequency: Two of D0140 per 12 months per grantee per patient. Not reimbursable on the same date as D0120, D0150, or D0180.

Dental hygienists may only provide for an established patient of record.

Comprehens ive oral new or D0150 $51.57 $51.57 $0.00 Evaluation used by general dentist and/or a specialist when evaluating a patient comprehensively. Applicable to new patients; established patients with significant health changes or other unusual circumstances by report; or established patients who have been absent from active treatment for three or more years. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately. This includes an evaluation for oral cancer, the evaluation and recording of the patient's dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occulusal relationships, periodontal conditions (including periodontal screening and/or charting), hard and soft tissue anomalies, etc. Frequency: One of D0150 per 36 months per grantee per patient. Two of D0120, D0150, D0180 per 12 months per grantee per patient.

Comprehens ive periodontal new or D0180 $45.04 $45.04 $0.00 This procedure is indicated for patients showing signs & symptoms of periodontal disease & patients with risk factors such as smoking or diabetes. It includes A comprehensive evaluation of periodontal conditions, including full mouth probing and periodontal charting.

Indicated for patients exhibiting signs or symptoms of periodontal disease, systemic medical conditions, or patients with social risk factors. It includes an evaluation for oral cancer, an evaluation of the patient’s medical history, a general assessment, and includes an evaluation of current dental conditions. Frequency: One of D0180 per 36 months per patient. Two of D0120, D0150, D0180 per 12 months per comprehensi ve series of D0210 $88.31 $88.31 $0.00 Radiographic survey of whole mouth, intended to display the crowns & roots of all teeth, periapical areas, interproximal areas and alveolar bone including edentulous areas.

Panoramic radiographic image D0330 & bitewing radiographic images D0270-D0277 taken on the same date of service shall not be billed as a D0210.

Minimum of 12-20 films is required. Payment for additional periapical radiographs within 60 days of a full mouth series D0277 or a panoramic film D0330 is not covered unless there is evidence of trauma. per patient. Any combination of x-rays taken on the same date of service that equals or exceeds the max allowable fee for D0210 must be billed and reimbursed as periapical first D0220 $13.21 $13.21 $0.00 Six of D0220 per 12 months per patient. Report additional radiographs as D0230. Working and final endodontic treatment films are not covered. Not covered if billed with D3310, D3320, D3330. Any combination of D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. Not allowed on the same day as D0210. periapical additional D0230 $13.21 $13.21 $0.00 D0230 must be utilized for additional films taken beyond D0220. Working and final endodontic treatment films are included in the endo codes. Not covered if billed with D3310, D3320, or D3330. Not allowed on the same day as D0210. Any Bitewing single D0270 $13.79 $13.79 $0.00 D0272 $22.20 $22.20 $0.00 D0273 $26.17 $26.17 $0.00 four D0274 $31.20 $31.20 $0.00 Vertical bitewings – seven to eight D0277 $46.25 $46.25 $0.00 per patient. Counts as a full mouth series. Counts as an intraoral complete series. Counts as an intraoral complete series.

Any combination of D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Panoramic D0330 $55.21 $55.21 $0.00 per grantee per patient. Counts as a full mouth series.

Prophylaxis adult D1110 $82.39 $82.39 $0.00 Removal of plaque, calculus and stains from the tooth structures and implants in the permanent and transitional dentition. It is intended to control local irritational factors. Frequency: ● Two of D1110, D4346, D4910 per 12 months per patient. ● May be alternated with D4910 for maintenance of periodontally-involved individuals. ● D1110 cannot be billed on the same day as D4341 – D4910. ● Only allowed for cases with a

history of surgical or nonsurgical periodontal treatment, excluding D4355.

Topical application of fluoride varnish D1206 $35.46 $35.46 $0.00 Topical fluoride application is to be used in conjunction with prophylaxis or preventive appointment. Should be applied to whole mouth. Frequency: up to four times per 12 calendar months. Cannot be used with D1208.

Topical application of fluoride excluding varnish D1208 $12.25 $12.25 $0.00 Any fluoride application, including swishing, trays or paint on variety, to be used in conjunction with prophylaxis or preventive appointment.

Frequency: one time per 12 calendar months. Cannot be used with D1206. D1206 varnish should be utilized in lieu of D1208 whenever possible.

Application of caries arresting medicament – per tooth D1354 $46.08 $46.08 $0.00 Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure. Frequency: Two of D1354 per 12 months per patient per tooth for permanent teeth. Not to exceed 4 times per tooth in a lifetime. Cannot be billed on the same day as D1355 or D3110 or D3120 or any D2000 series code (D2140–D2954).

Must Report tooth number.

Caries preventive medicament application – D1355 $5.83 $5.83 $0.00 For primary prevention or remineralization. Medicaments applied do not include topical fluorides. Medicaments that may be applied during the delivery of D1355 procedure include Silver Diamine Fluoride (SDF), Silver Nitrate (SN), thymol-CHX varnish, and topical povidone iodine (PVP-I). Cannot be billed on the same day as: D1206, D1208, D1354, D0140, D9110, or any restoration codes on the same day or within 12 months of D2140 thru D2954. Maximum of four D1355 per tooth per lifetime.

Must report tooth number.

D2140 $120.02 $110.02 $10.00

D2150 $150.59 $140.59 $10.00

D2160 $182.40 $172.40 $10.00

D2161 $218.93 $208.93 $10.00

D2330 $116.82 $106.82 $10.00

D2331 $142.18 $132.18 $10.00

D2332 $172.09 $162.09 $10.00 11, 22 – surfaces (anterior)

D2335 $205.55 $195.55 $10.00 . Frequency: One of D2140 – D2391 $120.02 $110.02 $10.00 D2392 $150.59 $140.59 $10.00 D2393 $182.40 $172.40 $10.00 D2394 $218.93 $208.93 $10.00 porcelain/cer amic D2740 $767.54 $717.54 $50.00 fused to high D2750 $760.70 $710.70 $50.00 fused to D2751 $698.14 $648.14 $50.00 fused to D2752 $724.56 $674.56 $50.00 cast D2781 $542.27 $492.27 $50.00 cast noble metal D2782 $542.27 $492.27 $50.00 porcelain/cer amic D2783 $542.27 $492.27 $50.00 This procedure does not include facial veneers. Frequency: One of D2740 – D2794 per 84 Second molars are only covered if it meets criteria and is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. cast high D2790 $783.98 $733.98 $50.00 cast D2791 $542.27 $492.27 $50.00 cast noble metal D2792 $542.27 $492.27 $50.00 Crown titanium and titanium alloys D2794 $757.16 $707.16 $50.00 Re-cement or re-bond inlay, onlay, veneer or coverage restoration D2910 $62.21 $52.21 $10.00 Not allowed within 6 months of placement.

Re-cement or re-bond crown D2920 $63.44 $53.44 $10.00 Not allowed within 6 months of placement.

Placement of Interim Direct Restoration D2940 $65.21 $55.21 $10.00 Direct placement of a restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, manage caries, create a seal for endodontic isolation, or prevent further deterioration until definitive treatment can be rendered. Not to be used for endodontic access closure, or as a base or liner under restoration.

One of D2940 per lifetime per tooth. RDH's will receive reimbursement when used for telehealth dentistry in partnership with treating dentist.

Core buildup, including any pins when required D2950 $160.082 25.00 $135.08 $25.00 . Refers to building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation. Frequency: One of D2950, D2952, D2954 per 84 Refers to building up of anatomical crown when restorative crown will be placed.

Not payable on the same tooth and same day as D2951.

Pin retention - per tooth, in addition to restoration D2951 $43.02 $33.02 $10.00 Pins placed to aid in retention of restoration. Can only be used in combination with a multi-surface amalgam.

Post and core in addition to crown, indirectly fabricated D2952 $232.12 $207.12 $25.00 Post and core are custom fabricated as a single unit.

Frequency: One of D2950, D2952, D2954 per 84 months per patient per tooth. Refers to building up of anatomical crown when restorative crown will be placed. Not payable on the same tooth and same day as D2951.

Prefabricate d post and core in addition to crown D2954 $189.50 $164.50 $25.00 Core is built around a prefabricated post. This procedure includes the core material. Frequency: One of D2950, D2952, D2954 per 84 Refers to building up of anatomical crown when restorative crown will be placed.

Not payable on the same tooth and same day as D2951.

Application of Hydroxyapati te Regeneratio n Medicament - per tooth D2991 $66.30 $56.30 $10.00 Preparation of tooth surfaces and topical application of a scaffold to guide hydroxyapatite regeneration. One of D2991 per Cannot be billed on the same day/same tooth as any other D2000's codes or D1354.

D3310 $725.80 $675.80 $50.00

Frequency: One D3310 per Teeth covered: 6-11 and 22-27. premolar D3320 $825.46 $775.46 $50.00 Teeth 4, 5, 12, 13, 20, 21, 28, 29 Frequency: One D3320 per Teeth covered: 4, 5, 12, 13, 20, 21, 28, and 29. molar tooth D3330 $987.37 $937.37 $50.00 Teeth 2, 3, 14, 15, 18, 19, 30, 31 Frequency: One D3330 per Second molars are only covered if it meets criteria and is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Teeth covered: 2, 3, 14, 15, 18, 19, 30, and 31.

Anterior D3346 $820.31 $770.31 $50.00 One of D3346 per lifetime per Program.

Premolar D3347 $932.28 $882.28 $50.00 Teeth 4, 5, 12, 13, 20, 21, 28, 29 One of D3347 per lifetime per Molar D3348 $1,102.92 $1,052.92 $50.00 Teeth 2, 3, 14, 15, 18, 19, 30, 31 One of D3348 per lifetime per Program. Second molars are scaling & root planing teeth per D4341 $235.20 $225.20 $10.00 UL, or UR This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as part of pre-surgical procedures in others. Frequency: ● One of D4341, D4342 per 36 months per patient per quadrant. A minimum of four affected teeth in the quadrant. ● Maximum of two quadrants per date of service in a nonhospital setting. ● Cannot be charged on same date as D1110. scaling & root planing teeth per D4342 $160.28 $160.28 $0.00 UL, or UR This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as part of pre-surgical procedures in others. Current periodontal charting must be present in patient chart documenting active periodontal disease. Frequency: ● One of D4341, D4342 per 36 months per patient per quadrant. A maximum of three teeth in the affected ● Maximum of two quadrants per date of service in a nonhospital setting..

Documentation of other treatment provided at same time will be requested. ● Cannot be charged on same date as D1110.

Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation D4346 $57.89 $47.89 $10.00 The removal of plaque, calculus, and stains from supra- and subgingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures. Frequency: Two of D1110, D4346 per 12 months per patient. Not reimbursed when billed on the same date of service as D1110, D4341, D4342, D4355, D4910.

Full mouth debridement to enable a comprehensi ve periodontal evaluation and diagnosis on a visit D4355 $100.04 $90.04 $10.00 One of (D4335) per 36 months per patient. D0150, D0160, D0180 D1110 is not reimbursable when provided on the same day of service as D4355. D4355 is not reimbursable if patient record indicates D1110 or D4910 have been provided in the previous 12 month period. Other D4000 series codes are not reimbursable when provided on the same date of service as D4355. maintenance D4910 $125.91 $125.91 $0.00 This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered. Frequency: ● Up to four times per fiscal year per patient. ● Cannot be charged on the same date as D4346. ● Cannot be charged within the first three months following active periodontal treatment.

D5110 $931.41 $851.41 $80.00 delivery of a complete maxillary denture to the patient. D5110 or D5120 cannot be used to report an immediate denture, D5130 or D5140. Routine follow-up adjustments/relines within 6 reimbursement. A complete denture is made after teeth have been removed and the gum and bone tissues have healed - or to replace an existing denture. This can vary greatly depending upon patient, oral health, overall health, and other confounding factors. Frequency: Program will only pay for one per every 60 months - documentation that maintained.

D5120 $932.94 $852.94 $80.00 delivery of a complete patient. D5110 or D5120 cannot be used to report an immediate denture, D5130, D5140. Routine follow-up adjustments/relines complete denture is made after teeth have been removed and the gum and bone tissues have healed - or to replace an existing denture. This can vary greatly depending upon patient, oral health, overall health, and other confounding factors. Frequency:

Program will only pay for one per every 60 months - D5130 $931.41 $851.41 $80.00 delivery of an immediate Routine follow-up adjustments/soft tissue condition immediate denture is made prior to teeth being extracted and is inserted same day of extraction of remaining natural teeth.

Frequency: D5130 can be per patient. Complete denture, D5110, may be considered 60 months after immediate denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be D5140 $932.94 $852.94 $80.00 delivery of an immediate patient. Routine follow-up adjustments/soft tissue condition immediate denture is made prior to teeth being extracted and is inserted same day of extraction of remaining natural teeth.

Frequency: D5140 can be per patient. Complete dentures, D5120, may be considered 60 months after immediate denture was reimbursed – documentation that existing prosthesis cannot be made serviceable must be D5211 $646.83 $586.83 $60.00 D5211 and D5212 are considered definitive treatments. partial resin base denture can be made right after having teeth resin base denture can also be will only pay for one resin maxillary per every 36 months - D5212 $646.83 $586.83 $60.00 patient. D5211 and D5212 are Routine follow-up adjustments/relines within 6 reimbursement. A partial resin base denture can be made right after having teeth extracted multiple). A partial resin base will only pay for one every 36 months - documentation that maintained.

D5213 $900.48 $840.48 $60.00

D5213 and D5214 are partial cast metal base can also be made right after having teeth cast metal base denture can be will only pay for one maxillary per every 60 months - D5214 $900.48 $840.48 $60.00 patient. D5213 and D5214 are partial cast metal base can be made right after having teeth cast metal base denture can also be made before having teeth will only pay for one mandibular per every 60 months - D5221 $646.83 $586.83 $60.00 D5221 can be reimbursed only once per lifetime per patient and must be on the same date of service as the extraction. relines within 6 months is to be immediate partial resin base denture can be made before the cost. Frequency: A maxillary partial denture may be considered 36 months after D5222 $646.83 $586.83 $60.00 patient. D5222 can be per patient and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 months is to be anticipated and reimbursement. An immediate partial resin base denture can be the cost. Frequency: A mandibular partial denture may be considered 36 months after D5223 $900.48 $840.48 $60.00 D5223 can be reimbursed only once per lifetime per patient and must be on the same date of service as the extraction. relines within 6 months is to be immediate partial cast metal framework with resin base denture can be made before the cost. Frequency: A maxillary partial denture may be considered 60 months after D5224 $900.48 $840.48 $60.00 patient. D5224 can be per patient and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 reimbursement. An immediate partial cast metal framework with resin base denture can be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and “try-in” appointments may be necessary and are included in the cost.

Frequency: A mandibular partial denture may be considered 60 months after immediate partial denture was reimbursed.

Documentation that existing Immediate Denture Form must be on file. flexible base D5225 $798.83 $738.83 $60.00 delivery of a partial maxillary denture to the patient. D5225 and D5226 are considered definitive treatment. Routine follow-up adjustments or relines partial flexible base can be made right after having teeth extracted multiple). A partial flexible base will only pay for one maxillary per every 36 months flexible base D5226 $798.83 $738.83 $60.00 delivery of a partial mandibular denture to the patient. D5225 and D5226 are considered definitive treatment. Routine follow-up adjustments or relines partial flexible base can be made right after having teeth extracted multiple). A partial flexible base will only pay for one mandibular per every 36 months - D5410 $54.41 $44.41 $10.00 D5410 per 12 months per client.

D5411 $54.41 $44.41 $10.00

D5411 per 12 months per client.

Partial D5421 $54.41 44.41 $10.00 D5421 per 12 months per client.

Partial D5422 $54.41 $44.41 $10.00 D5422 per 12 months per client.

Repair D5511 $131.84 $121.84 $10.00 Repair broken complete mandibular denture base.

Frequency: Two of D5511 per 12 Repair D5512 $131.84 $121.84 $10.00 Repair broken complete maxillary denture base.

Frequency: Two of D5512 per 12 Replace missing or broken teeth - complete denture - per D5520 $98.85 $88.85 $10.00 Replacement/repair of missing or broken teeth. Teeth 1 – 32 and must report tooth number.

Repair resin D5611 $99.55 $89.55 $10.00 Repair resin partial mandibular denture base. Frequency: Two D5611 per 12 months per Repair resin D5612 $99.55 $89.55 $10.00 Repair resin partial maxillary denture base. Frequency: Two D5612 per 12 months per Repair cast framework, D5621 $129.27 $119.27 $10.00 Repair cast partial mandibular framework. Frequency: Two of D5621 per 12 months per Repair cast framework, D5622 $129.27 $119.27 $10.00 Repair cast partial maxillary framework. Frequency: Two of D5622 per 12 months per Repair or replace materials – D5630 $139.66 $129.66 $10.00 Repair of broken clasp on partial denture base – per tooth. Teeth 1 – 32, report tooth number(s).

Frequency: One of D5630 per 12 Replace missing or teeth-per D5640 $100.04 $90.04 $10.00 Repair/replacement of missing tooth. Teeth 1 – 32, report tooth number(s). Frequency: One of D5640 per 12 months per patient Add tooth to existing D5650 $89.86 $79.86 $10.00 Adding tooth to partial denture base. Frequency: One of D5650 per 12 months per patient per tooth. Documentation may be requested when charged on partial delivered in last 12 months. Teeth 1 – 32, report tooth number(s).

Add clasp to existing D5660 $145.08 $135.08 $10.00 Adding clasp to partial denture base – per tooth. Frequency:

One of D5660 per 12 months per patient per tooth. Documentation may be requested when charged on partial delivered in last 12 months. Teeth 1 – 32, report tooth number(s).

D5710 $307.15 $282.15 $25.00

D5711 $308.35 $283.35 $25.00

D5720 $295.74 $270.74 $25.00

D5721 $295.74 $270.74 $25.00

D5730 $190.08 $180.08 $10.00

D5731 $190.08 $180.08 $10.00

D5740 $187.69 $177.69 $10.00

D5741 $189.49 $179.49 $10.00

D5750 $253.13 $228.13 $25.00

D5751 $254.31 $229.31 $25.00

D5760 $251.33 $226.33 $25.00

D5761 $251.33 $226.33 $25.00

Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7140 $119.07 $109.07 $10.00

Includes removal of tooth structure, minor smoothing of socket bone, and closure as necessary. Frequency: One of D7140 per lifetime per patient per tooth. Teeth 1 – 32.

Extraction, erupted requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiost eal flap if indicated D7210 $184.54 $174.54 $10.00 Includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure.

Frequency: One of D7210 per Teeth 1 - 32 tooth-soft tissue D7220 $220.66 $200.66 $20.00 Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation.

D7220 per lifetime per patient partially bony D7230 $272.40 $252.40 $20.00

Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal.

D7230 per lifetime per patient completely bony D7240 $316.18 $296.18 $20.00 Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal.

D7240 per lifetime per patient completely boney, with unusual surgical complication s D7241 $415.64 $395.64 $20.00 Most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth position. Teeth 1-32. Frequency:

One of D7241 per lifetime per patient per tooth. residual tooth roots (cutting procedure)

D7250 $194.64 $184.64 $10.00

Includes cutting of soft tissue and bone, removal of tooth structure, and closure. Cannot be charged for removal of broken off roots for recently extracted tooth. Teeth 1 – 32 Frequency:

One of D7250 per lifetime per patient per tooth. Will not be paid to the dentists or group that removed the tooth.

Primary closure of a sinus perforation D7261 $485.35 $475.35 $10.00 Subsequent to surgical removal of tooth, exposure of sinus requiring repair, or immediate closure of oroantral or oralnasal communication in absence of fisulous tract. Narrative of medical necessity may be required and if the sinus perforation was caused by a current grantee or provider of the program.

Incisional biopsy of oral tissue hard (bone, tooth)

D7285 $196.67 $186.67 $10.00

For partial removal of lesion only.

This procedure involves biopsy of osseous or intra-osseous lesions (example cyst, tumor) and is not used for apicectomy/periradicular surgery.

This procedure does not entail an excision. Only covered if there is a suspicious lesion. Must have a pathology report in file.

Incisional biopsy of oral tissuesoft D7286 $158.88 $148.88 $10.00 For partial removal of lesion .

This procedure is not used at the same time as codes for apicoectomy/periradicular curettage. This procedure does not entail an excision. Treatment notes must include documentation and proof that biopsy was sent for evaluation.

Only covered if there is a suspicious legion. y in D7310 $148.69 $138.69 $10.00 The alveoloplasty is distinct (separate procedure) from extractions. Usually in D7310 or D7311 per lifetime per patient per quadrant. Minimum of 4 extractions in the affected y in D7311 $148.69 $138.69 $10.00 The alveoloplasty is distinct (separate procedure) from extractions. Usually in preparation for a prosthesis or D7311 or D7310 per lifetime per patient per quadrant. Maximum of 3 extractions in the affected y not in D7320 $214.114 $204.11 $10.00 No extractions performed in an edentulous area. See D7310 if teeth are being extracted concurrently with the alveoloplasty. Usually in D7320 or D7321 per lifetime per patient per quadrant. y not in D7321 $214.11 $204.11 $10.00 No extractions performed in an edentulous area. See D7311 if teeth are being extracted concurrently with the alveoloplasty. Usually in D7320 or D7321 per lifetime per patient per quadrant.

Excision of benign Lesion up to 1.25 cm D7410 200.90 190.90 $10.00 Must have a pathology report in file. benign nonodontoge nic cyst or tumor-lesion diameter up to 1.25 cm D7460 $253.47 $243.47 $10.00 Must have a pathology report in file. lateral exostosis (maxilla or mandible)

D7471 $310.17 $300.17 $10.00

Per Arch LA, UA seating of denture and does not allow denture seal. torus palatinus D7472 $364.79 $354.79 $10.00 seating of denture and does not allow denture seal. torus mandibularis D7473 $355.79 $345.79 $10.00 seating of denture and does not allow denture seal.

Incision & drainage of abscess intraoral soft tissue D7510 $119.26 $109.26 $10.00 Incision through mucosa, including periodontal origins.

One of D7510 per lifetime per patient per tooth.

Palliative treatment of dental pain – per visit D9110 $82.04 $57.04 $25.00 Treatment that relieves pain but is not curative; services provided do not have distinct procedure codes. Not allowed with any other services other than radiographs. Cannot be billed when the only other service is writing a prescription.

Evaluation for moderate sedation, deep sedation or general anesthesia D9219 $43.83 $43.83 $0.00 One of D9219 per 12 months per grantee per patient. n of deep sedation/gen eral anesthesia first 15 minute thereof With or without con of nitrous oxide D9222 $124.76 $114.76 $10.00 One of D9222 per 1 day per n of deep sedation/gen eral anesthesia - 15 minute D9223 $110.09 $100.09 $10.00 Not allowed with D9243 n of sedation intravenous first 15 minute When sedation is achieved by n and titration of drug(s) intravenously . With or without con of nitrous oxide.

D9239 $124.76 $114.76 $10.00

Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and noninvasive monitoring protocol and remains in continuous attendance of the patient.

Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room. The level of anesthesia is determined by the provider’s documentation of the anesthetic effects upon the central nervous system. One of D9239 per 1 day per patient. n of sedation intravenous - 15 minute D9243 $110.09 $100.09 $10.00 Thirteen of D9243 per 1 day per patient. Not allowed with D9223 EXPLANATION OF RESTORATIONS Location Number of Surfaces Characteristics Anterior - Mesial, Distal, Incisal, Lingual, or Facial (or Labial) 1 Placed on one of the five surface classifications. . 2 Placed, without interruption, on two of the surface 3 Placed, without interruption, on three of the surface 4 or more Placed, without interruption, on four or more of the surface Posterior – Mesial, Distal, Occlusal, Lingual, or Buccal 1 Placed on one of the five surface classifications. 2 Placed, without interruption, on two of the surface 3 Placed, without interruption, on three of the surface 4 or more Placed, without interruption, on four or more of the surface NOTE: Tooth surfaces are reported using the letters in the following table.

Surface Code Buccal B Distal D Facial (or Labial)

F Incisal I Surface Code Lingual L Mesial M Occlusal O 8.970 PROVIDER STABILIZATION FUND 8.970.1 GENERAL DESCRIPTION 8.970.1.A In accordance with Colorado Senate Bill (SB) 25-290 Stabilization Payments for Safety Net Providers, the Provider Stabilization Fund was created to make stabilization payments to eligible safety net providers. The bill directed the state treasury to establish a Provider Stabilization Fund to collect the monies to be used for payments and set forth how the funds will be allocated and designated the Department of Health Care Policy & Financing (the Department) as the administrator of the payments. 8.970.1.B The Provider Stabilization Fund provides an allocation of monies to safety net providers that serve individuals who are considered low-income and uninsured. Monies shall be allocated based on the number of eligible patients in an amount proportional to the total number of eligible patients served by all safety net providers who qualify for monies from this fund.

8.970.2 DEFINITIONS 8.970.2.A Advisory Board means The Provider stabilization fund advisory board created pursuant to C.R.S. § 25.5-3-605, 8.970.2.B. Children’s Basic Health Plan also known as Child Health Plan Plus (CHP+) means the program as specified in Article 8 of Title 25.5, C.R.S. 8.970.2.C. Comprehensive Behavioral Health Provider has the same meaning as defined at C.R.S. § 27-50-101(11). 8.970.2.D. Eligible Patient means a low-income, uninsured individual who is a patient receiving medical services from a Qualified Provider:

Whose annual household income is at or below two hundred percent (200%) of the Federal Poverty Guideline (FPG);
Who is not enrolled in the Medical Assistance Program, the Children’s Basic Health Plan, Medicare or any other governmental health care coverage such as through Social Security, the Veterans Administration, Military Dependency (TRICARE or CHAMPUS), or the United States Public Health Service; and 3. For whom there is no Third Party Payer paying or reimbursing the safety net provider for all or a portion of the amount charged for the services provided to the individual. 8.970.2.E. Eligible Safety Net Provider - A Safety Net Provider who is identified by the Department to receive funding from the Provider Stabilization Fund. 8.970.2.G. Monies means funds appropriated, transferred, or credited to the Provider Stabilization Fund created in the State Treasury consisting of:
Money credited to the fund as a loan from the unclaimed property trust fund pursuant to C.R.S. § 38-13-801(6) ;
Money appropriated, transferred, or credited to the fund by the general assembly;
Gifts, grants, or donations the Department may receive from public or private sources for the fund. 8.970.2.H. Outside Entity means a business or professional that is not classified as an employee of the provider or the Department and does not have a direct or indirect financial interest with the provider, but has auditing experience or experience working directly with the Medical Assistance Program or similar services or grants for Eligible Patients. 8.970.2.I. Primary Care means care that deals with the individual rather than an organ system or an abnormal physiology and provides an array of services covering the preventive, diagnostic, and therapeutic needs of patients, including referral and coordination of care to other services. For purposes of the Provider Stabilization Fund, primary care may include other services based on a patient’s needs including dental, comprehensive behavioral health, and vision.
8.970.2.J. Safety Net Provider means a provider as defined at C.R.S. § 25.5-3-602(8). A comprehensive Community Behavioral Health provider as defined at C.R.S. § 27-50-101(11);
A Rural Health Clinic as defined at 42 U.S.C § 1395x(aa)(2);
A Federally Qualified Health Center as defined at 42 U.S.C. § 1395x(aa)(4); or 4. A health-care provider that is delivering primary care services and at least 50% of whose client caseload is individuals who are enrolled in Medicaid, Medicare, or the Children’s Basic Health Plan or who are Low-Income, Uninsured Individuals. 8.970.2.K. Sliding Fee Schedule means a tiered co-payment system that determines the level of a patient’s financial participation and guarantees that the patient financial participation is below usual and customary charges. Factors considered in establishing the tiered co-payment system are limited to financial status and the number of members in the patient’s family unit. 8.970.2.L. Third Party Payments or Third Party Payer means any individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient. Examples include the Medical Assistance Program; the Children’s Basic Health Plan; Medicare; commercial, individual or employmentrelated health insurance; court-ordered health insurance (such as that required by non-custodial parents); workers' compensation; automobile insurance; and long-term care insurance. 8.970.2.M. Unduplicated User/Patient Count means the sum of patients who have had at least one Visit/Encounter with an eligible safety net provider during the applicable calendar year, but does not include the same patient more than once.

The sum shall be calculated on a specific point-in-time occurring between the end of the applicable calendar year and prior to the submission of the application.

Each patient shall be counted once under only one payment source designation (Third Party Payer or Eligible Patient). The patient’s payment source designation shall be the payment source designation listed for the patient at the specific point-in-time in which the calculation is made. The sum shall not include:

Counting a patient more than once if the same patient returns for additional services (e.g., medical or dental) and/or products (e.g., pharmaceuticals) during the applicable calendar year;
Counting a patient more than once if the payment source designation changed during the applicable calendar year;
Persons who have only received services through an outreach event, community education program, nurse hotline, or other types of communitybased events or programs and services were not recorded on an individual basis;
Persons who have only received services from large-scale efforts such as mass immunization programs, screening programs, and health fairs; or 5. Persons whose only contact with the provider is to receive Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program) counseling and vouchers are not users and the contact does not generate an encounter. 8.970.2.N. Visit/Encounter means an appointment with medical personnel (physicians, physician assistants, nurse practitioners, dentists, behavioral health workers, etc.) in which the patient received health related services and/or products (e.g., pharmaceuticals or radiology) and the appointment included primary care that is customarily billable by a safety net provider..

8.970.3 PROVIDER ELIGIBILITY 8.970.3.A. Safety Net Providers who provide Primary Care to Eligible Patients and who meet all the requirements established for the Provider Stabilization Fund as of the date the application form is submitted to the Department shall receive monies appropriated to the Provider Stabilization Fund. Specifically, the provider shall:

Meet one of the conditions of a Safety Net Provider as specified in Section 8.970.2.K.; and 2. Submit a completed application form according to stated guidelines as specified under Section 8.970.4.

8.970.4 APPLICATION 8.970.4.A. The application form shall be available to providers annually and posted for public access on the Department's website at least 30 calendar days prior to the application due date. 8.970.4.B. At a minimum, the application form shall require responses that:

Demonstrate how the provider meets the criteria of a Safety Net Provider as defined in Section 8.970.2.K.;
Provide an Unduplicated User/Patient Count covering the applicable calendar year which, at a minimum, includes the number of patients enrolled in the Medical Assistance Program and the Children’s Basic Health Plan and the number of patients considered to be Eligible Patients; and 3. Provide certification that the Unduplicated User/Patient Count identified in

Section 8.970.4.B.2 has been verified by an Outside Entity. 8.970.4.C. Providers must complete and provide an application annually. The application must be made in compliance with all specifications in the application form, including format, data and documentation. Applications must be submitted directly to the Department by the required deadline. 8.970.4.D. All providers who submit an application will be notified within 45 days of the application deadline if the provider has met or did not meet the requirements to be a Eligible Qualified Provider. 8.970.4.E. Safety Net Providers who are eligible for the Primary Care Fund are able to use their Primary Care Fund application for the Provider Stabilization Fund.

Such providers must submit the Provider Stabilization Fund Attestation Form to the Department. The attestation form shall:

Be available to providers annually and posted for public access on the Department’s website at least 30 calendar days prior to the application due date;
Provide attestation that the Safety Net Provider wishes to use the data from their Primary Care Fund application for the Provider Stabilization Fund application;
Provide Safety Net Provider contact information and be signed by a representative of the Safety Net Provider.

8.970.5 DISBURSEMENT 8.970.5.A. Eligible Safety Net Providers are determined on a state fiscal year basis and shall receive only those monies received by the Provider Stabilization Fund during that same state fiscal year. Monies disbursed shall include all monies defined in 8.970.2.G. 8.970.5.B. Payments shall be based on the number of Eligible Patients in each Eligible Safety Net Provider’s Unduplicated User/Patient Count in an amount proportionate to the total number of Eligible Patients from all Eligible Safety Net Providers’ Unduplicated User/Patient Counts. 8.970.5.C. The schedule for the disbursement of monies to all Eligible Safety Net Providers shall be dependent on the source and when the funds are available to the Department, with a schedule as follows:

Money received by the Department as a loan from the unclaimed property trust or money appropriated, credited, or transferred by the general assembly shall be distributed to eligible providers no later than March 31 in State Fiscal Year 2025-26 and by September 30 in following State Fiscal Years.
Money received as a gift, grant, or donation shall be distributed in the first month of the quarter following the quarter the money was received.

(Example: Money gifted, granted, or donated between July 1 and September 30 would be distributed by October 3. Money received as a gift, grant, or donation during State Fiscal Year 2025-26 Quarters One and Two (July 1, 2025 - December 31, 2025) would be distributed no later than March 31, 2026.

8.970.6 ADVISORY BOARD 8.970.6.A. Advisory Board function and duties 1. Collaborate with the Department to seek, accept and expend gifts, grants or donations from private or public sources.

Collaborate with the Department to annually allocate money appropriated by the general assembly to the Provider Stabilization Fund.
Assist the Department with the annual Provider Stabilization Fund report as defined in C.R.S. § 25.5-3-606.
Act as consultation to the Department on obtaining federal matching money to the funds in the Provider Stabilization fund.
Support the Department with the implementation of the Safety Net Stabilization fund program. 8.970.6.B. Advisory Board appointment details. The advisory board was created by 25.5-3-605 to support the Department with the implementation of the Provider Stabilization Fund. Board members shall be appointed by the Governor with initial appointments being made no later than August 1, 2025. The Advisory Board shall elect a Chair and Vice-Chair from the provider and consumer members. 8.970.6.C. Advisory Board Membership Tenure, Compensation and Frequency of meetings shall be the following:
Advisory Board members shall serve a three-year term.
Advisory Board members shall serve without compensation or expense reimbursement.
Advisory board meetings shall be held quarterly or as determined necessary by the Chair. 8.970.6.D. Sunset Provisions. The Provider Stabilization Fund Advisory Board will be repealed, effective September 1, 2031, subject to review under the Colorado “Sunset” law.

Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.1000 MEDICAL ASSISTANCE - SECTION 8.1000 Medicare Modernization Act {#sec-10-ccr-2505-10-8.1000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.1000}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

MEDICAL ASSISTANCE - SECTION 8.1000 Medicare Modernization Act 10 CCR 2505-10 8.1000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ 8.1000 MEDICARE MODERNIZATION ACT – LOW-INCOME SUBSIDY ELIGIBILITY 8.1000.1 DEFINITIONS Action means a denial, reduction or termination of the Low-Income Subsidy.

Applicant means the Medicare Part D eligible individual applying for the Low-Income Subsidy.

Authorized Representative means a person designated by the Applicant to act on his/her behalf. Such authorization shall be in writing in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy regulations located at 45 C.F.R. parts 160 and 164. A written designated power of attorney may substitute for the HIPAA compliant release.

Medicaid Eligibility Sites includes any County Human or Social Services office, and departmentally designated Medical Assistance Sites that accepts and processes Medicaid applications.

Full-Benefit Dual Eligible individual means an individual who is receiving full Medicaid benefits and is a recipient of Medicare benefits.

Medicare Part D means the prescription drug benefit provided to Part D eligible individuals pursuant to the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).

Low-Income Subsidy (LIS) means the financial assistance under Medicare Part D that is available to individuals who have limited financial means to pay for copayments, deductibles or premiums, depending upon their resources and income.

Notice of action means a letter on Department letterhead which contains:

A statement of what action the Department or its designee intends to take;
The reasons for the intended action;
The specific regulations that support, or the change in federal or state law that requires the action;
An explanation of:

a. The Applicant's right to request an evidentiary hearing if one is available; or b. In cases of an action based on a change in law, the circumstances under which a hearing will be granted.

The method by which the Applicant may obtain a hearing;
That the Applicant may represent himself/herself or use legal counsel, a relative, a friend, or other spokesman at the hearing.

Part D eligible individual means an individual who is entitled to Medicare Part A or enrolled in Part B.

Resources means liquid resources of the Applicant (and, if married, his/her spouse who is living in the same household), such as checking and savings accounts, stocks, bonds, and other resources that can be readily converted to cash within 20 days.

8.1000.2 APPLICATION FOR THE LOW-INCOME SUBSIDY THROUGH THE SOCIAL

SECURITY ADMINISTRATION 8.1000.2.A. Applicants may apply for the Medicare Part D Low-Income Subsidy through the Social Security Administration (SSA). This can be done by calling SSA, visiting an SSA office, completing an online application, or completing an application form and mailing it to SSA. This is the encouraged method. 8.1000.2.B. If an applicant seeks assistance with an SSA application from a Medicaid Eligibility Site (internet, questions, filling out form), the Medicaid Eligibility Site shall assist the applicant. The Medicaid Eligibility Site shall order applications from SSA and provide to applicants on request. 8.1000.2.C. Any appeals, redeterminations, or notices applicable on a low-income subsidy application submitted through the SSA shall be the responsibility of the SSA.

8.1000.3 APPLICATION FOR THE LOW-INCOME SUBSIDY AT COLORADO MEDICAID

ELIGIBLITY SITES 8.1000.3.A. Applicants may also apply for the Medicare Part D Low-Income Subsidy at their county of residence Medicaid Eligibility Site. If an Applicant applies at his/her county or residence Medicaid Eligibility Site, the Applicant’s eligibility for a Medicare Savings Program (MSP) must first be determined. 8.1000.3.B. If the Applicant is determined to be eligible for a MSP, the Applicant shall be considered deemed eligible for the LIS and therefore shall not need to apply for the LIS. If the Applicant declines the MSP or is determined ineligible for an MSP, then the Applicant’s eligibility for the LIS shall be determined. 8.1000.3.C. Application requirements.

Applications for the LIS shall be considered complete when the Applicant or Authorized Representative applying on the Applicant’s behalf has:

a. Completed all required elements of the application;

b. Provided any statements from financial institutions, as requested, to support information in the application; and c. Certified, under penalty of perjury or similar sanction for false statements, as to the accuracy of the information provided on the application form.

Multiple applications. If the Applicant or his/her Authorized Representative has previously filed an application with their county of residence Medicaid Eligibility Site or SSA which seeks subsidy eligibility for any portion of the eligibility period covered by a subsequent application, the later application is void if the Applicant has received a positive subsidy determination on that earlier application from the State or SSA.

8.1000.3.D. RIGHT TO APPEAL

A notice of action to inform an Applicant shall be sent by the Medicaid Eligibility Site and include the following:

a. Regulatory basis for the decision.

b. Description of how the subsidy was calculated. What income, family size, and resources were used.

c. Premium percentage Applicant is approved for, or reason for denial.

d. Effective date of eligibility.

e. Who made the decision and how to contact them.

f. Appeal rights and procedures.

8.1000.3.E. OPPORTUNITY FOR HEARING

An Applicant shall have an opportunity for a state hearing where:

a. The Department or a Medicaid Eligibility Site made the LIS determination; and b. An application for LIS is denied or is not acted upon with reasonable promptness; and c. The Applicant requesting the hearing believes the action is erroneous.

An Applicant shall not have an opportunity for hearing if the sole issue is a federal or state law requiring an automatic change adversely affecting some or all Applicants.

8.1000.3.F. REQUEST FOR HEARING

The request for a hearing shall be in writing and contain:

a. The Applicant’s name, address and State Identification Number, if applicable;

b. The action, denial or failure to act promptly on which the requested appeal is based; and c. The reason for appealing the action.

The request for a hearing shall be filed with the Office of Administrative Courts within 30 calendar days of the date of the Notice of Action.
The Applicant or his/her Authorized Representative shall be entitled to examine the complete case file and any other documents to be used at hearing at a reasonable time before the hearing or during the hearing. Documents and information that are confidential as a matter of law shall be exempt from this requirement unless they are to be offered as evidence during the hearing.
If the Applicant makes an oral request for a hearing to the Department or its designee, the Department or its designee shall prepare a written request for the individual’s signature or have the individual prepare such a request.

8.1000.3.G. DENIAL OR DISMISSAL OF REQUEST FOR HEARING

The request for hearing shall be denied or dismissed if:

a. The Applicant withdraws the request in writing; or b. The Applicant fails to appear at a scheduled hearing without good cause. Good cause shall mean a sudden severe illness, an accident, or other particular occurrence which, by its emergent nature and drastic effect, prevented appearance at the hearing.

The Applicant shall have ten calendar days from the date of the notice of dismissal of the scheduled hearing to explain, in a letter to the Administrative Law Judge, the reason for his/her failure to appear. If the Administrative Law Judge finds that there was good cause for the nonappearance, the Administrative Law Judge shall schedule another hearing date.

8.1000.3.H. FAIR HEARINGS

A hearing shall cover an Action regarding eligibility;
Conference telephone hearings may be conducted as an alternative to face-to-face hearings. All applicable provisions of the face-to-face hearing shall apply to telephone hearings.
Upon receipt of notice of a Department hearing of an appeal, the county of residence Medicaid Eligibility Site shall arrange for a suitable hearing room appropriate to accommodate the number of persons, including witnesses, who are expected to be in attendance. A Medicaid Eligibility Site representative must attend.
Except as otherwise specifically provided in these rules, the provisions of Section 24-4- 105, C.R.S., as amended, shall apply to the conduct of fair hearings.
The hearing shall be private unless the Applicant requests, on the record, that the hearing be open to the public.
If the appellant is not fluent in English or has a language difficulty, the Department will arrange with county assistance to have a qualified interpreter present who will be sworn to translate correctly at the hearing.

8.1000.3.I. INITIAL DECISIONS

The Administrative Law Judge shall promptly prepare and issue a written Initial Decision and file it with the Office of Appeals of the Department. Initial decisions shall be based exclusively on evidence introduced at the hearing.
The Initial Decision shall be in writing and shall:

a. Summarize the facts.

b. Identify the regulations and evidence supporting the decision.

c. Advise the Applicant that failure to file exceptions to the provisions of the Initial Decision shall waive the right to seek judicial review of a final agency decision affirming those provisions.

The Administrative Law Judge shall be bound by the Department’s interpretation of statutes where the Department has regulations implementing such statutes.
The Administrative Law Judge shall have no jurisdiction or authority to determine issues of constitutionality or legality of the Department’s regulations.

8.1000.3.J. REVIEW BY THE OFFICE OF APPEALS

The Department’s Office of Appeals shall promptly serve the Initial Decision upon each party to the fair hearing by first class mail. Party shall include the Department even if the Department has not previously appeared as a party to the appeal.
Any party seeking to reverse, modify or remand the Initial Decision shall file exceptions with the Office of Appeals within 15 calendar days, plus three calendar days for mailing, of the date the Initial Decision is mailed to the parties.
Exceptions to Initial Decisions shall be in writing and shall state the specific grounds for reversal, modification or remand of the Initial Decision.
A transcript or a copy of the hearing tape is required where the party filing the exceptions asserts that the findings of fact in the Initial Decision are not supported by the weight of the evidence.

a. The party requiring a transcript or a copy of the hearing tape shall request the transcript or tape from the Office of Administrative Courts prior to the filing of exceptions or with the exceptions. The exceptions shall state that a transcript or tape has been requested.

b. The party requesting a transcript or copy of the hearing tape shall advance the cost therefore to the Office of Administrative Courts within five calendar days of the request.

c. While review of the Initial Decision is pending, the transcript or a copy of the hearing tape shall be available for examination by any party to the appeal, during regular business hours of the Office of Appeal.

The Office of Appeals shall promptly serve a copy of the exceptions on each party by first class mail. Each party may file a written response to an exception filed by another party within ten calendar days from the date the exceptions were mailed to the parties.
The parties shall not have the right to oral argument to the Office of Appeals.

8.1000.3.K. FINAL AGENCY DECISIONS

The Final Agency Decision shall be based on the record except that the Office of Appeals may remand for rehearing if a party establishes in its exceptions that material evidence has been discovered which the party could not, with reasonable diligence, have produced at the hearing.
The record shall consist only of:

a. The transcript or recording of testimony and exhibits, or an official report containing the substance of what happened at the hearing;

b. All papers and requests filed in the proceeding;

c. The Initial Decision of the Administrative Law Judge; and d. Any exceptions and requests filed in response to the Initial Decision of the Administrative Law Judge.

The Applicant shall have access to the record at a convenient place and time.
The Office of Appeals shall issue a Final Agency Decision within 90 calendar days from the date the request for a hearing is received unless an extension has been granted to the Applicant in which case the 90 calendar day period shall be increased accordingly.

8.1000.3.L. NOTIFICATION OF DECISION

The Applicant shall be provided, in writing, with:

a. A copy of the Final Agency Decision; and b. Notification of his/her right to seek judicial review and the effective date of the Final Agency Decision for purposes of requesting judicial review.

For purposes of requesting judicial review, the effective date of the Final Agency Decision shall be the third day after the date the decision is mailed to the parties, even if the third day falls on Saturday, Sunday or a legal holiday.

8.1000.3.M. CORRECTIVE ACTION

If the Final Agency Decision is favorable to the Applicant, corrective action shall be taken, within three working days after the effective date of the Final Agency Decision, retroactive to the date the incorrect action was taken.

8.1000.3.N. RECONSIDERATION OF FINAL AGENCY DECISION

A party may file a motion for reconsideration of a Final Agency Decision with the Office of Appeals:

a. Upon a showing of good cause for failure to file exceptions to the Initial Decision within the allowed 15 calendar day period; or b. Upon a showing that the Final Agency Decision is based upon a clear or plain error of fact or law.

The motion for reconsideration shall be filed, in writing, with the Office of Appeals within 15 calendar days of the date that the Final Agency Decision is mailed to the parties. The motion shall state the specific grounds for reconsideration.
The Office of Appeals shall promptly serve a copy of the motion for reconsideration on each party by first class mail. Each party may file a written response to a motion for reconsideration filed by another party within ten calendar days from the date the motion was mailed to the parties.
The Office of Appeals shall promptly serve a copy of its decision on the motion for reconsideration on all parties by first class mail.

8.1000.3.O. REDETERMINATION OF ELIGIBILITY

A redetermination of eligibility shall mean a case review and necessary verification to determine whether the Medicare client continues to be eligible for the LIS. Beginning as of the case approval date, a redetermination shall be accomplished each 12 months.
The county of residence Medicaid Eligibility Site shall promptly redetermine eligibility when:

a. It receives and verifies information which indicates a change in an client’s circumstances which may affect continued eligibility for the LIS; or b. It receives direction to do so from the Department.

A redetermination form, approved by the Department, shall be mailed to the person at least 30 days prior to the first of the month in which completion of eligibility redetermination is due. The redetermination form shall be used to inform the client of the redetermination and verification needed, but the form itself can not be required to be returned. The only verification that can be required at redetermination is the same minimal verification listed in 10 C.C.R. 2505-10, Section 8.105.5. The following procedures relate to mail-out redetermination:

a. A redetermination form shall be mailed to the client together with any other forms to be completed;

b. Required verification shall be returned by the client to the county of residence Medicaid Eligibility Site no later than ten working days after receipt of the redetermination verification information requires form;

c. When the client is unable to complete the forms due to physical, mental or emotional disabilities, or other good cause, and has no one to help him/her, the county of residence Medicaid Eligibility Site shall either assist the client or refer him/her to a legal or other resource. When initial arrangements or a change in arrangements are being made, an extension of up to 30 days may be allowed.

The action of the county of residence Medicaid Eligibility Site in assistance or referral shall be recorded in the case record.

When the redetermination verification information is not returned within the ten working day time period:

a. A second request form shall be mailed to the client;

b. A Department approved notice of proposed action taken shall be mailed with the forms notifying the client of termination of LIS eligibility, but such action will not be taken if the completed and signed forms are returned within the prior notice period, or the client can show good cause as to why the forms cannot be returned timely.

c. If no response is received by the end of the prior notice period, action to terminate shall be taken.

When the redetermination verification information is received by the county department, it shall be date stamped. Within ten working days, the verification information shall be thoroughly reviewed for completeness, accuracy, and consistency. All factors shall be evaluated as to their effect on eligibility. Verifications shall be documented in the case file. The case file shall be used as a checklist in the redetermination process, and shall be used to keep track of matters requiring further action. When additional information is needed:

a. Due to incomplete information, the request form shall be mailed back to the client with a letter specifying the items that require completion.

b. Due to inaccurate or inconsistent data, the Medicare client shall immediately be contacted by telephone or in writing so that the worker may secure the proper information.

8.1000.4 ELIGIBILITY FOR THE LOW-INCOME SUBSIDY 8.1000.4.A. Deemed Eligible.

An Applicant shall be deemed eligible for the full LIS if the Applicant is:

a. A Full-Benefit Dual Eligible;

b. A recipient of Supplemental Security Income benefits under title XVI of the Social Security Act; or c. Eligible for Medicaid as a Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB), or a Qualifying Individual (QI). 8.1000.4.B. Low-Income Subsidy.

Full premium subsidy. An Applicant shall be eligible for the Part D full premium subsidy if the Applicant meets the following requirements:

a. Has income below 135 percent of the Federal Poverty Limit (FPL).

b. Has resources at or below the resource thresholds set forth in 42 C.F.R. Section 423.773(b)(2) (2007). 42 C.F.R. Section 423.773(b)(2) (2007) is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address:

Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1714. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library. An Applicant’s resources include the assets or resources of the Applicant’s spouse.

Low-Income Subsidy. An Applicant shall be eligible for a Part D partial subsidy if the Applicant meets the following requirements:

a. Has income less than 150 percent of the FPL; and b. Has resources at or below the resource thresholds set forth in 42 C.F.R. Section 423.773(d)(2). 42 C.F.R. Section 423.773(d)(2) (2007) is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address:

8.1000.5 BENEFITS 8.1000.5.A. LIS is a Medicare Prescription Drug benefit and is not funded by the Department. 8.1000.5.B. Under Medicare Part D, the Department or its Medicaid Eligibility Sites are required to process LIS applications and any appeal arising from the Department’s LIS eligibility determination. 8.1000.5.C. Any appeal concerning the Medicare Prescription Drug benefit itself shall be submitted to Medicare. _________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the History link that appears above the text in 10 CCR 2505-10. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.2000 MEDICAL ASSISTANCE - SECTION 8.2000 [Repealed eff. 10/30/2017] {#sec-10-ccr-2505-10-8.2000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.2000}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

Medical Services Board MEDICAL ASSISTANCE – SECTION 8.2000 - Repealed eff. 10/30/2017 10 CCR 2505-10 8.2000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 03/04/2007, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.3000 MEDICAL ASSISTANCE - SECTION 8.3000 Healthcare Affordability and Sustainability Fee {#sec-10-ccr-2505-10-8.3000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.3000}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

MEDICAL ASSISTANCE – SECTION 8.3000 Healthcare Affordability and Sustainability Fee Collection and Disbursement 10 CCR 2505-10 8.3000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] ______________________________________________________________________ 8.3000: HEALTHCARE AFFORDABILITY AND SUSTAINABILITY FEE COLLECTION AND DISBURSEMENT

PURPOSE: Subject to federal approval by the Centers for Medicare and Medicaid Services (CMS), the Colorado Healthcare Affordability and Sustainability Enterprise Act of 2017 (Act), C.R.S. § 25.5-4-402.4, authorizes the Colorado Healthcare Affordability and Sustainability Enterprise (CHASE) to assess a healthcare affordability and sustainability fee, pursuant to rules adopted by the State Medical Services Board, to provide business services to hospitals as described in C.R.S. § 25.5-4-402.4(4)(a).

These business services include, but are not limited to, obtaining federal financial participation to increase reimbursement to hospitals for care provided under the state medical assistance program (Medicaid) including Disproportionate Share Hospital Payments pursuant to 42 U.S.C. § 1396r-4; expanding health coverage for parents of Medicaid eligible children, for children and pregnant women under the Child Health Plan Plus (CHP+), and for low-income adults without dependent children; providing a Medicaid buy-in program for people with disabilities; implementing twelve month continuous eligibility for Medicaid eligible children; paying CHASE’s administrative costs of implementing and administering the Act; consulting with hospitals to help them improve cost efficiency, patient safety, and clinical effectiveness; advising hospitals regarding potential changes to federal and state laws and regulations governing Medicaid; providing coordinating services to hospitals to help them adapt and transition to any new or modified performance tracking and payment systems for the Medicaid program; and providing funding for a health care delivery system reform incentive payments program.

8.3001: DEFINITIONS

“Act” means the Colorado Healthcare Affordability and Sustainability Enterprise Act of 2017, § 25.5-4-402.4, C.R.S.
“Alternative Sliding Fee Scale” means a tiered copayment system for a hospital’s Qualified Charity Care Program approved by the Department. A Hospital may request to use an Alternative Sliding Fee Scale for its Qualified Charity Care Program as an exception to the Standard Sliding Fee scale. The Alternative Sliding Fee Scale must determine the level of a patient’s financial participation by income and household size only and guarantee that the patient financial participation is below that required under Hospital Discounted Care.
“CHASE” or “Enterprise” means the Colorado Healthcare Affordability and Sustainability Enterprise described in C.R.S. § 25.5-4-402.4(3).
“CMS” means the federal Centers for Medicare and Medicaid Services.
“Critical Access Hospital” means a hospital qualified as a critical access hospital under 42 U.S.C. § 1395i-4(c)(2) and licensed or certified as a critical access hospital by the Colorado Department of Public Health and Environment.
“Department” means the Department of Health Care Policy and Financing established pursuant to C.R.S. § 25.5-1-104.
“Disproportionate Share Hospital Payment” or “DSH Payment” means the payments made to qualified hospitals that serve a disproportionate share of Medicaid and uninsured individuals as required under 42 U.S.C. § 1396r-4.

Federal law establishes an annual DSH allotment for each state that limits federal financial participation for total statewide DSH payments made to hospitals.

“Emergency Hospital Services” means treatment for conditions of an acute, severe nature which are life, limb, or disability threats requiring immediate attention, where any delay in treatment would, in the judgment of the responsible physician, threaten life or loss of function of a patient or viable fetus.
“Enterprise Board” means the Colorado Healthcare Affordability and Sustainability Enterprise Board described in C.R.S. § 25.5-4-402.4(7).
“Essential Access Hospital” means a Critical Access Hospital or General Hospital not located within a Metropolitan Statistical Area (MSA) designated by the United States Office of Management and Budget and having 25 or fewer licensed beds.
“Exclusive Provider Organization” or “EPO” means a type of managed care health plan where members are not required to select a primary care provider or receive a referral to receive services from a specialist. EPOs will not cover care provided out-of-network except in an emergency.
“Federal Poverty Guideline” or “FPG” means a measure of income level issued annually by the United States Department of Health and Human Services.
“Fund” means the healthcare affordability and sustainability fee cash fund described in C.R.S. § 25.5-4-402.4(5).
“General Hospital” means a hospital licensed as a general hospital by the Colorado Department of Public Health and Environment.
“High Volume Medicaid Hospital” means a hospital with at least 35,000 Medicaid Days per year .
“Health Maintenance Organization” or “HMO” means a type of managed care health plan that limits coverage to providers who work for or contract with the HMO and requires selection of a primary care provider and referrals to receive services from a specialist. HMOs will not cover care provided out-of-network except in an emergency.
“High Medicaid Utilization Hospital” means a hospital with a Medicaid payer mix greater than or equal to twenty-five percent (25%) and a Medicaid non-managed care patient days utilization rate greater than or equal to forty percent (40%).
“Heart Institute Hospital” means a hospital recognized as a HeartCARE Center by the American College of Cardiology (ACC) with at least 25,000 Medicaid Non- Managed Care Days per year.
“Hospital Discounted Care” means Health Care Billing for Indigent Patients as set forth in Title 25.5, Article 3, Part 5, C.R.S.
“Hospital-Specific Disproportionate Share Hospital Limit” or “Hospital-Specific DSH Limit” means a hospital’s maximum allowable Disproportionate Share Hospital payment eligible for Medicaid federal financial participation allowed under 42 U.S.C. § 1396r-4.
“Hospital Transformation Program Supplemental Medicaid Payments” or “HTP Supplemental Medicaid Payments” means the:

a. Outpatient Hospital Supplemental Medicaid Payment described in Section 8.3004.B., b. Inpatient Hospital Supplemental Medicaid Payment described in Section 8.3004.C., and c. Essential Access Hospital Supplemental Medicaid Payment described in

Section 8.3004.E.

The HTP Supplemental Medicaid Payments do not include the Hospital Quality Incentive Payment described in Section 8.3004.F. or Rural Support Program Hospital Supplemental Medicaid Payment described in Section 8.3004.G.
“Independent Metropolitan Hospital” means an independently owned and operated hospital located within a Metropolitan Statistical Area (MSA) designated by the United States Office of Management and Budget with at least 1,500 Medicaid Days per year.
“Inpatient Services Fee” means an assessment on hospitals based on inpatient Managed Care Days and Non-Managed Care Days.
“Inpatient Upper Payment Limit” means the maximum amount that Medicaid can reimburse a provider for inpatient hospital services and still receive federal financial participation.
“Long Term Care Hospital” means a General Hospital that is certified as a longterm care hospital by the Colorado Department of Public Health and Environment.
“Managed Care Day” means an inpatient hospital day for which the primary payer is a managed care health plan, including HMO, PPO, POS, and EPO days.
“Medicaid Day” means a Managed Care Day or Non-Managed Care Day for which the primary or secondary payer is Medicaid.
“Medicaid Managed Care Day” means a Managed Care Day for which the primary payer is Medicaid.
“Medicare Cost Report” means the Medicare hospital cost report, form CMS 2552-96 or CMS 2552-10, or any successor form created by CMS.
“MMIS” means the Medicaid Management Information System, the Department’s Medicaid claims payment system.
“MIUR” means Medicaid inpatient utilization rate which is calculated as Medicaid Days divided by total hospital days.
“Neonatal Intensive Care Unit Hospital” or “NICU Hospital” means a hospital with a NICU classification of Level III or IV according to guidelines published by the American Academy of Pediatrics (AAP).
“Non-Managed Care Day” means an inpatient hospital day for which the primary payer is an indemnity insurance plan or other insurance plan not serving as an HMO, PPO, POS, or EPO.
“Non-State-Owned Government Hospital” means a hospital that is either owned or operated by a local government.
“Outpatient Services Fee” means an assessment on hospitals based on outpatient hospital charges.
“Outpatient Upper Payment Limit” means the maximum amount that Medicaid can reimburse a provider for outpatient hospital services and still receive federal financial participation.
“Pediatric Specialty Hospital” means a hospital that provides care exclusively to pediatric populations.
“POS” or “Point of Service” means a type of managed care health plan that charges patients less to receive services from providers in the plan’s network and requires a referral from a primary care provider to receive services from a specialist.
“PPO” or “Preferred Provider Organization” means a type of managed care health plan that contracts with providers to create a network of participating providers. Patients are charged less to receive services from providers that belong to the network and may receive services from providers outside the network at an additional cost.
“Privately-Owned Hospital” means a hospital that is privately owned and operated.
“Psychiatric Hospital” means a hospital licensed as a psychiatric hospital by the Colorado Department of Public Health and Environment.
“Qualified Charity Care Program” means a program approved by the Department which at a minimum includes discounted Emergency Hospital Services for patients with incomes up to and including 250 percent of the FPG throughout the year, a. Where a patient’s copayment is determined by a Qualified Sliding Fee Scale, b. Where an patient’s copayment amount is valid for one year from the date of service or date of income determination, whichever is earlier, and c. Which exempts patient debts from permissible collection activities for patients who were determined eligible for the hospital’s Qualified Charity Care Program and have an FPG level at or below 250% or for those eligible patients for whom the hospital failed to meet the Patient Contact Best Effort requirements described in Section 8.922.A.7.

d. A Hospital’s Qualified Charity Care Program must comply with all other requirements under Hospital Discounted Care including but not limited to requirements to provide information in the patient’s preferred language, screening and application requirements described in Section 8.922., and allowing patient payment plans not exceeding the amount and duration required in Hospital Discounted Care, 44. “Qualified Sliding Fee Scale” means the Standard Sliding Fee Scale or an Alternative Sliding Fee Scale approved by the Department.

“Rehabilitation Hospital” means an inpatient rehabilitation facility.
“Respiratory Hospital” means a hospital that primarily specializes in respiratory related diseases.
“Rural Hospital” means a hospital not located within a Metropolitan Statistical Area (MSA) designated by the United States Office of Management and Budget.
“Safety Net Metropolitan Hospital” means a hospital that provides services within the Pueblo, Colorado Metropolitan Statistical Area designated by the United States Office of Management and Budget (Pueblo MSA) with no less than 15,000 Days per year reported on its Medicare Cost Report, Worksheet S-3, Part 1, Column 7 (Title XIX), lines 1-18, and 28 (adult, pediatrics, intensive care, and subunits).
“State-Owned Government Hospital” means a hospital that is either owned or operated by the State.
“Teaching Hospital” means a High-Volume Medicaid Hospital which provides supervised teaching experiences to graduate medical school interns and residents enrolled in a state institution of higher education, and in which more than fifty percent (50%) of its credentialed physicians are members of the faculty at a state institution of higher education.
“Standard Sliding Fee Scale” means the patient copayments for a hospital’s Qualified Charity Care Program for various health care services by income level as shown in the table and descriptions below.

Percent of FPG 0 - 40% and Homeless 0 - 40% 41 - 62% 63 - 81% 82 - 100% 101 - 117% 118 - 133% 134 - 159% 160 - 185% 186 - 200% 201 - 250% Ambulatory Surgery $0 $15 $65 $105 $155 $220 $300 $390 $535 $600 $630 Inpatient Facility $0 $15 $65 $105 $155 $220 $300 $390 $535 $600 $630 Hospital Physician $0 $7 $35 $55 $80 $110 $150 $195 $270 $300 $315 Emergency Department Emergency Transportation Outpatient Hospital Services $0 $7 $15 $15 $20 $20 $25 $25 $35 $35 $40 Clinic Services $0 $7 $15 $15 $20 $20 $25 $25 $35 $35 $40 Specialty Outpatient Prescription $0 $5 $10 $10 $15 $15 $20 $20 $30 $30 $35 Laboratory $0 $5 $10 $10 $15 $15 $20 $20 $30 $30 $35 Basic Radiology & Imaging $0 $5 $10 $10 $15 $15 $20 $20 $30 $30 $35 High-Level Radiology & Imaging $0 $30 $90 $130 $185 $250 $335 $425 $580 $645 $680 a. Inpatient facility charges are for all non-physician (facility) services received by a patient while receiving care in the hospital setting for a continuous stay of 24 hours or longer.

b. Ambulatory Surgery charges are for all non-physician (facility) Ambulatory Surgery operative procedures received by a patient who is admitted to and discharged from the hospital setting on the same day. The patient is also responsible for the corresponding Hospital Physician charges.

c. Hospital Physician charges are for services provided directly by a physician in the hospital setting, including inpatient, ambulatory surgery, and emergency room care.

d. Clinic Services charges are for all non-physician (facility) and physician services received by a patient while receiving care in the outpatient clinic setting. Outpatient charges include primary and preventive medical care.

This charge does not include radiology or laboratory services performed at the clinic.

e. Emergency Department charges are for all non-physician (facility) services received by a patient while receiving Emergency Hospital Services or Urgent Care in the hospital setting for a continuous stay less than 24 hours.

f. Specialty Outpatient charges are for all non-physician (facility) and physician services received by a patient while receiving care in the specialty outpatient setting. These services can be provided in standalone clinics and outpatient hospital settings. Specialty Outpatient charges include distinctive medical care (i.e., oncology, orthopedics, hematology, pulmonary) that is not normally available as primary and preventive medical care. Specialty Outpatient charges do not include radiology, laboratory, emergency room, or ambulatory surgery services provided in a hospital setting.

g. Emergency Transportation charges are for transportation provided by an ambulance.

h. Laboratory Service charges are for all laboratory tests received by a patient while receiving care in the outpatient hospital or clinic setting.

Laboratory Service charges may not be charged in addition to charges for emergency room or inpatient services provided in the hospital setting.

i. Basic Radiology and Imaging Service charges are for all radiology and imaging services received by a patient while receiving care in the outpatient hospital or clinic setting. Basic Radiology and Imaging Service charges may not be charged in addition to charges for emergency room or inpatient services provided in the hospital setting.

j. Prescription charges are for prescription drugs received by a patient at a Qualified Health Care Provider’s pharmacy as an outpatient service. To encourage the availability of discounted prescription drugs, providers are allowed to modify (increase or decrease) the Prescription Copayment with the written approval of the Department.

k. High-Level Radiology and Imaging Service charges are for patients receiving Magnetic Resonance Imaging, Computed Tomography, Positron Emission Tomography or other Nuclear Medicine services, Sleep Studies, or Catheterization Laboratory in the outpatient hospital, emergency room, or clinic setting.

l. Outpatient Hospital Service charges are for all non-physician (facility) and physician services received by a patient while receiving non-Emergency Care or non-Urgent Care in the outpatient clinic setting. Outpatient Hospital Services charges include primary and preventive medical care.

This charge does not include radiology, laboratory, emergency room, or ambulatory surgery services provided in a hospital setting.

m. Patients who are seen in the hospital setting in an observation bed should be charged the emergency room copay if their stay is less than 24 hours and the inpatient facility copay if their stay is 24 hours or longer.

“Sole Community Hospital” means a hospital that is designated as a sole community hospital by the Centers for Medicare and Medicaid Services (CMS) as the only source of inpatient hospital services reasonably available in a geographic area, due to factors like an isolated location, poor accessibility from nearby hospitals, or the inability of nearby hospitals to provide necessary services.
“Supplemental Medicaid Payments” means the:

a. Outpatient Hospital Supplemental Medicaid Payment described in Section 8.3004.B., b. Inpatient Hospital Supplemental Medicaid Payment described in Section 8.3004.C., c. Essential Access Hospital Supplemental Medicaid Payment described in

Section 8.3004.E., d. Hospital Quality Incentive Payment described in Section 8.3004.F., and e. Rural Support Program Hospital Supplemental Medicaid Payment described in Section 8.3004.G.

“Uninsured Cost” means uninsured days and charges allocated to routine and ancillary cost centers and multiplied by the most recent provider-specific per diem cost and cost-to-charge ratio from the Medicare Cost Report.
“Urban Center Safety Net Specialty Hospital” means a hospital located in a Metropolitan Statistical Area designated by the United States Office of Management and Budget where its Medicaid Days plus uninsured inpatient days relative to total inpatient hospital days per year, rounded to the nearest percent, equals, or exceeds 65%.
“Urgent Care” means treatment needed because of an injury or serious illness that requires treatment within 48 hours.

8.3002: RESPONSIBILITIES OF THE ENTERPRISE AND HOSPITALS

8.3002.A. DATA REPORTING

For purposes of calculating the Outpatient Services Fee, Inpatient Services Fee and the distribution of supplemental payments, the Enterprise shall distribute a data reporting template to all hospitals. The Enterprise shall include instructions for completing the data reporting template, including definitions and descriptions of each data element to be reported. Hospitals shall submit the requested data to the Enterprise within thirty (30) calendar days after receiving the data reporting template or on the stated due date, whichever is later. The Enterprise may estimate any data element not provided directly by the hospital.

a. For hospitals that do not participate in the electronic funds process utilized by the Enterprise for the collection of fees, payments to hospitals shall be processed by the Enterprise within two business days of receipt of the Outpatient Services Fee and Inpatient Services Fee.

b. For hospitals that do not participate in the electronic funds process utilized by the Enterprise for the disbursement of payments, payments to hospitals shall be processed through a warrant (paper check) by the Enterprise within two business days of receipt of the Outpatient Services Fee and Inpatient Services Fee.

Hospitals shall submit days and charges for Medicaid Managed Care, out-ofstate Medicaid, and uninsured patients, Managed Care Days, and any additional elements requested by the Enterprise.
The Enterprise shall distribute a data confirmation report to all hospitals annually.

The data confirmation report shall include a listing of relevant data elements used by the Enterprise in calculating the Outpatient Services Fee, the Inpatient Services Fee and the supplemental payments. The data confirmation report shall clearly state the manner and timeline in which hospitals may request revisions to the data elements recorded by the Enterprise. Revisions to the data will not be permitted by a hospital after the dates outlined in the data confirmation report.

The hospital shall certify that based on best information, knowledge, and belief, the data included in the data reporting template is accurate, complete, and truthful, is based on actual hospital records, and that all supporting documentation will be maintained for a minimum of six years. The certification shall be made by the hospital’s Chief Executive Officer, Chief Financial Officer, or an individual who reports directly to the Chief Executive Officer or Chief Financial Officer with delegated authority to sign for the Chief Executive Officer or Chief Financial Officer so that the Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification.

8.3002.B. FEE ASSESSMENT AND COLLECTION

Establishment of Electronic Funds Process. The Enterprise shall utilize an Automated Clearing House (ACH) debit process to collect the Outpatient Services Fee and Inpatient Services Fee from hospitals and an Electronic Funds Transfer (EFT) payment process to deposit supplemental payments in financial accounts authorized by hospitals. The Enterprise shall supply hospitals with all necessary information, authorization forms and instructions to implement this electronic process.
The Outpatient Services Fee and Inpatient Services Fee will be assessed on an annual basis and collected in twelve monthly installments. Payments to hospitals will be calculated on an annual basis and disbursed in twelve monthly installments.

a. For those hospitals that participate in the electronic funds process utilized by the Enterprise, fees will be assessed and payments will be disbursed on the second Friday of the month, except when State offices are closed during the week of the second Friday, then fees will be assessed and payment will be disbursed on the following Friday of the month. If the Enterprise must diverge from this schedule due to unforeseen circumstances, the Enterprise shall notify hospitals in writing or by electronic notice as soon as possible.

i. The Enterprise may assess fees and disburse payments for Urban Center Safety Net Specialty Hospitals on an alternate schedule determined by the Department.

b. At no time will the Enterprise assess fees or disburse payments prior to the state fiscal year for which they apply.

Electronic Funds Process Waiver. Hospitals not exempt from the Outpatient Services Fee and Inpatient Services Fee must participate in the electronic funds process utilized by the Enterprise for the collection of fees and the disbursement of payments unless the Enterprise has approved an alternative process. A hospital requesting to not participate in the electronic fee collection process and/or payment process must submit a request in writing or by electronic notice to the Enterprise describing an alternative fee collection process and/or payment process. The Enterprise shall approve or deny the alternative process in writing or by electronic notice within 30 calendar days of receipt of the request.

8.3003: HEALTHCARE AFFORDABILITY AND SUSTAINABILITY FEE

8.3003.A. OUTPATIENT SERVICES FEE

Federal requirements. The Outpatient Services Fee is subject to federal approval by CMS. The Enterprise shall demonstrate to CMS, as necessary for federal financial participation, that the Outpatient Services Fee is in compliance with 42 U.S.C. §§ 1396b(w), 1396b(w)(3)(E), and 1396b(w)(4).
Exempted hospitals. Psychiatric Hospitals, Long Term Care Hospitals and Rehabilitation Hospitals are exempted from the Outpatient Services Fee.
Calculation methodology. The Outpatient Services Fee is calculated on an annual basis and is capped at 1.8020% of total hospital outpatient charges, with the following exception:

a. High Volume Medicaid Hospitals’ Outpatient Services Fee is capped at 1.7869% of total hospital outpatient charges.

The Outpatient Services Fee for federal fiscal year 2024-25 (October 1, 2024, through September 30, 2025) is 1.6940% of total hospital outpatient charges, with the following exception:

a. For High Volume Medicaid Hospitals, the Outpatient Services Fee is 1.6798% of total hospital outpatient charges.

8.3003.B. INPATIENT SERVICES FEE

Federal requirements. The Inpatient Services Fee is subject to federal approval by CMS. The Enterprise shall demonstrate to CMS, as necessary for federal financial participation, that the Inpatient Services Fee is in compliance with 42 U.S.C. §§ 1396b(w), 1396b(w)(3)(E), and 1396b(w)(4).
Exempted hospitals. Psychiatric Hospitals, Long Term Care Hospitals and Rehabilitation Hospitals are exempted from the Inpatient Services Fee.
Calculation methodology. The Inpatient Services Fee is calculated on an annual per inpatient day basis and is capped at $122.18 per day for Managed Care Days and $546.15 per day for all Non-Managed Care Days, with the following exceptions:

a. High Volume Medicaid Hospitals’ Inpatient Services Fee is capped at $63.79 per day for Managed Care Days and $285.14 per day for all Non- Managed Care Days, and b. Essential Access Hospitals’ Inpatient Services Fee is capped at $48.87 per day for Managed Care Days and $218.46 per day for Non-Managed Care Days.

The Inpatient Services Fee for federal fiscal year 2024-25 (October 1, 2024, through September 30, 2025) is $116.64 per Managed Care Day and $521.40 per Non-Managed Care Day, with the following exceptions:

a. For High Volume Medicaid Hospitals, the Inpatient Services Fee is capped at $60.90 per Managed Care Day and $272.22 per Non-Managed Care Day.

b. For Essential Access Hospitals, the Inpatient Services Fee is capped at $46.66 per Managed Care Day and $208.56 per Non-Managed Care Day.

8.3003.C. ASSESSMENT OF HEALTHCARE AFFORDABILITY AND

SUSTAINABILITY FEE

The Enterprise shall calculate the Inpatient Services Fee and Outpatient Services Fee under this section on an annual basis in accordance with the Act. Upon receiving a favorable recommendation by the Enterprise Board, the Inpatient Services Fee and Outpatient Services Fee shall be subject to approval by the CMS and the Medical Services Board. Following these approvals, the Enterprise shall notify hospitals, in writing or by electronic notice, of the annual fee to be collected each year, the methodology to calculate such fee, and the fee assessment schedule. Hospitals shall be notified, in writing or by electronic notice, at least thirty calendar days prior to any change in the dollar amount of the Inpatient Services Fee and the Outpatient Services Fee to be assessed.
The Inpatient Services Fee and the Outpatient Services Fee will be assessed on the basis of the qualifications of the hospital in the year the fee is assessed as confirmed by the hospital in the data confirmation report. The Enterprise will prorate and adjust the Inpatient Services Fee and Outpatient Services Fee for the expected volume of services for hospitals that open, close, relocate or merge during the payment year.
In order to receive a Supplemental Medicaid Payment or DSH Payment, hospitals must meet the qualifications for the payment in the year the payment is received as confirmed by the hospital during the data confirmation report.

Payments will be prorated and adjusted for the expected volume of services for hospitals that open, close, relocate or merge during the payment year.

8.3003.D. REFUND OF EXCESS FEES

If, at any time, fees have been collected for which the intended expenditure has not received approval for federal Medicaid matching funds by CMS at the time of collection, the Enterprise shall refund to each hospital its proportion of such fees paid within five business days of receipt. The Enterprise shall notify each hospital of its refund amount in writing or by electronic notice. The refunds shall be paid to each hospital according to the process described in Section 8.3002.B.
After the close of each federal fiscal year the Enterprise shall present a summary of fees collected, expenditures made or encumbered, and interest earned in the Fund during the federal fiscal year to the Enterprise Board.

a. If fees have been collected for which the intended expenditure has received approval for federal Medicaid matching funds by CMS, but the Enterprise has not expended or encumbered those fees at the close of each federal fiscal year:

i. The total dollar amount to be refunded shall equal the total fees collected, less expenditures made or encumbered, plus any interest earned in the Fund, less the minimum Fund reserve recommended by the Enterprise Board.

ii. The refund amount for each hospital shall be calculated in proportion to that hospital’s portion of all fees paid during the federal fiscal year.

iii. The Enterprise shall notify each hospital of its refund in writing or by electronic notice 30 days before payment is made. The refunds shall be paid to each hospital by September 30 of each year according to the process described in Section 8.3002.B.

8.3004: SUPPLEMENTAL MEDICAID AND DISPROPORTIONATE SHARE

HOSPITAL PAYMENTS

8.3004.A. CONDITIONS APPLICABLE TO ALL SUPPLEMENTAL PAYMENTS

All Supplemental Medicaid Payments are prospective payments subject to the Inpatient Upper Payment Limit and Outpatient Upper Payment Limit, calculated using historical data, with no reconciliation to actual data for the payment period.

In the event that data entry or reporting errors, or other unforeseen payment calculation errors are realized after a supplemental payment has been made, reconciliations and adjustments to impacted hospital payments may be made retroactively, as determined by the Enterprise.

No hospital shall receive a DSH Payment exceeding its Hospital-Specific Disproportionate Share Hospital Limit. If upon review, the Disproportionate Share Hospital Payment, described in 10 CCR 2505-10, Section 8.3004.D, exceeds the Hospital-Specific Disproportionate Share Hospital Limit for any qualified hospital, the hospital’s payment shall be reduced to the Hospital-Specific Disproportionate Share Hospital Limit retroactively. The amount of the retroactive reduction shall be retroactively distributed to other qualified hospitals by each hospital’s percentage of Uninsured Costs compared to total Uninsured Costs for all qualified hospitals not exceeding their Hospital-Specific Disproportionate Share Hospital Limit.
In order to receive a Supplemental Medicaid Payment or Disproportionate Share Hospital Payment, hospitals must meet the qualifications for the payment in the year the payment is received as confirmed by the hospital during the data confirmation report. Payments will be prorated and adjusted for the expected volume of services for hospitals that open, close, relocate or merge during the payment year.

8.3004.B. OUTPATIENT HOSPITAL SUPPLEMENTAL MEDICAID PAYMENT

Qualified hospitals. Hospitals providing outpatient hospital services to Medicaid clients are qualified to receive this payment except as provided below.
Excluded hospitals. Psychiatric Hospitals are not qualified to receive this 3. Calculation methodology for payment. For each qualified hospital, the annual payment shall equal outpatient billed costs, adjusted for utilization and inflation, multiplied by a percentage adjustment factor. Outpatient billed costs equal outpatient billed charges multiplied by the Medicare cost-to-charge ratio. The percentage adjustment factor may vary for State-Owned Government Hospitals, Non-State-owned Government Hospitals, Privately-Owned Hospitals, for urban and rural hospitals, for State University Teaching Hospitals, for Pediatric Specialty Hospitals, for Urban Center Safety Net Specialty Hospitals, or for other hospital classifications, except that the adjustment factor for a Safety Net Metropolitan Hospital shall be equal to the adjustment factor for a Privately- Owned Independent Metropolitan Hospital. Total payments to qualified hospitals shall not exceed the Outpatient Upper Payment Limit. The percentage adjustment factor for each qualified hospital shall be published annually in the Colorado Medicaid Provider Bulletin.

8.3004.C. INPATIENT HOSPITAL SUPPLEMENTAL MEDICAID PAYMENT

Qualified hospitals. Hospitals providing inpatient hospital services to Medicaid clients are qualified to receive this payment, except as provided below.
Excluded hospitals. Psychiatric Hospitals are not qualified to receive this 3. Calculation methodology for payment. For each qualified hospital, the annual payment shall equal Medicaid Non-Managed Care Days multiplied by an adjustment factor. The adjustment factor may vary for State-Owned Government Hospitals, Non-State-owned Government Hospitals, Privately-Owned Hospitals, for urban and rural hospitals, for State University Teaching Hospitals, for Pediatric Specialty Hospitals, for Urban Center Safety Net Specialty Hospitals, or for other hospital classifications, except that the adjustment factor for a Safety Net Metropolitan Hospital shall be at least equal to the adjustment factor for a Privately-Owned Independent Metropolitan Hospital. Total payments to qualified hospitals shall not exceed the Inpatient Upper Payment Limit. The adjustment factor for each qualified hospital shall be published annually in the Colorado Medicaid Provider Bulletin.

8.3004.D. DISPROPORTIONATE SHARE HOSPITAL SUPPLEMENTAL

PAYMENT

Qualified hospitals are hospitals that:

a. Have at least two obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric care for Medicaid clients or are exempt from the obstetrician requirement pursuant to 42 U.S.C. § 1396r- 4(d)(2)(A) are qualified to receive this payment, and b. Have a Qualified Charity Care Program, or c. Have a MIUR equal to or greater than the mean plus one standard deviation of all MIURs for Colorado hospitals, or d. Are Critical Access Hospitals or Rural Hospitals designated as Sole Community Hospitals pursuant to 42 U.S.C. § 1395ww(d)5(D)(iii).

Excluded hospitals. Psychiatric Hospitals are not qualified to receive this 3. Calculation methodology for payment.

a. Total DSH payments shall equal Colorado’s total computable DSH allotment pursuant to 42 U.S.C. § 1396r–4(f)(3)

b. No qualified hospital shall receive a payment greater than 100% of their Hospital-Specific DSH Limit.

c. A qualified hospital with uninsured patient write-off costs greater than 950% of the state-wide average shall receive a payment equal to a minimum of 90.00% of their Hospital-Specific DSH Limit.

d. A qualified State-Owned Government Teaching Hospitals shall receive a payment equal to a minimum of 96.00% of their Hospital Specific DSH Limit.

e. A qualified Critical Access Hospital or Rural Hospital shall receive a payment equal to 100.00% of their Hospital Specific DSH Limit.

f. A qualified hospital not owned/operated by a healthcare system network within a Metropolitan Statistical Area and have less than or equal to 50 licensed beds shall receive a payment equal to a minimum of 40.00% of their Hospital-Specific DSH Limit.

g. All remaining qualified hospitals shall receive a payment calculated as the percentage of uninsured costs to total uninsured costs for all remaining qualified hospitals, multiplied by the remaining funds.

h. A Low MIUR hospital shall have their Hospital-Specific DSH Limit equal 20.00%.

i. A low MIUR hospital is a hospital with a MIUR less than or equal to 22.50%.

i. The payment percentage of the hospital specific DSH limit shall be published in provider bulletin 8.3004.E. ESSENTIAL ACCESS HOSPITAL SUPPLEMENTAL MEDICAID PAYMENT 1. Qualified hospitals. Essential Access Hospitals are qualified receive this 2. Calculation methodology for payment. For each qualified hospital, the annual payment shall equal the available Essential Access funds divided by the total number of qualified Essential Access Hospitals.

8.3004.F. HOSPITAL QUALITY INCENTIVE PAYMENT

Qualified hospitals. Hospitals providing hospital services to Medicaid clients are qualified to receive this payment except as provided below.
Excluded hospitals. Psychiatric Hospitals are not qualified to receive this 3. Calculation methodology for payment. For each qualified hospital, the annual payment shall equal adjusted discharge points multiplied by dollars per-adjusted discharge point.

a. Adjusted discharge points equal normalized points awarded multiplied by adjusted Medicaid discharges. Normalized points awarded equals the sum of points awarded, normalized to a 100-point scale for measures a hospital is not eligible to complete. The measures and measure groups are published annually in the Colorado Medicaid Provider Bulletin.

Adjusted Medicaid Discharges equal inpatient Medicaid discharges multiplied by a discharge adjustment factor.

i. The discharge adjustment factor equals total Medicaid charges divided by inpatient Medicaid charges. The discharge adjustment factor is limited to 5.

ii. For qualified hospitals with less than 200 inpatient Medicaid discharges, inpatient Medicaid discharges shall be multiplied by 125%.

b. Dollars per-adjusted discharge point are determined using a qualified hospital’s normalized points awarded. Dollars per-adjusted discharge point are tiered so that qualified hospitals with more normalized points awarded receive more dollars per-adjusted discharge point. There are five tiers delineating the dollars per-adjusted discharge point with each tier assigned a certain normalized points awarded range. For each tier the dollars per-adjusted discharge point increase by a multiplier.

The multiplier and normalized points awarded for each tier are:

Tier Normalized Points Awarded Dollars Per- Adjusted Discharge Point 1 1-19 0(x) 2 20-39 1(x) 3 40-59 2(x) 4 60-79 3(x) 5 80-100 4(x)

The dollars per discharge point shall equal an amount such that the total quality incentive payments made to all qualified hospitals shall equal seven percent (7.00%) of total hospital payments in the previous state fiscal year.

A hospital shall have the opportunity to request a reconsideration of points awarded that are provided with the preliminary scoring letter.

a. To be considered for payment, a hospital shall submit a survey through the data collection tool on or before May 31 of each year.

b. A preliminary scoring letter containing the scores and scoring rationale shall be provided to a hospital that submits a survey within ninety calendar days of May 31. The preliminary scoring letter will be delivered to each hospital that submitted a survey via the data collection tool.

c. A hospital that believes a measure in the preliminary scoring letter was inaccurately scored may submit a reconsideration request within ten business days of delivery of the preliminary scoring letter. The request must be made by electronic notice.

i. The reconsideration request must be provided following the process established through the HQIP scoring review and reconsideration period user guide. Reconsideration requests may not be accepted if they are not provided through this process.

d. A response to the reconsideration request shall be provided within ten business days upon receipt of the reconsideration request via electronic notice. The response shall provide whether a change to a measure score was made or if the reconsideration request was denied.

e. If a hospital is not satisfied with the reconsideration response, the hospital may request the reconsideration be escalated to the Special Financing Division Director within five business days of delivery of the reconsideration response. Any escalations must be provided to the Department via electronic notice.

i. The escalation request must be provided following the process established through the HQIP scoring review and reconsideration period user guide. Escalation requests may not be accepted if they are not provided through this process.

f. A response to the escalation request shall be provided to the hospital within ten business days via electronic notice. The response shall provide whether a change to a measure score was made or if the escalation request was denied. The escalation response is final, and points awarded may not be reconsidered further.

g. No other reconsiderations of points awarded, both preliminary and final, may be accepted by the Department outside of this process. The Department’s decision is not an adverse action subject to administrative or judicial review under the Colorado Administrative Procedure Act (ACA).

8.3004.G. RURAL SUPPORT PROGRAM HOSPITAL SUPPLEMENTAL

MEDICAID PAYMENT

Qualified hospitals. Hospitals that meet all the following criteria:

a. Is state licensed as a Critical Access Hospital or is a Rural Hospital, participating in Colorado Medicaid, b. Is a nonprofit hospital, and c. Meets one of the below:

i. Meets one of the below: Their average net patient revenue for the three-year 2016, 2017, and 2018 cost report period is in the bottom ten percent (10%) for all Critical Access Hospitals and Rural Hospitals, or ii. Their funds balance for the 2019 cost report period is in the bottom two and one-half percent (2.5%) for all Critical Access Hospitals and Rural Hospitals not in the bottom 10% of the three-year average net patient revenue for all Critical Access Hospitals and Rural Hospitals, 2. Calculation methodology for payment. For a qualified hospital, the annual payment shall equal twelve million dollars ($12,000,000) divided by the number of qualified hospitals.

The payment shall be calculated once and reimbursed in monthly installments over the subsequent six federal fiscal years.
A qualified hospital must submit an attestation form every year to receive the available funds. If a qualified hospital does not submit the required attestation form their funds for the year shall be redistributed to other requalified hospitals.

8.3004.H REIMBURSEMENT OF SUPPLEMENTAL MEDICAID PAYMENTS AND

DISPROPORTIONATE SHARE HOSPITAL PAYMENT

The Enterprise shall calculate the Supplemental Medicaid Payments and DSH Payment under this section on an annual basis in accordance with the Act. Upon receiving a favorable recommendation by the Enterprise Board, the Supplemental Medicaid Payments and DSH Payment shall be subject to approval by the CMS and the Medical Services Board. Following these approvals, the Enterprise shall notify hospitals, in writing or by electronic notice, of the annual payment made each year, the methodology to calculate such payment, and the payment reimbursement schedule. Hospitals shall be notified, in writing or by electronic notice, at least thirty calendar days prior to any change in the dollar amount of the Supplemental Medicaid Payments or the DSH Payment to be reimbursed.

8.3004.I HOSPITAL TRANSFORMATION PROGRAM

Qualified hospitals shall participate in the Hospital Transformation Program (HTP). The HTP leverages supplemental payments as incentives designed to improve patient outcomes and lower Medicaid cost. Qualified hospitals are required to complete certain reporting activities. Qualified hospitals not completing a reporting activity shall have their supplemental Medicaid payments reduced. The reduced supplemental Medicaid payments shall be paid to qualified hospitals completing the reporting activity. The HTP is a multi-year program with a program year (PY) being on a federal fiscal year (October 1 through September 30) basis.

Qualified hospitals. Hospitals providing hospital services to Medicaid clients shall participate in the HTP except as provided below.
Excluded hospitals. Psychiatric Hospitals, Rehabilitation Hospitals, or Long-Term Care Hospitals shall not participate in the HTP.
Calculation methodology for payment.

a. Each program year includes reporting activities that a qualified hospital is required to complete. A qualified hospital not completing a reporting activity shall have their HTP Supplemental Medicaid Payments reduced by a designated percent.

b. The dollars not paid to those qualified hospitals shall be redistributed to qualified hospitals completing the reporting activity. A qualified hospital’s distribution shall equal their percent of HTP Supplemental Medicaid Payments to the total HTP Supplemental Medicaid Payments for all qualified hospitals completing the reporting activity, multiplied by the total reduced dollars for qualified hospitals not completing the reporting activity.

c. The reduction and redistribution shall be calculated using the HTP Supplemental Medicaid Payments effective during the reporting activity period. The reduction and redistribution for reporting activities shall occur at the same time during the last quarter of the subsequent program year.

e. There are five HTP reporting activities. The reporting activities are listed below, along with the total percent at-risk associated with each reporting activity.

i. Application (1.5% at-risk total) – Qualified hospitals must provide interventions and measures focusing on improving processes of care and health outcomes and reducing avoidable utilization and cost. The percent at-risk shall be scored on timely and satisfactory submission.

ii. Implementation Plan (1.5% at-risk total) – Qualified hospitals must submit a plan to implement interventions with clear milestones that shall impact their measures. The percent at-risk shall be scored on timely and satisfactory submission.

iii. Quarterly Reporting (0.5% at-risk per report) – Qualified hospitals must report quarterly on the different activities that occurred in that quarter. For any given quarter, this includes interim activity reporting, milestone reporting, self-reported data associated with the measures, and Community and Health Neighborhood Engagement (CHNE) reporting. The percent at-risk shall be scored on timely and satisfactory submission.

iv. Milestone Report (2.0% at-risk per report in PY 2, 4.0% at-risk per report in PY 3) – Qualified hospitals must report on achieved/missed milestones over the previous two quarters. The percent at-risk shall be scored on timely and satisfactory submission and for achievement of milestones. Qualified hospitals that miss a milestone can have the reduction for the milestone reduced by 50% if they submit a course correction plan with the subsequent Milestone Report. A course correction reduction for a missed milestone can only be done once per intervention.

v. Sustainability Plan (8.0% at-risk total) – Qualified hospitals must submit a plan demonstrating how the transformation efforts will be maintained after the HTP is over. The percent at-risk shall be scored on timely and satisfactory submission.

f. A qualified hospital not participating in the HTP may have the entirety of their HTP Supplemental Medicaid Payments withheld.

A hospital shall have the opportunity to request a reconsideration of scores for reporting compliance, milestone completion (including milestone amendments and course corrections), and performance measure data accuracy.

a. The scoring review and reconsideration period begins when the Department notifies hospitals of initial scores. This period consists of multiple steps that will span 45 business days.

i. The Department completes initial review of reports within 20 business days of report due date.

ii. The Department notifies hospital of scores available for viewing and the scoring review and reconsideration period begins within 21 business days of report due date.

iii. The hospital request for reconsideration is due within 10 business days of release of initial scores.

iv. The Department issues final scores and reconsideration decisions within 14 business day of the scoring review and reconsideration period close date.

b. All hospitals will receive electronic notification when initial scores are released to the Department’s web portal.

c. To submit a request for reconsideration of an initial score, a hospital must utilize the scoring review and reconsideration form available on the Department’s web portal. It must identify the specific scoring elements the hospital would like reconsidered and the rationale for the reconsideration request. The form must be emailed following the proper guidelines as mentioned on the form.

i. Late report submissions and report revisions are not accepted through the reconsideration process.

ii. The hospital will receive an electronic notification of the outcome of the reconsideration request.

d. If a hospital is not satisfied with the reconsideration response, the hospital may request the reconsideration be escalated to the Project Manager or the Special Financing Division Director. Initial escalations to the Project Manager must be made within five business days of delivery of the reconsideration response. Final escalations to the Special Financing Division Director must be made within 15 business days of delivery of the reconsideration response. Any escalations must be provided to the Department via electronic notice.

i. The escalation request must be provided following the process established through the HTP scoring review and reconsideration period user guide. Escalation requests may not be accepted if they are not provided through this process.

e. A response to the initial escalation request shall be provided to the hospital within ten business days via electronic notice. A response to the final escalation request shall be provided to the hospital within 20 business days via electronic notice. Any response shall provide whether a change to a measure score was made or if the escalation request was denied. The escalation response is final, and points awarded may not be reconsidered further.

f. No other reconsiderations of scores, both preliminary and final, may be accepted by the Department outside of this process. The Department’s decision is not an adverse action subject to administrative or judicial review under the Colorado Administrative Procedure Act (ACA). ______________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.4000 MEDICAL ASSISTANCE - SECTION 8.4000 Hospital Expenditure Report Data Collection {#sec-10-ccr-2505-10-8.4000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.4000}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

MEDICAL ASSISTANCE – SECTION 8.4000 Hospital Expenditure Report Data Collection 10 CCR 2505-10 8.4000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ 8.4000

PURPOSE: To supply data for the Hospital Financial Transparency Report, which is an annually prepared written report detailing uncompensated hospital costs and the different categories of expenditures, by major payor group, made by hospitals in the state.

8.4001.A DEFINITIONS

“Certified Financial Statements” means financial statements, along with accompanying notes, that have been prepared in accordance with Generally Accepted Accounting Principles and that have been audited by an independent certified public accountant(s) in accordance with generally accepted auditing standards.
“Critical Access Hospital” means a hospital qualified as a critical access hospital under 42 U.S.C. § 1395i-4(c)(2) and licensed or certified as a critical access hospital by the Colorado Department of Public Health and Environment.
“DATABANK Program” means the Colorado Hospital Association program that collects hospital utilization and financial data.
“Enterprise Board” means the Colorado Healthcare Affordability and Sustainability Enterprise Board described at Section 25.5-4-402.4(7), C.R.S..
“General Hospital” means a hospital licensed as a general hospital by the Colorado Department of Public Health and Environment.
“Health System” is a larger corporation or an organizational structure that owns, contains, or operates more than one hospital.
“Long Term Care Hospital” means a General Hospital that is certified as a long-term care hospital by the Colorado Department of Public Health and Environment.
“Medicare Cost Report” means the Medicare hospital cost report, form CMS 2552-96 or CMS 2552-10, or any successor form created by CMS, and the annual required submission of worksheets and schedules by Medicare certified providers used for Medicare reimbursement.
“Psychiatric Hospital” means a hospital licensed as a psychiatric hospital by the Colorado Department of Public Health and Environment.
“Quarterly Financial Statements” means internal unaudited financial statements including an income statement and balance sheet prepared in accordance with Generally Accepted Accounting Principles.
“Rehabilitation Hospital” means an inpatient rehabilitation facility.

8.4002 RESPONSIBILITIES OF THE DEPARTMENT AND HOSPITALS FOR ANNUAL REPORTING

REQUIREMENTS

8.4002.A ANNUAL STATEMENT SUBMISSION

For the purposes of ongoing data compilation for the Hospital Financial Transparency Report, all General Hospitals and Critical Access hospitals shall submit their Certified Financial Statements, Medicare Cost Reports, and a hospital specific statement of cash flows a. Hospitals shall submit a Certified Financial Statement within 120 days after the end of its fiscal year, unless the Department grants an extension in writing in advance of that date.

b. Hospitals shall submit annual Medicare Cost Reports to the Department within thirty (30) days after submitting them to CMS.

c. Hospitals shall submit a specific statement of cash flows within a time frame specified by HCPF, but not less than 120 days after the hospital’s fiscal year end.

Psychiatric Hospitals, Long Term Care Hospitals and Rehabilitation Hospitals are exempted from submitting Certified Financial Statements, Medicare Cost Reports and statements of cash flows.
For a hospital that operates within a Health System or other corporate structure, and is normally included in the Health System or other corporate structure’s Certified Financial Statements a. The hospital may submit the Health System or other corporate structure’s Certified Financial Statements if the statements separately identify the financial information for each licensed hospital operating in the state including:

i. A statement of operations.

ii. A balance sheet.

iii. If available, a statement of changes in net assets (or equity).

iv. If available, a statement of cash flows.

b. For hospitals in which the consolidated Certified Financial Statements do not separately identify the financial information for each licensed hospital operating in the state, then the hospital shall submit the financial statements that were submitted with its Medicare Cost Report and shall submit a reconciliation of the consolidated financial statement and hospital-specific revenue and expenses reported on the Medicare Cost Report pursuant to the federal centers for Medicare and Medicaid services provider reimbursement manual form 339.

If total revenues and total expenses on the submitted financial statements differ from the Medicare Cost Report, the hospital shall submit a reconciliation.
A hospital may choose to submit a written explanation of operating, investing, or financing decisions that impact the interpretation of the Certified Financial Statements or Medicare Cost Report.
A hospital may choose to submit a written explanation detailing changes in reporting methodology between fiscal periods that would impact the interpretation of the statements and what period may be affected. Examples of reporting methodologies that could change include:

a. Measurements of financial assets and liabilities.

b. Recording of retirement benefit plans.

c. Recording of income tax expense.

d. Rates of depreciation.

The Department is not responsible for the review and authentication of the Certified Financial Statements and the Medicare Cost Report. The authentication of the submitted Certified Financial Statements and the Medicare Cost Report is the responsibility of the hospital or Health System.
Submissions shall be certified by the hospital’s Chief Executive Officer, Chief Financial Officer, or an individual who reports directly to the Chief Executive Officer or Chief Financial Officer with delegated authority to sign for the Chief Executive Officer or Chief Financial Officer so that the Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification.

8.4002.B ANNUAL REPORTING SUBMISSION

For the purposes of ongoing data compilation for the Hospital Transparency Report, hospitals shall report utilization, financial, service line, and large project information on the hospital for the requested fiscal year. The Department shall make available or distribute a data reporting template to all hospitals.

a. The Department shall inform hospitals of the fiscal period of the request.

b. The Department shall include instructions for completing the data reporting template, including definitions and descriptions of each reported data field, which will include at a minimum those items required by Section 25.5-4-402.8(2)(b)(III), C.R.S., as well as several required by Section 25.5-4-402.8(2)(b)(II), C.R.S.

c. Hospitals shall return the completed reporting template to the Department within thirty (30) days after receiving the request or on the stated due date, whichever is later.

Hospitals shall submit the following items required by Section 25.5-4-402.8(2)(b)(II), C.R.S.

a. Hospitals shall submit an annual summary of the hospital’s transfer of cash, equity, investments, or other assets to and from related parties, including but not limited to the hospital’s parent organization along with the report pursuant to Section 25.5-4- 402.8(2)(b)(III), C.R.S.. Hospitals shall submit this summary within 120 days after the end of its fiscal year, unless the Department grants an extension in writing in advance of that date. A hospital may aggregate the transfers for each entity receiving or making the transfer. The summary shall include:

i. The purpose of the transfer, and ii. Whether the transfer was made within or outside of Colorado.

b. Hospitals shall submit changes to no more than twenty-five categories of specific major service lines along with the report pursuant to Section 25.5-4-402.8(2)(b)(III), C.R.S..

i. HCPF shall determine up to twenty-five service line categories and inform hospitals of them before the submission period begins.

c. Hospitals shall submit a narrative report of major planned and completed projects and capital investments greater than twenty-five million dollars along with the report pursuant to Section 25.5-4-402.8(2)(b)(III), C.R.S.. Hospitals shall submit this summary within 120 days after the end of its fiscal year, unless the Department grants an extension in writing in advance of that date. Except the information HCPF receives from hospitals regarding planned activities is confidential, proprietary, contains trade secrets, and is not a public record pursuant to Part 2 of Article 72 of Title 24.

Hospitals shall submit a roll-forward schedule detailing the changes in property, plant, and equipment balances from the beginning to the end of the reporting period.

a. Changes shall be appropriately categorized as either purchases, other acquisitions, sales, disposals, depreciation expense or other changes. Significant amounts categorized as other changes should be separately described. The roll-forward schedule should provide details of changes by property, plant, and equipment category including, but not limited to land, buildings, buildings – accumulated depreciation, building improvements, building improvements – accumulated depreciation, leasehold improvements – leasehold improvements – accumulated depreciation, equipment, equipment – accumulated depreciation, other and other – accumulated depreciation. The beginning and ending balances on the roll-forward schedule should agree to the respective balance sheet.

For the purposes of compiling historic data for the Hospital Financial Transparency Report, hospitals shall report no later than July 1, 2024.

a. The Department shall make available or distribute a data reporting template to all hospitals b. For each fiscal year 2014-15 through 2019-20, a summary of the hospital’s transfer of cash, equity, investments, or other assets to and from related parties, including but not limited to the hospital’s parent organization. A hospital may aggregate the transfer of each entity receiving or making the transfer. The summary shall include:

i. The purpose of the transfer, and ii. Whether the transfer was made within or outside of Colorado.

b. For each fiscal year from 2014-15 through 2019-20, information on affiliations and a report of physician practice acquisitions including but not limited to:

i. The names and transaction price of acquired hospitals, affiliated hospitals, newly constructed hospitals, and rehabilitation hospitals, ii. The names and transaction price of acquired or affiliated physician group practices, and iii. The number and transaction price of individual physician practices acquired or affiliated.

c. For each fiscal year from 2019-20 through 2022-23, details of significant other revenue that would otherwise be reported in the Medicare Cost Report.

d. HCPF shall include instructions for completing the one-time data reporting template, including definitions and descriptions of each reported data field, which will include at a minimum those items required by. Section 25.5-4-402.8(2)(b.5), C.R.S.

e. Hospitals shall return the completed reporting template to the Department within thirty (30) days after receiving the request or on the stated due date, whichever is later.

Psychiatric Hospitals, Long Term Care Hospitals and Rehabilitation Hospitals are exempted from the reporting submission.
The Department shall determine the reasonableness of the data submitted by comparing it to the submitted Certified Financial Statement.
Submissions shall be certified by the hospital’s Chief Executive Officer, Chief Financial Officer, or an individual who reports directly to the Chief Executive Officer or Chief Financial Officer with delegated authority to sign for the Chief Executive Officer or Chief Financial Officer so that the Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification.

8.4002.C DEPARTMENT REPORTING & TRANSPARENCY

The Department is responsible for the compilation of the hospital submissions.
The Department shall consult with the Enterprise Board on the structure and format of the Hospital Expenditure Report at the Enterprise Board meetings.
The Department shall share the hospital’s data in the Hospital Financial Transparency Report and a copy of the report with the hospital a minimum of fifteen (15) days before the report is publicly available or issued to the Enterprise Board.
After the collection and review of the data submission, a machine-readable format of the hospital data shall be made available to the statewide hospital association at no cost to the association.
HCPF shall report on the annual Hospital Transparency Report during HCPF’s State Measurement for Accountable, Responsive, and Transparent Government Act hearing.

8.4003 RESPONSIBILITIES OF THE DEPARTMENT AND HOSPITALS FOR QUARTERLY

REPORTING REQUIREMENTS

8.4003.A QUARTERLY STATEMENT SUBMISSIONS

All General Hospitals and Critical Access Hospitals shall submit Quarterly Financial Statements within ninety (90) days of the end of the calendar quarter.
Psychiatric Hospitals, Long Term Care Hospitals and Rehabilitation Hospitals are exempted from submitting Quarterly Financial Statements.
For a hospital that operates within a Health System or other corporate structure, and is normally included in the Health System or other corporate structure’s Quarterly Financial Statements, the hospital may submit the Health System or other corporate structure’s Quarterly Financial Statements.
A hospital may choose to submit a written explanation detailing changes in reporting methodology between fiscal periods that would impact the interpretation of the statements and what period may be affected. Examples of reporting methodologies that could change include:

a. Measurements of financial assets and liabilities.

b. Recording of retirement benefit plans.

c. Recording of income tax expense.

d. Rates of depreciation.

The Department is not responsible for the review and authentication of the Quarterly Financial Statements. The authentication of the submitted Quarterly Financial Statements is the responsibility of the hospital or Health System.
Submissions shall be certified by the hospital’s Chief Executive Officer, Chief Financial Officer, or an individual who reports directly to the Chief Executive Officer or Chief Financial Officer with delegated authority to sign for the Chief Executive Officer or Chief Financial Officer.

8.4003.B QUARTERLY REPORTING SUBMISSION

For the purposes of ongoing quarterly data compilation for the Hospital Financial Transparency Report, hospitals shall report Quarterly Financial Statements for the requested quarter. The Department shall make available or distribute a data reporting template to all hospitals.

a. The Department shall inform hospitals of the time period of the request.

c. Hospitals shall return the completed reporting template to the Department within ninety (90) days after receiving the request or on the stated due date, whichever is later.

8.4003.C DEPARTMENT QUARTERLY REPORTING & TRANSPARENCY

The Department is responsible for the compilation of the hospital Quarterly Financial Statement submissions.
The Department shall provide any analysis, report, or presentation based on the Quarterly Financial Statements to each hospital at least fifteen (15) days prior to the public release of any analysis, report, or presentation. The Department shall clearly state any analysis, report, or presentation based on Quarterly Financial Statements is unaudited when applicable.
After the collection and review of the Quarterly Financial Statement submissions, a machinereadable format of the hospital data shall be made available to the statewide hospital association at no cost to the association.

8.4004.A HOSPITAL FINANCIAL TRANSPARENCY COMPLIANCE AND CORRECTIVE

ACTION PROCESS

If a hospital does not provide all the of the information required pursuant to subsection (2)(b) of

section 25.5-4-402.8, C.R.S., HCPF shall inform the hospital of its noncompliance within sixty (60) days and identify the information the hospital needs to provide.

a. If a hospital does not comply, HCPF shall issue a corrective action plan with a timeline of sixty (60) days required for compliance.

b. If a hospital continues not to comply, HCPF may create a mandatory pay-for-reporting compliance measure within the Hospital Transformation Program that is tied to the Healthcare Affordability and Sustainability Fee Supplemental Payment.

If HCPF determines a hospital’s noncompliance with reporting requirements is knowing or willful or there is a repeated pattern of noncompliance, HCPF shall consider the size of the hospital and the seriousness of the violation in setting a fine amount, not to exceed the amounts specified in

Section 25.5-4-402.8(2)(g)(II), C.R.S. _________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 03/04/2007, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.5000 MEDICAL ASSISTANCE - SECTION 8.5000 Hospital Community Benefit Accountability {#sec-10-ccr-2505-10-8.5000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.5000}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

MEDICAL ASSISTANCE - SECTION 8.5000 Hospital Community Benefit Accountability 10 CCR 2505-10 8.5000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ 8.5000 HOSPITAL COMMUNITY BENEFIT ACCOUNTABILITY

PURPOSE: To require hospitals to report to the Department of Health Care Policy and Financing information on their Community Benefit activities, planning and investments.

8.5001 DEFINITIONS

“Community” means the community that a hospital has defined as the community that it serves pursuant to 26 CFR § 1.501(r)-3(b).

“Community Based Organization” means a public or private nonprofit organization of that represents a community or significant segments of a community or work towards community-focused goals beyond one particular community and provides educational or related services to individuals in the community under 20 USC § 7801(5).

“Community Benefit” means the actions that hospitals take to qualify as an organization organized and operated for the charitable purpose of promoting health pursuant to § 501(c)(3) of federal Internal Revenue Code. These actions include demonstrating that the hospital provides benefits to a class of persons that is broad enough to benefit the community, and that it operates to serve a public rather than private interest. Community Benefit may also refer to the dollar amount spent on the community in the form of Free or Discounted Health Care Services; Provider Recruitment, Education, Research and Training; and Community spending activities.

“Community Benefit Implementation Plan” means a plan that satisfies the requirements of an implementation strategy as described in 26 CFR § 1.501(r)-3(c).

“Community Benefit Priorities” means Community Benefit activities that are documented within the Reporting Hospital’s Community Health Needs Assessment or otherwise established pursuant to the IRS Form 990, Schedule H and its instructions.

“Community Health Center” means a federally qualified health center as defined in 42 U.S.C. § 1395x (aa)(4) or a rural health clinic as defined in 42 U.S.C. § 1395x (aa)(2).

“Community Health Needs Assessment” means a community health needs assessment that satisfies the requirements of 26 CFR § 1.501(r)-3(b).

“Community Identified Health Need” means a health need of a Community that is identified in a Community Health Needs Assessment.

“Free or Discounted Health Care Services” means health care services provided by the hospital to persons who meet the hospital’s criteria for financial assistance and are unable to pay for all or a portion of the services, or physical or behavioral health care services funded by the hospital but provided without charge to patients by other organizations in the Community. Free or Discounted Health Care Services do not include the following:

Services reimbursed through the Colorado Indigent Care Program (CICP);
Bad debt or uncollectable amounts owed that the hospital recorded as revenue but wrote off due to a patient’s failure to pay, or the cost of providing care to such patients;
The difference between the cost of care provided under Medicaid or other means-tested government programs or under Medicare and the revenue derived therefrom;
Self-pay or prompt pay discounts; or 5. Contractual adjustments with any third-party payers.

“Health System” means a larger corporation or organizational structure that owns, contains, or operates more than one hospital.

“Local Public Health Agency" means a county or district public health agency established pursuant to C.R.S. § 25-1-506, or a local department of public health.

“Medicaid Shortfall” means the cost of Medicaid reflected on the IRS Form 990, Schedule H, Worksheet 3.

“Programs that Address Behavioral Health” means funding or in-kind programs or services intended to improve an individual's mental and emotional well-being and are reportable on the IRS Form 990, Schedule H and its instructions. Programs that Address Behavioral Health are designed to address, but are not limited to:

Mental health disorders;
Serious psychological distress;
Serious mental disturbance;
Unhealthy stress;
Tobacco use prevention; and 6. Substance use.

“Programs that Address Community Based Health Care” means funding or in-kind programs or services that improve types of person-centered care delivered in the home and community and are not billable to a third party. A variety of health and human services can be provided. Community Based Health Care addresses the needs of people with functional limitations who need assistance with everyday activities such as getting dressed or bathing.

“Programs that Address the Social Determinants of Health” means funding or in-kind programs or services that improve social, economic, and environmental conditions that impact health in the Community. Social and economic conditions that impact health include education; employment; income; family and social support; and Community safety. Environmental conditions that impact health include air and water quality, housing, and transit. Programs that Address the Social Determinants of Health include but are not limited to the following:

Job training programs;
Support for early childhood and elementary, middle, junior-high, and high school education;
Programs that increase access to nutritious food and safe housing;
Medical Legal Partnerships; and 5. Community-building activities that could be included in Part II of Schedule H of the Form 990.

“Provider Recruitment, Education, Research and Training,” “Workforce development,” “Health professions education,” and “Research” defined within the Internal Revenue Service form 990 as:

“Workforce development” means the recruitment of physicians and other health professionals to medical shortage areas or other areas designated as underserved, and collaboration with educational institutions to train and recruit health professionals needed in the Community (other than the health professions education activities entered on Part I, line 7f), 2. “Health Professions Education” means educational programs that result in a degree, a certificate, or training necessary to be licensed to practice as a health professional, as required by C.R.S. 12-240-110, or continuing education necessary to retain state license or certification by a board in the individual's health profession specialty, a. Health Professions Education does not include education or training programs available exclusively to the organization's employees and medical staff or scholarships provided to those individuals. However, it does include education programs if the primary purpose of such programs is to educate health professionals in the broader community. Costs for medical residents and interns can be included, even if they are considered employees for purposes of Form W- 2, Wage and Tax Statement.
“Research” means any study or investigation the goal of which is to generate increased generalized knowledge made available to the public (for example, knowledge about underlying biological mechanisms of health and disease, natural processes, or principles affecting health or illness; evaluation of safety and efficacy of interventions for disease such as clinical trials and studies of therapeutic protocols; laboratory-based studies; epidemiology, health outcomes, and effectiveness; behavioral or sociological studies related to health, delivery of care, or prevention; studies related to changes in the health care delivery system; and communication of findings and observations, including publication in a medical journal). The organization can include the cost of internally funded research it conducts, as well as the cost of research it conducts funded by a taxexempt or government entity.

“Reporting Hospital” means 1. A hospital licensed as a general hospital pursuant to Part 1 of Article 3 of Title 25 of the Colorado Revised Statutes and exempt from federal taxation pursuant to Section 501(c)(3) of the federal Internal Revenue Code, but not including a general hospital that is federally certified or undergoing federal certification as a long-term care hospital pursuant to 42 CFR § 412.23(e) or that is federally certified or undergoing federal certification as a critical access hospital pursuant to 42 CFR § 485 Subpart F, 2. A hospital established pursuant to C.R.S. § 25-29-103, or 3. A hospital established pursuant to C.R.S. § 23-21-503.

“Safety Net Clinic” means a Community clinic licensed or certified by the Department of Public Health and Environment pursuant to C.R.S. § 25-1.5-103 (1)(a)(I) or (1)(a)(II).

8.5002 HOSPITAL REQUIREMENTS

8.5002.A PUBLIC MEETING REQUIREMENTS

Each Reporting Hospital shall convene a public meeting at least once per year to seek feedback regarding the hospital’s Community Benefit activities during the previous year and the hospital’s Community Benefit Implementation Plan for the upcoming year.
Reporting Hospitals may convene a joint public meeting with one or more other participating hospitals that share some or all of the hospital’s Community.
Reporting Hospitals may convene multiple Community Benefit meetings throughout the year.
During at least one public meeting the Reporting Hospitals shall at minimum:

a. Present priority areas identified in the Reporting Hospital’s most recent Community Health Needs Assessment and any other Community spending options recommended by the Reporting Hospital. Each priority recommendation presented shall clearly identify the source of the recommendation;

b. Solicit public input for the Reporting Hospital’s recommendations and any additional Community Benefit activity;

c. Present the Reporting Hospital’s specific Community Benefit activities;

d. Present the amount funded for each specific Community Benefit activity; and e. Present a description of how the Community Benefit activities and funding amounts align with the Community Identified Needs.

Reporting Hospitals may only add Community Benefit Priorities to the Reporting Hospital’s Community Benefit Implementation Plan if:

a. The Community Benefit Priorities were presented during at least one public meeting;

b. The public was provided an opportunity to provide feedback through either public testimony to be recorded in the minutes of the public meeting(s) or through correspondence including, but not limited to email, written letter, or phone call.

The Reporting Hospital will summarize this feedback in its annual submission materials;

c. The Reporting Hospital shall maintain a submission period of 30 days following the Community public meeting to allow for additional comments and recommendations from Community members. Nothing in this process will preclude hospitals from integrating priorities pursuant to the Internal Revenue Service’s Community Health Needs Assessment process;

d. The reporting hospital shall inform all community members through a public communication of a summary of the feedback received, whether or not the recommendation was incorporated into the Reporting Hospital’s Community Benefit Implementation Plan, and if the recommendation was not incorporated, an explanation for its absence. A Reporting Hospital may post the summary of feedback on a public facing website and provide notice through the Reporting Hospitals standard community outreach practices; and e. The Reporting Hospital shall indicate that the implemented Community Benefit Priorities are either a result of community feedback or based upon the Reporting Hospital’s recommendation.

Reporting Hospitals may conduct a public meeting combines the purpose of this Section 8.5002.A with other purposes, such as those required by the Community Health Needs Assessment process provided at 26 CFR § 1.501(r)-3, or other Community engagement efforts, so long as the public meeting meets the minimum requirements in this section.
Each Reporting Hospital shall invite, at a minimum, representatives from the following entities to participate in the meeting if any such entities operate in the hospital’s Community:

a. Local Public Health Agencies;

b. Local chambers of commerce and economic development organizations;

c. Local health care consumer organizations;

d. School districts;

e. County governments;

f. City and town governments;

g. Community Health Center;

h. Certified rural health clinics or primary care clinics located in a county that has been designated as a rural or frontier county;

i. Area agencies on aging;

j. Safety Net Clinics;

k. Health care consumer advocacy organizations;

l. The general public, m. Tribal councils of Colorado’s land-based tribes, specifically including members of the tribal council or its designees;

n. Urban Indian Organizations, specifically including their members; and o. Institutions of higher learning, specifically including their members.

Each Reporting Hospital shall invite, at a minimum, representatives from the following agencies to participate in the meeting:

a. The Department of Health Care Policy and Financing, b. The Department of Public Health and Environment, c. The Department of Human Services, d. The Colorado Commission on Higher Education, e. The Office of Saving People Money on Health Care, and f. The Division of Insurance within the Department of Regulatory Agencies 9. Each Reporting Hospital shall issue invitations by:

a. Placing advertisements in each major newspaper published in the hospital’s Community at least 30 days prior to the scheduled meeting. A major newspaper is a newspaper that is accessible, known to the members of the Reporting Hospital’s Community, and is a newspaper of record for the Reporting Hospital’s Community;

b. Posting invitations at least 30 days prior to the meeting date, including but not limited to:

i. On the Reporting Hospital’s website and social media page(s), ii. In the Reporting Hospital’s e-newsletters, and iii. Through email lists dedicated to Community outreach.

Reporting Hospitals shall request anonymous demographic information such as race, ethnicity, primary language spoken, and income from attendees. Reporting Hospitals shall inform meeting attendees that demographic data is voluntary and will not be publicly disclosed by the Reporting Hospital or by the Department. The Department will only share demographic information in a deidentified, aggregate manner. Reporting Hospitals may deidentify and aggregate this data during their submission to the Department.
Reporting Hospitals shall undertake the following efforts to promote broad Community notification and participation in the public meetings and to make meetings accessible:

a. Collaborate with Community Based Organizations and other Community partners to distribute invitations to the public, b. Engage with organizations that specialize in the representation of under-served groups within the Reporting Hospital’s Community, b. When hosting in-person meetings ensure that locations are accessible to those with physical disabilities and those that utilize mobility aids, c. Advertise that American Sign Language services and interpretation services for individuals with limited English proficiency are available upon request, d. Upon request, provide American Sign Language services and, for individuals with limited English proficiency, provide language and interpretation services to ensure meaningful access such as those described in 45 C.F.R. § 92.201.

e. Reporting Hospitals may also undertake additional activities including but not limited to the following:

i. Advertise the public meeting in additional newspapers in the Community, including those that are published in languages other than English;

ii. Advertise the public meeting via radio stations broadcast in the Community, including radio stations that broadcast in languages other than English;

iii. Use neutral or external facilitators to lead Community meetings. To the extent possible facilitators should represent the demographics of the Community members being engaged and, if possible, the facilitator should not be employed by the Reporting Hospital;

iv. Schedule the public meeting outside of the typical workday hours and consider hosting meeting(s) at Community locations other than hospital campuses;

v. Provide multiple avenues for Community meetings by conducting hybrid meetings, with simultaneous in-person and virtual participation options.

For virtual meetings, Reporting Hospital staff should provide appropriate orientation, technical assistance, captioning, and other assistive services;

vi. Schedule multiple meetings to be held on different days or at different times in order to accommodate a broader range of participants’ schedules;

vii. Provide transportation and childcare for participants in the public meeting, and viii. Provide reimbursement for transportation and childcare expenses incurred for the purposes of participating in the public meeting.

ix. Collaborate with Local Public Health Agencies operating wholly or partially in the Reporting Hospital’s Community on public meetings planning and execution including but not limited to:

a. Meeting time and location;

b. Meeting topics; and c. Communications notifying Community members of the meeting.

Reporting Hospitals should ensure that Community engagement goals reflect partnerships and collaboration with the Community and not solely state or federal requirements.

8.5002.B HOSPITAL REPORTING REQUIREMENTS

Each Reporting Hospital shall complete a Community Health Needs Assessment at least every three (3) years and shall submit a copy of the Community Health Needs Assessment to the Department on or before September 13, 2024, and then on or before July 1 every year thereafter.

a. Acquired or new hospitals shall complete their first Community Health Needs Assessment as described under 26 CFR § 1.501(r)-3(d).

Each Reporting Hospital shall complete a Community Benefit Implementation Plan that addresses the needs described in the Community Health Needs Assessment and that shall submitted to the Department on or before September 13, 2024, and then on or before July 1 every year thereafter.

a. Each Reporting Hospital is required to complete a Community Benefit Implementation Plan that:

i. Addresses the needs described by the Reporting Hospital’s Community Health Needs Assessment, ii. Includes an explanation of the Community served by the hospital facility, and iii. Describes how the Community was determined pursuant to 26 CFR § 1.501(r)-3(b).

Each Reporting Hospital shall submit to the Department on or before September 13, 2024, and then on or before July 1 every year thereafter a report on its most recent public meeting held to satisfy its Community Health Needs Assessment requirements under 26 CFR § 1.501(r)-3.
Each Reporting Hospital shall submit to the Department a report on the public meetings held during the previous reporting cycle on or before September 13, 2024, and then shall provide a report on the public meeting held after the submission date from the previous year on or before July 1 every year thereafter.
Each public meeting report shall include at minimum:

a. Date, time, and location of the meeting;

b. Outreach efforts to ensure broad Community participation and accessibility;

c. Individuals and organizations, including the populations served by the organizations, invited to the meeting;

d. To the extent this information is provided by attendees, a list of individual meeting attendees and organizations represented;

e. Meeting agenda;

f. A summary of the meeting discussion;

g. Actions taken as a result of feedback from meeting participants;

h. Content of meeting discussion including the Community Benefit Priorities discussed and the decisions made regarding those Community Benefit Priorities;

i. Community feedback received and how the Reporting Hospital plans to incorporate the feedback into the Reporting Hospital’s Community Benefit Implementation Plan; and j. Any demographic data collected voluntarily from attendees, such as data concerning race, ethnicity, and income. This data may be reported in a deidentified and aggregate manner.

Each Reporting Hospital shall submit to the Department on or before September 13, 2024, and then on or before July 1 every year thereafter a report on Community Benefits that shall include the following:

a. A copy of the most recently submitted Form 990 to the federal Internal Revenue Service including Schedule H. Associated worksheets may be submitted.

i. Reporting Hospitals that are part of a Health System or other corporate structure that files a consolidated form 990 to the federal Internal Revenue Service shall provide information that was included in Parts I, II, III, and V of Schedule H of Form 990 for each Reporting Hospital separately. Associated worksheets may be submitted.

ii. Reporting Hospitals not required to submit Schedule H of the Form 990 to the federal Internal Revenue Service shall complete Parts I, II, III, and V of Schedule H of Form 990 available on the federal Internal Revenue Service’s website. Associated worksheets may be submitted.

b. A description of spending made by the Reporting Hospital or related entities that were included in Parts I, II, and III of Schedule H of Form 990 that includes at a minimum the following:

i. Cost of the Community Benefit spending, the amount funded for each activity, 1) If a Reporting Hospital receives grants or philanthropic funding that would be classified as restricted funding by the Internal Revenue Service and cannot be counted for the purposes of Community Benefit, the reporting hospital may provide additional information to the Department about the activity.

ii. Indicate if the Community Benefit activity addressed a Community Identified Health Need.

iii. For any Community Benefit activity spending that addressed a Community Identified Health Need the Reporting Hospital shall provide each specific Community Benefit activity within the following applicable categories, and shall distinguish if the activity was funded through direct cash or cash expenditures from in-kind contributions:

Free or Discounted Health Care Services;
Programs that Address Behavioral Health;
Programs that Address the Social Determinants of Health;
Programs that Address Community Based Health Care;
Provider Recruitment, Education, Research, and Training; distinguishing if educational activities were invested internally or externally; and 6. All services and programs that addressed Community Identified Health Needs.

iv. For any Community Benefit activity that addressed one or more Community Identified Health Needs provide evidence that shows how the spending improves Community health outcomes and directly corresponding to the relevant Community Identified Health Needs.

c. The Reporting Hospital’s total expenses included in Line 18 of Section 1 of the submitted Form 990. Reporting Hospitals not required to submit Form 990 to the federal Internal Revenue Service shall complete Line 18 of Section 1 of Form 990 available on the federal Internal Revenue Service’s website.

d. The Reporting Hospital’s revenue less expenses included in Line 19 of Section 1 of the submitted form 990. Reporting Hospitals not required to submit Form 990 to the federal Internal Revenue Service shall complete Line 19 of Section 1 of Form 990 available on the federal Internal Revenue Service’s website.

In the event that the due date falls on a weekend or state holiday, the reporting deadline shall be extended to the next business day.
Each Reporting Hospital shall post the report to their public website and submit to the Department the website address where the report has been posted.
A hospital licensed as a general hospital pursuant to part 1 of Article 3 of Title 25 that is not a Reporting Hospital may report on Community Benefits, costs, and shortfalls consistent with this section.
Reporting Hospitals may provide additional information on Community Benefit spending that are not reportable on the IRS Form 990, Schedule H that address Community- Identified Health Needs.

8.5003 DEPARTMENT REQUIREMENTS

The Department shall develop a website or web-based reporting platform for each Reporting Hospital to submit its reports and ensure that the reports are available to the public on the Department’s website.
The Department shall review each Reporting Hospital’s Community Health Needs Assessment and each Reporting Hospital’s annual Community Benefit Implementation Plan before the release of the report authorized in C.R.S. § 25.5-4-402.8, to identify the highest priority areas reported by Reporting Hospital’s Communities.
As part of the report authorized in C.R.S. § 25.5-4-402.8, the Department shall submit to the General Assembly a report that includes the following:

a. Community Benefits as defined in Part I and Part II of the Schedule H as a percentage of total expenses.

b. Community Benefit as defined in Part I and Part II of the Schedule H as a percentage of total operating expenses.

c. The amount each Reporting Hospital invested in the following areas, including that amount as a percentage of total Community Benefit spending in Part I and II of Schedule H:

i. Free or Discounted Health Care Services that addressed Community identified health needs;

ii. Programs that Address Behavioral Health;

iii. Programs that Address Social Determinants of Health;

iv. Programs that Address Community Based Health Care;

v. Provider Recruitment, Education, Research and Training; and vi. All services and programs that addressed Community identified health needs.

d. Community Benefits as defined in Part I and Part II of the Schedule H as a percentage of Reporting Hospital’s patient revenues.

e. A summary of Community Benefits as defined in Part I and Part II of the Schedule H for each Reporting Hospitals compared to comparable categories expensed by for profit hospitals within Colorado, if available.

f. The reported Medicaid Shortfall for each Reporting Hospital.

g. Relevant service line spending or activity reported by each Reporting Hospital that are not reportable as Community Benefit to the Internal Revenue Service but do address Community-Identified Health Needs.

h. A summary of Community Benefit legislation or activities being performed outside of Colorado.

i. A summary of each Reporting Hospital’s Community Benefit spending and evidence that shows how the spending improves Community health outcomes.

j. A summary of each Reporting Hospital’s compliance with Community Benefit requirements. Reporting Hospitals deemed non-compliant with Community Benefit reporting will be provided an opportunity to comment on the department’s assessment of compliance prior to the publication of the report pursuant to C.R.S. § 25.5-1-703.

k. The highest priority areas as reported by Communities from the Reporting Hospital’s Community Health Needs Assessment and Implementation Plan compared to the Reporting Hospital’s reported spending.

l. The highest priority areas as identified in Local Public Health Agencies community health assessments and public health improvement plans to the extent possible that the information is provided to the Department.

m. Legislative recommendations for the General Assembly.

n. The estimated federal and state income tax exemptions and the property tax exemptions received by each Reporting Hospital, which shall be calculated by the Colorado Department of Revenue.

o. Any other information the Department determines will be useful for the General Assembly and members of the public to understand the effectiveness of Reporting Hospitals’ Community Benefit and other financial implications to the Reporting Hospital, such as Medicaid Shortfall.

The Department shall post the reports submitted to the General Assembly to a public web page created for that purpose.
The Department shall provide documentation submitted by Reporting Hospital’s under

Section 8.5002.B to Local Public Health Agencies upon request. Information that contains personally identifiable information shall be deidentified prior to delivery to Local Public Health Agencies.

8.5004 HOSPITAL COMMUNITY BENEFIT ACCOUNTABILITY COMPLIANCE AND CORRECTIVE

ACTION PROCESS

If the Department finds that a reporting hospital is not in compliance with the state’s Community Benefit requirements under C.R.S. § 25.5-1-702-703, the Department shall:

a. Notify the Reporting Hospital of its noncompliance and identify the information that needs to be provided;

b. Notify the non-compliant Reporting Hospital of the due date of requested information;

c. If the Reporting Hospital does not provide the requested information, the Department shall require the Reporting Hospital to submit a corrective action plan within 120 days for approval by the Department. The Department shall not publicly report on noncompliance until after a corrective action plan would be due to the Department.

d. If noncompliance continues or the Reporting Hospital fails to submit a corrective action plan, or if the Department determines the Reporting Hospital’s noncompliance is knowing or willful or a repeated pattern of noncompliance exists the Department shall consider the size of the hospital and the seriousness of the violation in setting a fine amount, i. For Reporting Hospitals owned by or affiliated with a hospital system comprised of three or more hospitals, the fine shall not be more than $20,000 per week, per violation.

ii. For all other Reporting Hospitals, the fine shall not be more than $5,000 per week, per violation.

e. Reporting Hospitals shall expend the amount fined on Community Benefit priorities described in the Reporting Hospital’s current Community Benefit Implementation Plan within one year after the fine is imposed. Each Reporting Hospital shall report on how the money collected through fines is expended in the Reporting Hospital’s annual report to the Department. _________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.6000 MEDICAL ASSISTANCE - SECTION 8.6000 Novel Coronavirus Disease (COVID-19) Rules [Emergency rules expired 01/06/2024] {#sec-10-ccr-2505-10-8.6000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.6000}

_________________________________________________________________________ DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

Medical Services Board MEDICAL ASSISTANCE -SECTION 8.6000 Novel Coronavirus Disease (COVID-19) Rules - Emergency rules expired 01/06/2024 10 CCR 2505-10 8.6000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 8.7000 MEDICAL ASSISTANCE - SECTION 8.7000 Home and Community Based Services {#sec-10-ccr-2505-10-8.7000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.7000}

Department of Health Care Policy and Financing MEDICAL ASSISTANCE - SECTION 8.7000 HOME AND COMMUNITY BASED SERVICES 10 CCR 2505-10 8.7000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] 8.7000 Home and Community-Based Services 8.7000.A Legal Authority 1. Authority a. These rules are promulgated under the authorities established in Section 25.5-10, C.R.S.

b. These rules and the program guidelines, standards and policies of the Colorado Department of Health Care Policy and Financing, shall apply to all Case Management Agencies, Community Centered Boards, Provider Agencies and regional centers receiving funds administered by the Colorado Department of Health Care Policy and Financing.

Scope and Purpose a. These rules govern services and supports for individuals with disabilities authorized and funded in whole or in part through the Colorado Department of Health Care Policy and Financing. These services and supports include the following, as provided by the Colorado Revised Statutes and through annual appropriation authorizations by the Colorado General Assembly:

i. Services and supports provided to residents of a State operated facility or program or purchased by the Department.

ii. The purchase of services and supports through Community Centered Boards, Case Management Agencies, and Provider Agencies.

iii. Other services and supports specifically authorized by the Colorado General Assembly.

iv. Services and supports funded through Home and Community- Based Services under Sections 1915(c), 1915(k), 1902(a)(10), and 1902(a)(1) of the Social Security Act and under Section 25.5- 4- 401, et seq., C.R.S.

Consequences for Non-Compliance a. Pursuant to Title 25.5, Article 10, C.R.S., upon a determination by the Executive Director or designee that services and supports have not been provided in accordance with the program or financial administration standards contained in these rules, the Executive Director or designee may reduce, suspend, or withhold payment to a Case Management Agency, or Provider Agency from which the Department purchases services or supports directly.

b. Prior to initiating action to reduce, suspend, or withhold payment to a Case Management Agency, for failure to comply with rules and regulations of the Department, the Executive Director or designee shall specify the reasons therefore in writing and shall specify the actions necessary to achieve compliance.

The Department retains the authority to enter emergency orders, when necessary, to preserve the health, safety or welfare of the public or of persons receiving services, including, but not limited to, situations that:

a. Are ongoing or likely to recur if not promptly corrected or otherwise resolved and, likely to result in serious harm to the individual or others; or, b. Arise out of a Provider Agency discontinuance of operation generally, or discontinuance of services to a particular individual because the Provider Agency is unable to ensure that person's safety or the safety of others.

The party requesting the Department to enter an emergency order shall submit all relevant documentation to the Department to which the opposing party shall have the opportunity to respond. The Department may request additional information as needed and shall determine the timeframes for the submission of documentation and responses. In addition to ruling on the request for emergency order, the Department may review the substantive issues involved in the dispute and determine the required course of action. 8.7001 Home and Community-Based Services Member Rights and 8.7001.A Definitions: Unless otherwise specified, the following definitions apply throughout Sections 8.7000-8.7600.
Age-Appropriate Activities and Materials means activities and materials that foster social, intellectual, communicative, and emotional development and that challenge the individual to use their skills in these areas while considering their chronological age, developmental level, and physical skills. 1- A. Community First Choice (CFC) means services and supports authorized by a 1915(k) granted pursuant to the Social Security Act and provided in home or community settings to a Member who requires a level of institutional care that would otherwise be provided in a hospital, nursing facility, inpatient psychiatric institution for individuals under 21 years of age, or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID). 1- B. Contractor means an individual who performs work on behalf of a Provider Agency but is not an employee of the Agency.
Covered HCBS means any Home and Community-Based Service(s) provided under the Colorado State Medicaid Plan, a Colorado Medicaid waiver program, Community First Choice, or a State-funded program administered by the Department. This category excludes Respite Services and Palliative/Supportive Care services provided outside the child's home as a benefit of the Children with Life-Limiting Illness Waiver.
Discrimination means the unfair or prejudicial treatment of people and groups based on characteristics such as race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or disability. 3- B. Guardian means an individual at least 21 years of age, resident, or non-resident, who has qualified as a Guardian of a minor or incapacitated person pursuant to appointment by a Parent or by the court. The term includes a limited, emergency, and temporary substitute Guardian as set forth in Section 15-14-102 (4), C.R.S, but not a Guardian Ad Litem.
Home and Community-Based Services (HCBS) Setting means any physical location where Covered HCBS are provided.

a. HCBS Settings include, but are not limited to, Provider-Owned or - Controlled Non-Residential Settings, Other Non-Residential Settings, Provider-Owned or -Controlled Residential Settings, and Other Residential Settings.

b. If Covered HCBS are provided at a physical location to one or more individuals, the setting is considered an HCBS Setting, regardless of whether some individuals at the setting do not receive Covered HCBS.

The requirements of Section 8.7001.B apply to the setting as a whole and protect the rights of all individuals receiving services at the setting regardless of payer source.

Informed Consent means the informed, freely given, written agreement of the individual (or, if authorized, their Guardian or other Legally Authorized Representative) to a Rights Modification. The Case Manager ensures that the agreement is informed, freely given, and in writing by confirming that the individual (or, if authorized, their Guardian or other Legally Authorized Representative) understands all of the information required to be documented in

Section 8.7001.B.4 and has signed the Department-prescribed form to that effect.

Intensive Supervision means one-on-one (1:1), line-of-sight, or 24-hour supervision. Intensive Supervision is a Rights Modification if the individual verbally or non-verbally expresses that they do not want the supervision or if the supervision limits an individual’s privacy, autonomy, access to the community, or other rights protected in Section 8.7001.B, because of the individual’s challenging behavior(s).
Legally Authorized Representative means a person with legal authority to represent an individual in a particular matter. Such a person may be:

a. the Parent of a minor;

b. the court-appointed Guardian of an individual, only with respect to matters within the scope of, and in the manner authorized by, the guardianship order; or c. anyone granted authority pursuant to any other type of court order or voluntary appointment or designation (e.g., conservator, agent under power of attorney, member of a supportive community in connection with a supported decision-making agreement, Long-Term Services and Supports Representative under Section 8.7001.A.8, or Authorized Representative under Sections 8.7515 or 8.7528), only with respect to matters within the scope of, and in the manner authorized by, the court order or voluntary appointment or designation.

In situations arising under subsections b and c, the applicable court order or voluntary appointment or designation must be consulted to determine whether it is still in effect, and to ensure the appointed or designated person exercises only those powers it specifically grants 8. Long-Term Services and Supports Representative means a person designated by the individual receiving services, by the Parent of a minor, or by the Guardian of the Member receiving services, if appropriate, to assist the individual in acquiring or utilizing part or all of their Long-Term Services and Supports. This term encompasses any authorized representative as defined by Sections 25.5-6- 1702 and 25.5-10-202, C.R.S.

a. A Long-Term Services and Supports Representative shall have the judgment and ability to assist the individual in acquiring and utilizing the services covered by the designation.

b. The appointment of a Long-Term Services and Supports Representative shall be in writing and shall be subject to the standards set forth in Section 8.7001.C.5. 8- B. Member means a person enrolled in the state medical assistance program, the children’s basic health plan, HCBS waiver program, Community First Choice, or State General Fund program.

Other Non-Residential Setting means a physical location that is non-residential and that is not owned, leased, operated, or managed by an HCBS Provider Agency or by an independent Contractor providing nonresidential services.

a. Other Non-Residential Settings include, but are not limited to, locations in the community where Covered HCBS are provided.

Other Residential Setting means a physical location that is residential and that is not owned, leased, operated, or managed by an HCBS Provider Agency or by an independent Contractor providing residential services.

a. Other Residential Settings include, but are not limited to, Residential Settings owned or leased by individuals receiving HCBS or their families (personal homes) and those owned or leased by relatives paid to provide HCBS unless such relatives are independent Contractors of HCBS Provider Agencies.

Person-Centered Support Plan means a service and support plan that is directed by the individual whenever possible, with the individual’s representative acting in a participatory role as needed, is prepared by the Case Manager, identifies the supports needed for the individual to achieve personally identified goals, and is based on respecting and valuing individual preferences, strengths, and contributions.
Plain Language means language that is understandable to the individual and in their native language, and it may include pictorial methods, if warranted. 12-B. Provider Agency means an Agency certified by the Department and which has a contract with the Department to provide one or more of the services listed at

Section 8.7500.

Provider-Owned or -Controlled Non-Residential Setting means a physical location that is non-residential and that is owned, leased, operated, or managed by an HCBS Provider Agency or by an independent Contractor providing nonresidential services.

a. Provider-Owned or -Controlled Non-Residential Settings include, but are not limited to, provider-owned facilities where Adult Day, Day Treatment, Specialized Habilitation, Supported Community Connections, Prevocational Services, Supported Employment Services, and Youth Day Services (including Youth Day Services at homes owned, leased, or operated by Provider Agencies/independent Contractors) are provided.

Provider-Owned or -Controlled Residential Setting means a physical location that is residential and that is owned, leased, operated, or managed by an HCBS Provider Agency or by an independent Contractor providing residential services.

a. Provider-Owned or -Controlled Residential Settings include, but are not limited to, Alternative Care Facilities (ACFs); Supported Living Program (SLP) and Transitional Living Program (TLP) facilities; group homes for adults with Intellectual or Developmental Disabilities (IDD) (Group Residential Services and Supports (GRSS)); Host Homes for adults with IDD; any Individual Residential Services and Supports (IRSS) setting that is owned or leased by a service Provider Agency or independent Contractor of a Provider Agency; foster care homes, Host Homes, group homes, residential child care facilities, and Qualified Residential Treatment Programs (QRTPs) in which Children's Habilitation Residential Program (CHRP) services are provided; and Mental Health Transitional Living Homes. 14-B. Provider Participation Agreement means the contract between the Department and the Provider Agency that describes the terms and conditions governing participation in the programs administered by the Department.

Restraint means any manual method or direct bodily contact or force, physical or mechanical device, material, or equipment that restricts normal functioning or movement of all or any portion of a person's body, or any drug, medication, or other chemical that restricts a person's behavior or restricts normal functioning or movement of all or any portion of their body. Physical or hand-over-hand assistance is a Restraint if the individual verbally or non-verbally expresses that they do not want the assistance or if the assistance limits an individual’s autonomy or other rights protected in Section 8.7001.B.
Restrictive or Controlled Egress Measures means devices, technologies, or approaches that have the effect of restricting or controlling egress or monitoring the coming and going of individuals. The following measures are deemed to have such an effect and are Restrictive or Controlled Egress Measures: locks preventing egress; audio monitors, chimes, motion-activated bells, silent or auditory alarms, and alerts on entrances/exits at residential settings; and wearable devices that indicate to anyone other than the wearer their location or their presence/absence within a building. Other measures that have the effect of restricting or controlling egress or monitoring the coming and going of individuals are also Restrictive or Controlled Egress Measures.
Rights Modification means any situation in which an individual is limited in the full exercise of their rights.

a. Rights Modifications include, but are not limited to:

i. the use of Intensive Supervision if deemed a Rights Modification under the definition in Section 8.7001.A.6 above;

ii. the use of Restraints;

iii. the use of Restrictive or Controlled Egress Measures;

iv. modifications to the other rights in Section 8.7001.B.2 (basic criteria applicable to all HCBS Settings) and Section 8.7001.B.3 (additional criteria for HCBS Settings);

v. any provider actions to implement a court order limiting any of the foregoing individual rights; and vi. rights modifications under Section 25.5-10-218(3), C.R.S. vi.

b. Modifications to the rights to dignity and respect, the rights in Sections 8.7001.B.2.a.vi-vii covering such matters as Person-Centeredness, civil rights, and freedom from abuse, and the right to physical accessibility are not permitted.

c. For children under age 18, a limitation or restriction to any of the rights in Sections 8.7001.B.2 and 8.7001.B.3 that is typical for children of that age, including children not receiving HCBS, is not a Rights Modification.

Consider age-appropriate behavior when assessing what is typical for children of that age. If the child is not able to fully exercise the right because of their age, then there is no need to pursue the Rights Modification process under Section 8.7001.B.4. However, if the proposed limitation or restriction is above and beyond what a typically developing peer would require, then it must be handled as a Rights Modification under

Section 8.7001.B.4. 8.7001.B Individual Rights under the Home and Community-Based Services (HCBS) Settings Final Rule 1. Statement of Purpose, Scope, and Enforcement a. The purpose of this Section 8.7001.B is to implement the requirements of the federal Home and Community-Based Services (HCBS) Settings Final

Rule, 79 Fed. Reg. 2947 (2014), codified at 42 C.F.R. § 441.301(c)(4).

These rules identify individual rights that are protected at settings where people live or receive HCBS. They also set out a process for modifying these rights as warranted in individual cases. These rules apply to all HCBS under all authorities, except where otherwise noted.

b. This Section 8.7001.B is enforced pursuant to existing procedures.

Basic Criteria Applicable to All HCBS Settings a. All HCBS Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.7001.B.4:

i. The setting is integrated in and supports full access of individuals to the greater community, including opportunities to seek employment and work in competitive integrated settings, control personal resources, receive services in the community, and engage in community life, including with individuals who are not paid staff/Contractors and do not have disabilities, to the same degree of access as individuals not receiving HCBS.

Individuals are not required to leave the setting or engage in community activities. Individuals must be offered and have the opportunity to select from Age-Appropriate Activities and Materials both within and outside of the setting.
Integration and engagement in community life includes supporting individuals in accessing public transportation and other available transportation resources.
Individuals receiving HCBS are not singled out from other community members through requirements of individual identifiers, signage, or other means.
Individuals may communicate privately with anyone of their choosing.
Methods of communication are not limited by the provider.

a) The setting must always provide access to shared telephones if it is a Provider-Owned or -Controlled Residential Setting and during business hours if it is a Provider-Owned or -Controlled Non-Residential Setting.

b) Individuals are allowed to maintain and use their own cell phones, tablets, computers, and other personal communications devices, at their own expense.

c) Individuals are allowed to access telephone, cable, and Ethernet jacks, as well as wireless networks, in their rooms/units, at their own expense.

Individuals have control over their personal resources, including money and personal property. If an individual is not able to control their resources, an Assessment of their skills must be completed and documented in their Person- Centered Support Plan. The Assessment and Person- Centered Support Plan must identify what individualized assistance the provider or other person will provide and any training for the individual to become more independent, based on the outcome of the Assessment.

a) Provider Agencies may not insist on controlling an individual's funds as a condition of providing services and may not require individuals to sign over their Social Security checks or paychecks.

b) A Provider Agency may control an individual's funds if the individual so desires, or if it has been designated as their representative payee under the Social Security Administration's (SSA's) policies. If a Provider Agency holds or manages an individual's funds, their signed Person-Centered Support Plan must:

i) Document the request or representative payee designation;

ii) Document the reasons for the request or designation; and iii) Include the parties' agreement on the scope of managing the funds, how the Provider Agency should handle the funds, and what they define as “reasonable amounts” under Section 25.5- 10-227, C.R.S.

c) The Provider Agency must ensure that the individual can access and spend money at any time, including on weekends, holidays, and evenings, including with assistance or supervision if necessary.

ii. The setting is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a residential setting. The setting options are identified and documented in the Person-Centered Support Plan and are based on the individual's needs, preferences, and, for residential settings, resources available for room and board.

iii. The setting ensures an individual's rights of privacy, dignity, and respect, and freedom from coercion and Restraint.

The right of privacy includes the right to be free of cameras, audio monitors, and devices that chime or otherwise alert others, including silently, when a person stands up or passes through a doorway.

a) The use of cameras, audio monitors, chimes, and alerts in (a) interior areas of residential settings, including common areas as well as bathrooms and bedrooms, and in (b) typically private areas of nonresidential settings, including bathrooms and changing rooms, is acceptable only under the standards for modifying rights on an individualized

basis pursuant to Section 8.7001.B.4.

b) If an individualized Assessment indicates that the use of a camera, audio monitor, chime, or alert in the areas identified in the preceding paragraph is necessary for an individual, this modification must be reflected in their Person-Centered Support Plan. The Person-Centered Support Plans of other individuals at that setting must reflect that they have been informed in Plain Language of the camera(s)/monitor(s)/chime(s)/alert(s) and any methods in place to mitigate the impact on their privacy. The provider must ensure that only appropriate staff/Contractors have access to the camera(s)/monitor(s)/chime(s)/alert(s) and any recordings and files they generate, and it must have a method for secure disposal or destruction of any recordings and files after a reasonable period.

c) Cameras, audio monitors, chimes, and alerts on staffonly desks and exterior areas, cameras on the exterior sides of entrances/exits, and cameras typically found in integrated employment settings, generally do not raise privacy concerns, so long as their use is similar to that practiced at non-HCBS Settings. In Provider-Owned or -Controlled Settings, notice must be provided to all individuals that they may be on camera and specify where the cameras are located. If such devices have the effect of restricting or controlling egress or monitoring the coming and going of individuals, they are subject to the Rights Modification requirements of Section 8.7001.B.4.

d) Audio monitors, chimes, motion-activated bells, silent or auditory alarms, and alerts on entrances/exits at residential settings have the effect of restricting or controlling egress and are subject to the Rights Modification requirements of Section 8.7001.B.4. If such devices on entrances/exits at non-residential settings have the effect of restricting or controlling egress or monitoring the coming and going of individuals, they are subject to the Rights Modification requirements of Section 8.7001.B.4.

The right of privacy includes the right not to have one's name or other confidential items of information posted in common areas of the setting.

iv. The setting fosters individual initiative and autonomy, and the individual is afforded the opportunity to make independent life choices. This includes, but is not limited to, daily activities, physical environment, and with whom to interact.

v. The setting facilitates individual choice regarding services and supports, and who provides them.

vi. The Person-Centered Support Plan drives the services afforded to the individual, and the setting staff/Contractors are trained on this concept and person-centered practices, as well as the concept of dignity of risk.

vii. Each individual is afforded the opportunity to:

Lead the development of, and grant informed consent to, any provider-specific treatment, care, supports, or service plan;
Have freedom of religion and the ability to participate in religious or spiritual activities, ceremonies, and communities;
Live and receive services in a clean, safe environment;
Be free to express their opinions and have those included when any decisions are being made affecting their life;
Be free from physical abuse and inhumane treatment;
Be protected from all forms of sexual exploitation;
Access necessary medical care which is adequate and appropriate to their condition;
Exercise personal choice in areas including personal style;
Accept or decline services and supports of their own free will and on the basis of informed choice.

viii. Nothing in this rule shall be construed to prohibit necessary assistance as appropriate to those individuals who may require such assistance to exercise their rights.

ix. Nothing in this rule shall be construed to interfere with the ability of a Guardian or other Legally Authorized Representative to make decisions within the scope of their guardianship order or other authorizing document.

Additional Criteria for HCBS Settings a. Provider-Owned or -Controlled Residential Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.7001.B.4:

i. The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a legally enforceable agreement by the individual, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the State, county, city, or other designated entity. For settings in which landlord/tenant laws do not apply, a lease, residency agreement, or other form of written agreement must be in place for each individual, and the document must provide protections that address eviction processes and appeals comparable to those provided under the jurisdiction's landlord/tenant law.

The lease, residency agreement, or other written agreement must:

a) Provide substantially the same terms for all individuals;

b) Be in Plain Language, or if the Provider Agency/its independent Contractor cannot adjust the language, at least be explained to the individual in Plain Language;

c) Provide the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of their State, county, city, or other designated entity, or comparable responsibilities and protections, as the case may be, and indicate the authorities that govern these responsibilities, protections, and related disputes;

d) Specify that the individual will occupy a particular room or unit;

e) Explain the conditions under which people may be asked to move or leave;

f) Provide a process for individuals to dispute/appeal and seek review by a neutral decisionmaker of any notice that they must move or leave, or tell individuals where they can easily find an explanation of such a process, and state this information in any notice to move or leave;

g) Specify the duration of the agreement;

h) Specify rent or room-and-board charges;

i) Specify expectations for maintenance;

j) Specify that staff/Contractors will not enter a unit without providing advance notice and agreeing upon a time with the individual(s) in the unit;

k) Specify refund policies in the event of a resident's absence, hospitalization, voluntary or involuntary move to another setting, or death; and l) Be signed by all parties, including the individual or, if within the scope of their authority, their Guardian or other Legally Authorized Representative.

The lease, residency agreement, or other written agreement may:

a) Include generally applicable limits on furnishing/decorating of the kind that typical landlords might impose; and b) Provide for a security deposit or other provisions outlining how property damage will be addressed.

The lease, residency agreement, or other written agreement may not modify the individual rights protected under Sections 8.7001.B.2 and 8.7001.B.3, such as (a) by imposing individualized terms that modify these conditions or (b) by requiring individuals to comply with house rules or resident handbooks that modify everyone's rights.
Provider Agencies and their independent Contractors must engage in documented efforts to resolve problems and meet residents' care needs before seeking to move individuals or asking them to leave. Provider Agencies and their independent Contractors must have a substantial reason for seeking any move/eviction (e.g., protection of someone's health/safety), and minor personal conflicts do not meet this threshold.
A violation of a lease or residency agreement, a change in the resident's medical condition, or any other development that leads to a notice to leave must include at least 30 calendar days' notice to the individual (or, if authorized, their Guardian or other Legally Authorized Representative).
If an individual has not moved out after the end of a 30-day (or longer) notice period, the Provider Agency/its independent Contractor may not act on its own to evict the individual until the individual has had the opportunity to pursue and complete any applicable Grievance, Complaint, dispute resolution, and/or court processes, including obtaining a final decision on any appeal, request for reconsideration, or further review that may be available.
A Provider Agency/its independent Contractor may not require an individual who has nowhere else to live to leave the setting.
This Subsection 8.7001.B.3.a.i. does not apply to children under age 18.

ii. Individuals have the right to dignity and privacy, including in their living/sleeping units. This right to privacy includes the following criteria:

Individuals must have a key or key code to their home, a bedroom door with a lock and key, lockable bathroom doors, privacy in changing areas, and a lockable place for belongings, with only appropriate staff/Contractors having keys to such doors and locks. Staff/Contractors must knock and obtain permission before entering individual units, bedrooms, bathrooms, and changing areas.

Staff/Contractors may use keys to enter these areas and to open private storage spaces only under limited circumstances agreed upon with the individual. If an individual’s lockable place for their belongings is a locker, the Provider Agency must supply a padlock and key/combination.

Individuals shall have choice in a roommate/housemate.

Provider Agencies must have a process in place to document expectations and outline the process to accommodate choice.

Individuals have the right to furnish and decorate their sleeping and/or living units in the way that suits them, while maintaining a safe and sanitary environment and, for individuals age 18 and older, complying with the applicable lease, residency agreement, or other written agreement.

iii. The Residential Setting does not have institutional features not found in a typical home, such as staff uniforms; entryways containing staff postings or messages; or labels on drawers, cupboards, or bedrooms for staff convenience.

iv. Individuals have the freedom and support to determine their own schedules and activities, including methods of accessing the greater community;

v. Individuals have access to food at all times, choose when and what to eat, have input in menu planning (if the setting provides food), have access to food preparation and storage areas, can store and eat food in their room/unit, and have access to a dining area for meals/snacks with comfortable seating where they can choose their own seat, choose their company (or lack thereof), and choose to converse (or not);

vi. Individuals are able to have visitors of their choosing at any time and are able to socialize with whomever they choose (including romantic relationships);

vii. The setting is physically accessible to the individual, and the individual has unrestricted access to all common areas, including areas such as the bathroom, kitchen, dining area, and comfortable seating in shared areas. If the individual wishes to do laundry and their home has laundry machines, the individual has physical access to those machines; and viii. Individuals are able to smoke and vape nicotine products in a safe, designated outdoor area, unless prohibited by the restrictions on smoking near entryways set forth in the Colorado Clean Indoor Air Act, Section 25-14-204(1)(ff), C.R.S., or any law of the county, city, or other local government entity.

b. Other Residential Settings in which one or more individuals receiving 24hour residential services and supports reside must have all of the qualities of and protect all of the same individual rights as Provider-Owned or - Controlled Residential Settings, as listed above, other than Subsection 8.7001.B.3.a.i relating to a lease or other written agreement providing protections against eviction, subject to the Rights Modification process in

Section 8.7001.B.4.

c. Other Residential Settings in which no individuals receiving 24-hour residential services and supports reside are excluded from this Section 8.7001.B.3.

i. This group of settings includes, but is not limited to, homes in which no individual receives Individual Residential Service and Supports (IRSS) and one or more individuals receive Consumer-Directed Attendant Support Services (CDASS), Health Maintenance Services, Homemaker Services, In-Home Support Services (IHSS), and/or Personal Care Services.

d. Provider-Owned or -Controlled Non-Residential Settings must have all of the qualities of and protect all of the same individual rights as Provider- Owned or -Controlled Residential Settings, as listed above, other than Subsection 8.7001.B.3.a.i relating to a lease or other written agreement providing protections against eviction and Subsection 8.7001.B.3.a.ii relating to privacy in one's living/sleeping unit, subject to the Rights Modification process in Section 8.7001.B.4.

i. Provider-Owned or -Controlled Non-Residential Settings must afford individuals privacy in bathrooms and changing areas and a lockable place for belongings, with only the individuals and appropriate staff/Contractors having keys to such doors and locks.

In addition to supplying a locker, the Provider Agency must supply a padlock and key/combination.

ii. This Section 8.7001.B.3 does not require Non-Residential Settings to provide food if they are not already required to do so under other authorities. This Section 8.7001.B.3 requires Non- Residential Settings to ensure that individuals have access to their own food at any time.

e. Other Non-Residential Settings must have all of the qualities of and protect the same individual rights as Provider-Owned or -Controlled Non- Residential Settings, as stated immediately above, to the same extent for HCBS participants as they do for other individuals, subject to the Rights Modification process in Section 8.7001.B.4.

Rights Modifications a. Any modification of an individual's rights must be supported by a specific assessed need and justified in the Person-Centered Support Plan, pursuant to the process set out in Sections 8.7001.B.4.c and 8.7001.B.4.d below. Rights Modifications may not be imposed across-the-board and may not be based on the convenience of the Provider Agency/its independent Contractor. The Provider Agency/its independent Contractor must ensure that a Rights Modification does not infringe on the rights of individuals not subject to the modification. Wherever possible, Rights Modifications should be avoided or minimized, consistent with the concept of dignity of risk.

b. The process set out in Sections 8.7001.B.4.c-d below applies to all Rights Modifications.

c. For a Rights Modification to be implemented, the following information must be documented in the individual's Person-Centered Support Plan, and any Provider Agency/its independent Contractor implementing the Rights Modification must maintain a copy of the documentation:

i. The right to be modified.

ii. The specific and individualized assessed need for the Rights Modification.

iii. The positive interventions and supports used prior to any Rights Modification, as well as the plan going forward for the Provider Agency/its independent Contractor to support the individual in learning skills so that the modification becomes unnecessary.

iv. The less intrusive methods of meeting the need that were tried but did not work.

v. A clear description of the Rights Modification that is directly proportionate to the specific assessed need. Rights of an individual receiving services may be modified only in a manner that will promote the least restriction on the individual’s rights and in accordance with rules herein.

vi. A plan for regular collection of data to measure the ongoing effectiveness of and need for the Rights Modification, including specification of the positive behaviors and objective results that the individual can achieve to demonstrate that the Rights Modification is no longer needed.

vii. An established timeline for periodic reviews of the data collected under the preceding paragraph. The Rights Modification must be reviewed and updated as necessary upon reassessment of functional need at least every 12 months, and sooner if the individual's circumstances or needs change significantly, the individual requests a review/revision, or another authority requires a review/revision.

viii. The Informed Consent of the individual (or, if authorized, their Guardian or other Legally Authorized Representative) agreeing to the Rights Modification, as documented on a completed and signed Department-prescribed form. To be completed, the form must be filled out using Plain Language, addressed directly to the individual, and it must address only one Rights Modification.

Informed Consent may not be requested or granted for a Rights Modification extending beyond the 12-month or shorter period as set out in Section 8.7001.B.4.c.vii.

ix. An assurance that interventions and supports will cause no harm to the individual, including documentation of the implications of the modification for the individual's everyday life and the ways the modification is paired with additional supports or other approaches to prevent harm or discomfort and to mitigate any effects of the modification.

x. Alternatives to consenting to the Rights Modification, along with their most significant likely consequences.

xi. An assurance that the individual will not be subject to retaliation or prejudice in their receipt of appropriate services and supports for declining to consent or withdrawing their consent to the Rights Modification.

d. Additional Rights Modification process requirements:

i. Prior to obtaining Informed Consent, the Case Manager must offer the individual the opportunity to have an advocate, who is identified and selected by the individual, present at the time that Informed Consent is obtained. The Case Manager must offer to assist the individual, if desired, in identifying an independent advocate who is not involved with providing services or supports to the individual. These offers and the individual's response must be documented by the Case Manager.

ii. Any Provider Agencies that desire or expect to be involved in implementing a Rights Modification may supply to the Case Manager information required to be documented under this

Section 8.7001.B.4, except for documentation of Informed Consent and the offers and response relating to an advocate, which may be obtained and documented only by the Case Manager. The individual determines whether any information supplied by the Provider Agency is satisfactory before the Case Manager enters it into their Person-Centered Support Plan.

iii. When a Rights Modification is proposed, it is reviewed by the individual, their Guardian or other Legally Authorized Representative, and the rest of the individual’s Member Identified Team and, if consented to, it is documented in the Personiv. When a right has been modified, the continuing need for such modification shall be reviewed by the individual's Member Identified Team, as led by the individual or their Guardian or other Legally Authorized Representative, at a frequency decided by the team, but at least every six months.

Such review shall include the original reason for modification, current circumstances, success or failure of programmatic intervention, and the need for continued modification.
Restoration of affected rights shall occur as soon as circumstances justify.
If the review indicates that changes are needed to the Rights Modification, the Case Manager shall obtain a new signature on an updated Department-prescribed Informed Consent form. If the review indicates that no changes are needed, then the original signature is still valid for the remaining period (up to six months).

v. At the time a right is modified, such action if subject to Human Rights Committee review shall be referred to the Human Rights Committee for review and recommendation. Such review shall include an opportunity for the individual or Member who is affected, Parent of a minor, Guardian or other Legally Authorized Representative, after being given reasonable notice of the meeting, to present relevant information to the Human Rights Committee.

e. Use of Restraints i. If Restraints are used with an individual at an HCBS Setting, their use must:

Be based on an assessed need after all less restrictive interventions have been exhausted;
Be documented in the individual's Person-Centered Support Plan as a modification of the generally applicable rights protected under Section 8.7001.B.2, consistent with the Rights Modification process in this Section 8.7001.B.4; and 3) Be compliant with any applicable waiver or CFC program.

ii. Prone Restraints are prohibited in all circumstances. Nothing in this Subsection 8.7001.B.4.e permits the use of any Restraint that is precluded by other authorities.

f. If Restrictive or Controlled Egress Measures are used at an HCBS Setting, they must:

i. Be implemented on an individualized (not setting-wide) basis;

ii. Make accommodations for individuals in the same setting who are not at risk of unsafe wandering or exit-seeking behaviors;

iii. Be documented in the individual's Person-Centered Support Plan as a modification of the generally applicable rights protected under Section 8.7001.B.2, consistent with the Rights Modification process in this Section 8.7001.B.4, with the documentation including:

An Assessment of the individual's unsafe wandering or exitseeking behaviors (and the underlying conditions, diseases, or disorders relating to such behaviors) and the need for safety measures;
Options that were explored before any modifications occurred to the Person-Centered Support Plan;
The individual's understanding of the setting's safety features, including any Restrictive or Controlled Egress Measures;
The individual's choices regarding measures to prevent unsafe wandering or exit-seeking;
The individual's (or, if authorized, their Guardian's or other Legally Authorized Representative's) consent to restrictiveor controlled-egress goals for care;
The individual's preferences for engagement within the setting's community and within the broader community; and 7) The opportunities, services, supports, and environmental design that will enable the individual to participate in desired activities and support their mobility; and iv. Not be developed or used for non-person-centered purposes, such as punishment or staff/Contractor convenience.

g. If there is a serious risk to anyone's health or safety, a Rights Modification may be implemented or continued for a short time without meeting all the requirements of this Section 8.7001.B.4, so long as the Provider Agency/its independent Contractor immediately (a) implements staffing and other measures to deescalate the situation and (b) reaches out to the Case Manager to set up a meeting as soon as possible, and in no event past the end of the third business day following the date on which the risk arises. At the meeting, the individual can grant or deny their Informed Consent to the Rights Modification. The Rights Modification may not be continued past the conclusion of this meeting or the end of the third business day, whichever comes first, unless all the requirements of this

Section 8.7001.B.4 have been met.

h. When a Provider Agency proposes a Rights Modification and supplies to the Case Manager the unsigned Informed Consent form with all of the information required to be documented under this Section 8.7001.B.4, except for documentation that may be obtained only by the Case Manager, the Case Manager shall arrange for a meeting with the individual to discuss the proposal and facilitate the individual's decision regarding whether to grant or deny their Informed Consent. Except when the timeline in Section 8.7001.B.4.g applies, the Case Manager shall arrange for this meeting to occur by the end of the tenth business day following the date on which they received from the Provider Agency all of the required information. The individual may elect to make a final decision during or after this meeting. If the individual does not inform their Case Manager of their decision by the end of the fifth business day following the date of the meeting, they are deemed not to have consented. 8.7001.C Additional Provisions Regarding Rights and Responsibilities of Members and Other Individuals 1. Member and Other Individual Rights a. An individual receiving services has the same legal rights and responsibilities guaranteed to all other individuals under the federal and state constitutions and federal and state laws including, but not limited to, those contained in Sections 25.5-10-201 through 240, C.R.S., unless such rights are modified pursuant to state or federal law. Many rights of Members and other individuals and a process for modifying those rights in individual cases are set forth in Section 8.7001.B. Members and other individuals have additional rights as set forth below and elsewhere in these rules. These additional rights apply not just at HCBS Settings, but also in the context of Case Management, and unless otherwise specified, they are not subject to modification.

b. Every person has the right to receive the same consideration and treatment as anyone else regardless of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or disability.

c. No individual, their Family Members, Guardians, or other Legally Authorized Representatives may be retaliated against in their receipt of Case Management services or supports or direct services and supports as a result of attempts to advocate on their own behalf.

d. Each individual receiving services has the right to read or have explained in their and their family’s native language any policies and/or procedures adopted by their provider(s) and their Case Management Agency.

e. The individual and the individual’s Legally Authorized Representative as necessary is fully informed of the individual’s rights and responsibilities.

f. The individual and/or the individual’s Legally Authorized Representative participates in the development and approval of, and is provided a copy of, the individual’s Person-Centered Support Plan.

g. The individual and/or the individual’s Legally Authorized Representative selects service providers from among available qualified and willing providers.

h. The individual and/or the individual’s Legally Authorized Representative has access to a uniform Complaint system provided for all individuals served by the Case Management Agency.

i. The individual who applies for or receives publicly funded benefits and/or the individual’s Legally Authorized Representative has access to a uniform appeal process, which meets the requirements of Section 8.057 when benefits or services are denied or reduced, and the issue is appealable.

j. Members shall have the right to read or have explained any rules or regulations adopted by the Department and policies and procedures of the Case Management Agency pertaining to such people’s activities and services and supports, and to obtain copies of Sections 25.5-10-201 through 240, C.R.S., rules, policies or procedures at no cost or at a reasonable cost in accordance with Section 24-72-205, C.R.S.

k. Members and other individuals have the right to request that an Assessment be completed even if the intake Case Management Agency staff determines otherwise. If an Assessment is requested, the Case Management Agency must complete it.

l. Members and other individuals have the right to include anyone they would like in the service and Person-Centered Support Planning process.

m. Members and other individuals have the right to be provided with support to help them direct the planning process to the maximum extent possible and to help them make informed choices and decisions.

n. Members and other individuals have the right to schedule the planning process at a time and place convenient to them.

o. Members and other individuals have the right to choose any Long-Te r m Services and Supports programs and services that they are eligible for.

Members may only enroll in one waiver at a time.

p. Members and other individuals have the right to know in advance if services are going to be stopped.

q. Members and other individuals have the right to be provided with services and supports that do not have any potential conflict of interest with their Case Management or the development of their Person-Centered Support 2. Case Management Requirement for Preservation of Member Rights a. Members have the right to receive Case Management services in accordance with Section 8.7201.J in the preservation of their rights.

b. If rights are not preserved by Case Management Agencies to the degree necessary, Members may engage in the Complaint process with the Agency or escalate their Complaints to the Department of Health Care Policy & Financing (HCPF) via the escalation process on the Department of Health Care Policy & Financing website and/or explained to them by their Case Manager.

Member and Other Individual Rights to Access the Case Management Agency a. Members and other individuals have the right to access the Case Management Agency without physical or programmatic barriers, in compliance with the Americans with Disabilities Act, 42 U.S.C. § 12101, et seq.

b. Members and other individuals have a right to request meetings outside of the Case Management Agency office.

c. Members and other individuals have the right to be free from Discrimination and to file a Complaint with a Case Management Agency about their services without fear of retaliation. This includes if or when an advocate files a Complaint on behalf of a Member or individual.

d. Members and other individuals have the right to Person-Centered Case Management delivery. Case Management Agency functions shall be based on a person-centered model of Case Management service delivery.

Member Responsibilities a. To the degree possible, each Member or Guardian is responsible to:

i. Provide accurate information regarding the individual’s ability to complete Activities of Daily Living, ii. Assist in promoting the individual’s independence, iii. Cooperate in the determination of Financial Eligibility for Medicaid, iv. Participate in all waiver program and CFC program required activities, including but not limited to:

Level of Care Screen;
Needs Assessment;
Person-Centered Support Planning;
Monitoring, including in the Member’s home; and 5) All required in-person activities except in cases of natural disaster, pandemic or other emergency v. Notify the Case Manager within thirty (30) calendar days or as soon as possible when:
There are changes in the individual’s support system, medical, physical or psychological condition or living situation including any hospitalizations, emergency room admissions, or placement in a nursing home or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID), 2) The individual has not received an HCBS waiver service during one (1) month, 3) There are changes in the individual’s care needs, 4) There are problems with receiving HCBS Waiver Services, 5) There are changes that may affect Medicaid Financial Eligibility, including changes in income or assets, 6) There are changes in legal status, such as guardianship or Legally Authorized Representative.

Use of a Long-Term Services and Supports Representative a. People who are eligible for services and supports and their Legally Authorized Representative(s) shall have the opportunity at the time of enrollment and at each annual review of the Person-Centered Support Plan to designate a Long-Term Services and Supports Representative to be included in their Member Identified Team. The designation of a Long- Term Services and Supports Representative must occur with informed consent of the person receiving services or, if applicable, their Legally Authorized Representative.

b. Such designation shall be in writing and shall specify the duration of the Long-Term Services and Supports Representative's involvement and specific authority in assisting the Member in acquiring or utilizing Long- Term Services and Supports and in protecting their rights.

c. The written designation of a Long-Term Services and Supports Representative shall be maintained in the record of the person receiving d. The person receiving services or, if applicable, their Legally Authorized Representative may withdraw their designation of a Long-Term Services and Supports Representative at any time. 8.7100 Waiver/Program Eligibility Requirements 8.7100.A Definitions Unless otherwise specified, the following definitions apply throughout Section 8.7000- 8.7500.

Activities of Daily Living means basic self-care activities including bathing, bowel and bladder control, dressing, eating, independent ambulation, and needing supervision to support behavior, medical needs, and memory and cognition.
Agency means any public or private entity operating in a for-profit or nonprofit capacity, with a defined administrative and organizational structure. At Health Care Policy and Financing’s discretion, any sub-unit of the Agency that is not geographically close enough to share administration and supervision on a frequent and adequate basis shall be considered a separate Agency for purposes of certification and contracts.
Applicant means an individual or Member who is seeking a Long-Term Services and Supports eligibility determination and who has not affirmatively declined to apply for Medicaid or participate in an Assessment.
Assessment is as defined at Section 8.7200.B.1 5. BBA Working Disabled Group is as defined at 42 U.S.C § 1396a(a)(10)(A)(ii)(XIII)).
Brain Injury means an injury to the brain of traumatic or acquired origin that results in residual physical, cognitive, emotional, and behavioral difficulties of a non-progressive nature and is limited to the following broad diagnoses found within the most current version of the International Classification of Diseases (ICD) at the time of Assessment:

a. Nonpsychotic mental disorders due to brain damage; or b. Anoxic brain damage; or c. Compression of the brain; or d. Toxic encephalopathy; or e. Subarachnoid and/or intracerebral hemorrhage; or f. Occlusion and stenosis of precerebral arteries; or g. Acute, but ill-defined cerebrovascular disease; or h. Other and ill-defined cerebrovascular disease; or i. Late effects of cerebrovascular disease; or j. Fracture of the skull or face; or k. Concussion resulting in an ongoing need for assistance with Activities of Daily Living; or l. Cerebral laceration and contusion; or m. Subarachnoid, subdural, and extradural hemorrhage, following injury; or n. Other unspecified intracranial hemorrhage following injury; or o. Intracranial injury; or p. Late effects of musculoskeletal and connective tissue injuries; or q. Late effects of injuries to the nervous system; or r. Unspecified injuries to the head resulting in an ongoing need for assistance with Activities of Daily Living.

Case Management is as defined at Section 25.5-6-1701 C.R.S including the calculation of Member payment.
Case Management Agency (CMA) means a public, private, or non-governmental non-profit Agency that meets all applicable state and federal requirements and is certified by the Department to provide Case Management services for Home and Community-Based Services (HCBS) waivers.
Member is as defined in 8.7001.A.8-B.
Complex Behavior means behavior that occurs related to a diagnosis by a licensed physician, psychiatrist, or psychologist that includes one or more substantial disorders of the cognitive, volitional, or emotional process that grossly impairs judgment or capacity to recognize reality or to control behavior.
Complex Medical Needs means needs that occur as a result of a chronic medical condition diagnosed by a licensed physician that has lasted or is expected to last at least twelve (12) months, requires skilled care, and that without intervention may result in a severely life-altering condition.
Congregate Facility means a residential facility that provides room and board to three or more adults who are not related to the owner and who, because of impaired capacity for independent living, elect protective oversight, personal services, and social care but do not require regular twenty-four hour medical or nursing care.
Uncertified Congregate Facility means a facility as defined at Section 8.7100.A.12 that is not certified as an Alternative Care Facility.
Continued Stay Review means a re-assessment conducted by a Case Management Agency as defined in Section 8.7202.F.
Comprehensive Review of the Person's Life Situation means a thorough review of all aspects of the person's current life situation by the Provider Agency in conjunction with other Members of the Member Identified Team.
Corrective Action Plan is as defined at Section 8.7200.B.11 17. Cost Containment means the same as Provisions for Compliance with Federal Cost Effectiveness at 8.7100.A.52-A.
Crisis means an event, series of events, and/or state of being of greater than normal severity for the Member and/or Family that is outside the manageable range for the Member or their Family and poses a danger to self, family, and/or the community. Crisis may be self-identified, family- identified, and/or identified by an outside party.
Deinstitutionalized means transferred from institutional care to community-based care.
Diverted means maintained in institutional care.
Developmental Delay means one or more of the following:

a. A child less than five years of age who is at risk of having a Developmental Disability because of the presence of one or more of the following measurements as determined by a qualified health professional utilizing appropriate diagnostic methods and procedures:

i. Chromosomal conditions associated with delays in development, ii. Congenital syndromes and conditions associated with delays in development, iii. Sensory impairments associated with delays in development, iv. Metabolic disorders associated with delays in development, v. Prenatal and perinatal infections and significant medical problems associated with delays in development, vi. Low birth weight infants weighing less than 1200 grams, or vii. Postnatal acquired problems resulting in delays in development.

b. A child under five years of age who has the equivalence of twenty-five percent (25%) or greater delay in one or more of the five domains of development when compared with chronological age; or equivalence of 1.5 standard deviations or more below the mean in one or more of the five domains of development as determined by a qualified health professional utilizing appropriate diagnostic methods and procedures. The five domains are:

i. Adaptive development;

ii. Cognitive development;

iii. Communication development;

iv. Physical development, including vision and hearing; and, v. Social or emotional development.

c. A child under three years of age who lives with one or both Parents who have been determined to have a Developmental Disability by a Case Management Agency.

Developmental Disabilities Professional means a person who has a bachelor’s degree and a minimum of two years’ experience in the field of Developmental Disabilities or a person with at least five years of experience in the field of Developmental Disabilities with competency in the following areas:

a. Understanding of civil, legal, and human rights;

b. Understanding of the theory and practice of positive and non-aversive behavioral intervention strategies; and c. Understanding of the theory and practice of non-violent crisis and behavioral intervention strategies.

Developmental Disability means a disability that:

a. Is manifested before the person reaches 22 years of age;

b. Constitutes a substantial disability to the affected individual, as demonstrated by the criteria below at Subsections 8.7100.A.23.c.i and/or 8.7100.A.23.c.ii; and, c. Is attributable to an Intellectual and Developmental Disability or related conditions which include Prader-Willi syndrome, cerebral palsy, epilepsy, autism, or other neurological conditions when such conditions result in impairment of general intellectual functioning or adaptive behavior similar to that of a person with an Intellectual and Developmental Disability.

Unless otherwise specifically stated, the federal definition of “developmental disability” at 42 U.S.C. § 15002(8) shall not apply.

i. Impairment of general intellectual functioning means that the person has been determined to have a full-scale intellectual quotient equivalent which is two or more standard deviations below the mean (70 or less assuming a scale with a mean of 100 and a standard deviation of 15).

A secondary score comparable to the General Abilities Index for a Wechsler Intelligence Scale that is two or more standard deviations below the mean may be used only if a full-scale score cannot be appropriately derived.
Score shall be determined using a norm-referenced, standardized test of general intellectual functioning comparable to a comprehensively administered Wechsler Intelligence Scale or Stanford-Binet Intelligence Scales, as revised or current to the date of administration. The test shall be administered by a licensed psychologist or a school psychologist.
When determining the intellectual quotient equivalent score, a maximum confidence level of ninety percent (90%) shall be applied to the full-scale score to determine if the interval includes a score of 70 or less and shall be interpreted to the benefit of the Applicant being determined to have a Developmental Disability.

ii. Adaptive behavior similar to that of a person with intellectual disability means an overall adaptive behavior composite or equivalent score that is two or more standard deviations below the mean.

Measurements shall be determined using a normreferenced, standardized Assessment of adaptive behaviors that is appropriate to the person's living environment and comparable to a comprehensively administered Vineland Scale of Adaptive Behavior, as revised or current to the date of administration. The Assessment shall be administered and determined by a professional qualified to administer the 2) When determining the overall adaptive behavior score, a maximum confidence level of ninety percent (90%) shall be applied to the overall adaptive behavior score to determine if the interval includes a score of 70 or less and shall be interpreted to the benefit of the Applicant being determined to have a Developmental Disability.

d. A person shall not be determined to have a Developmental Disability if it can be demonstrated such conditions are attributable to only a physical or sensory impairment or a mental illness.

Early and Periodic Screening Diagnosis and Treatment (EPSDT) is as defined in

Section 8.280.1.

Extraordinary Needs means Complex Behavior and/or Medical Support Needs that, without care provided in a residential childcare facility, would place a child at risk of unwarranted child welfare involvement or other system involvement.
Extreme Safety Risk to Self means a factor in addition to specific Support Level scores that are considered in the calculation of a Member’s Support Level. This factor shall be identified when a Member:

a. Displays self-destructiveness related to self-injury, suicide attempts, or other similar behaviors that seriously threaten the Member's safety; and, b. Has a Rights Modification in accordance with Sections 8.7001 or 8.7001.B.4 or has a court order that imposes line of sight supervision unless the Member is in a controlled environment that limits the ability of the Member himself or herself.

Family as used in rules pertaining to support services and the Family Support Services Program means a group of interdependent persons residing in the same household that consists of a Family Member with a Developmental Disability or a child under the age of five years with a Developmental Delay, and one or more of the following:

a. A mother, father, brother(s), sister(s) or any combination; or, b. Extended blood relatives such as grandparent(s), aunt(s) or uncle(s); or, c. An adoptive Parent(s); or, d. One or more persons to whom legal custody of a person with a Developmental Disability has been given by a court; or e. A spouse and/or their children.

Financial Eligibility means eligibility based on the individual's financial circumstances, including income and resources.
Functional Eligibility means eligibility based on the criteria for Long-Te r m Services and Supports as determined by the Department’s prescribed Assessment instrument, the Long-Term Services and Supports Level of Care Eligibility Determination Screen.
Functional Needs Assessment means a comprehensive, in-person evaluation using the Long-Term Services and Supports Level of Care Eligibility Determination Screen and medical verification provided using the Professional Medical Information Page to determine if the individual meets the institutional Level of Care (LOC).
Group Residential Services and Supports (GRSS) means residential habilitation provided in group living environments of four to eight Members receiving services who live in a single residential setting, which is licensed by the Colorado Department of Public Health and Environment as a residential care facility or residential community home for persons with Developmental Disabilities.
Grievance means the formal expression of a Complaint.
Guardian means an individual at least 21 years of age, resident, or non-resident, who has qualified as a Guardian of a minor or incapacitated person pursuant to appointment by a Parent or by the court. The term includes a limited, emergency, and temporary substitute Guardian as set forth in Section 15-14-102 (4), C.R.S, but not a Guardian Ad Litem.
Guardian Ad Litem means a person appointed by a court to act in the best interests of a child involved in a proceeding pursuant to Title 19, Article 3, C.R.S., or the “School Attendance Law of 1963,” set forth in Title 22, Article 33, C.R.S.
Home and Community-Based Services (HCBS) waiver means services and supports authorized by a waiver granted pursuant to 42 U.S.C. 1396n(c) of 1935 (the Act) and provided in community settings to a Member who requires a level of institutional care that would otherwise be provided in a hospital, nursing facility, or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID).
Hospital Level of Care is as defined at 42 CFR §440.10.
Inability for Independent Ambulation means (1) the individual does not walk, and requires the use of a wheelchair or scooter in all settings, whether or not they can operate the wheelchair or scooter safely, on their own, or (2) the individual does walk, but requires the use of a walker or cane in all settings, whether or not they can use the walker or cane safely, on their own, or (3) the individual does walk but requires “touch” or “stand-by” assistance to ambulate safely in all settings.
Increased Risk Factors means situations or events that occur at a certain frequency or pattern historically that have led to Crisis.
Institution means a hospital, nursing facility, or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) for which the Department makes Medicaid payment under the Medicaid State Plan.
Intellectual and Developmental Disability means a disability that manifests before the person reaches 22 years of age, that constitutes a substantial disability to the affected person, and that is attributable to an Intellectual and Developmental Disability or related conditions, including Prader-Willi syndrome, cerebral palsy, epilepsy, autism, or other neurological conditions when the condition or conditions result in impairment of general intellectual functioning or adaptive behavior similar to that of a person with an Intellectual and Developmental Disability. Unless otherwise specifically stated, the federal definition of “developmental disability” found in 42 U.S.C. sec. 15001 et seq., does not apply.

a. Impairment of general intellectual functioning means the person has been determined to have an intellectual quotient equivalent which is two or more standard deviations below the mean (70 or less assuming a scale with a mean of 100 and a standard deviation of 15), as measured by an instrument which is standardized, appropriate to the nature of the person's disability, and administered by a qualified professional. the standard error of measurement of the instrument should be considered when determining the intellectual quotient equivalent. When an individual's general intellectual functioning cannot be measured by a standardized instrument, then the Assessment of a qualified professional shall be used.

b. Adaptive behavior similar to that of a person with Intellectual and Developmental Disabilities means the person has overall adaptive behavior which is two or more standard deviations below the mean in two or more skill areas (communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work), as measured by an instrument which is standardized, appropriate to the person's living environment, and administered and clinically determined by a qualified professional. These adaptive behavior limitations are a direct result of, or are significantly influenced by, the person's Substantial intellectual deficits and may not be attributable to only a physical or sensory impairment or mental illness.

Substantial intellectual deficit(s) means an intellectual quotient that is between 71 and 75 assuming a scale with a mean of 100 and a standard deviation of 15, as measured by an instrument which is standardized, appropriate to the nature of the person's disability, and administered by a qualified professional. the standard error of measurement of the instrument should be considered when determining the intellectual quotient equivalent.
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) means a publicly or privately operated facility that provides health and habilitation services to a Member with an intellectual or Developmental Disability or related conditions.
Level of Care (LOC) means the specified minimum amount of assistance a Member must require to receive services in an institutional setting under the Medicaid State Plan.
Level of Care Assessment means a comprehensive evaluation with the Individual seeking services and others chosen by the Individual to participate, conducted by the Case Manager utilizing the Department’s prescribed Assessment instrument, Long-Term Services and Supports Level of Care Eligibility Determination Screen, with supporting diagnostic information from the Individual’s medical providers, to determine the Individual’s level of functioning for admission or continued stay in Long-Term Services and Supports programs.
Level of Care Screen means an Assessment conducted in accordance with

Section 8.7202.E. 45-B. Licensed Mental Health Professional means a mental health provider who possesses one or more of the following Colorado licenses: Psychologist, Psychiatrist, or other licensed mental health professional. All licenses shall be active and in good standing.

Life-Limiting Illness means a medical condition or set of medical conditions that, in the opinion of the medical specialist involved, has a prognosis of death that is highly probable before the child reaches adulthood at age 19. A Life-Limiting Illness means a medical condition or set of condition that, in the opinion of the medical specialist involved, has a prognosis of death that is highly probable before the child reaches adulthood. Conditions that are incurable, irreversible, and that usually result in death are considered as one criterion for eligibility for the HCBS-CwCHN waiver.
Long-Term Services and Supports (LTSS) means the services and supports used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine daily activities.
Medicaid Eligible means an individual meets the criteria for Medicaid benefits based on the individual’s financial determination and disability determination when applicable.
Nursing Facility Level of Care is as defined at 42 CFR §440.40.
Parent means the biological or adoptive Parent.
Professional Medical Information Page (PMIP) means the medical information form signed by a Licensed Medical Professional used to certify Level of Care.
Provider Agency means an Agency certified by the Department and which has a contract with the Department to provide one or more of the services listed at

Section 8.7500. 52-A. Provisions for Compliance with Federal Cost Effectiveness means the person centered and needs based assessed approach in which HCBS waiver services are approved. They ensure HCBS waiver services are not duplicative, are based on assessed need of the member seeking services, and that services are the most economical and reliable means to meet an identified need of a member.

Extreme Safety Risk to Others means a factor in addition to specific Support Level scores that are considered in the calculation of a Member's Support Level.

This factor shall be identified when a Member has:

a. A significant challenging behavior that poses a current and serious safety risk to others, involving harm to another person including arson, and poses a risk of repeating similar serious action; and has either, b. A Rights Modification in accordance with Section 8.7001 that imposes line of sight supervision unless the Member is in a controlled environment; or, c. A court order, parole and/or probation that imposes line of sight supervision unless the Member is in a controlled environment that limits their ability to engage in the behaviors that pose a serious risk or to leave the controlled environment unsupervised.

Public Safety Risk-Not Convicted means a factor in addition to specific Support Intensity Scale scores that is considered in the calculation of a Member's Support Level. This factor shall be identified when a Member has:

a. Not been found guilty through the criminal justice system, but does pose a current and serious risk of committing actions involving harm to another person or arson; and, b. A Rights Modification in accordance with Section 8.7001 or through parole or probation, or a court order that imposes line of sight supervision unless the Member is in a controlled environment that limits his or her ability to engage in the behaviors that pose a risk or to leave the controlled environment unsupervised.

Reassessment means a periodic reevaluation according to the requirements at

Section 8.7200.B.27.

Referral means any notice or information (written, verbal, or otherwise) presented to a Case Management Agency that indicates that a person may be appropriate for services or supports provided through the disabilities system and for which the Case Management Agency determines that some type of follow-up activity for eligibility is warranted.
Respondent means a person participating in the Support Intensity Scale Assessment who has known the Member for at least three months and has knowledge of the Member and their abilities. The Respondent must have recently observed the Member in one or more places such as home, work, or in the 58. Request for Developmental Disability Determination means written document, either handwritten or a signed standardized form, which is submitted to a Case Management Agency requesting that a determination of Developmental Disability be completed.

a. Screening for Early Intervention Services means a preliminary review of how a child is developing and learning in comparison to other similarly situated children for the purpose of determining if early intervention services are medically necessary.

Seclusion means the placement of a Member alone in a closed room for the

purpose of punishment. Seclusion for any purpose is prohibited. 59-B. Serious Emotional Disturbances (SED) means a mental, behavioral or emotional disorder that meets these criteria:

a. Has been diagnosed by a Licensed Mental Health Professiona according to criteria set forth in the current Diagnostic and Statistical Manual of Mental Disorders; the DC:0–5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood; or the International Classification of Diseases, b. Has functional impairments, which interferes with the Member’s functioning in family, social relationships, school or community, and c. Which have caused the Member to experience an emotional disturbance within the past 12 months for children aged 6 and older or the past 3 months for children aged 5 and younger, prior to application on a continuous or intermittent basis, as determined and documented by a Licensed Mental Health Professional.

d. SED shall not include substance-related disorders, or primary conditions or problems classified in the DSM as other conditions that may be a focus of clinical attention.

Support Intensity Scale Interviewer means an individual formally trained in the administration and implementation of the Supports Intensity Scale by a Department-approved trainer using the Department-approved curriculum.

Support Intensity Scale Interviewers must maintain a standard for conducting Support Intensity Scale Assessments as measured through periodic interviewer reliability reviews.

Support means any task performed for the Member where learning is secondary or incidental to the task itself or an adaptation is provided.
Supports Intensity Scale (SIS) means the standardized Assessment tool that gathers information from a semi-structured interview of Respondents who know the Member well. It is designed to identify and measure the practical support requirements of adults with Developmental Disabilities.
Support Level means a numeric value determined using an algorithm that places Members into groups with other Members who have similar overall support 63-A. Target Group Criteria means the factors that define a specific population to be served through an HCBS waiver. Target Group Criteria can include physical or behavioral disabilities, chronic conditions, age, or diagnosis, and may include other criteria such as demonstrating an exceptional need.
TWWIIA Basic Coverage Group comprise working individuals who are at least 16 but less than 65 years of age who, except for their income and resource levels, are eligible to receive Supplemental Security Income (SSI).
Three Hundred Percent (300%) Eligible persons mean those:

a. Whose income does not exceed 300% of the SSI benefit level, b. Who, except for the level of their income, would be eligible for an SSI payment, and c. Who are not eligible for medical assistance (Medicaid) unless they are recipients in an HCBS program or are in a nursing facility or hospitalized for one calendar month.

Utilization Review Contractor (URC) means the Agency contracted with the Department to review the HCBS waiver applications for determination of eligibility based on the additional targeting criteria.
Utilization Review means a review conducting for the purpose of approving or denying admission or continued stay in the waiver based on Level of Care needs, clinical necessity, amount and scope, appropriateness, efficacy or efficiency of health care services, procedures, or settings.
Waiver Services means optional services defined in the current federally approved HCBS waiver documents and does not include Medicaid State Plan benefits. 8.7100.B Eligible Persons 1. HCBS Waiver Services shall be offered to persons who meet all the eligibility requirements below provided the individual can be served within the capacity limits in the federal waiver. The HCBS waivers:

a. Shall not constitute an entitlement to services from the Department, b. Shall be subject to annual appropriations by the Colorado General Assembly, c. Shall ensure enrollments do not to exceed the federally approved capacity, and d. May limit the individual waiver program’s enrollment when utilization of the HCBS waiver program is projected to exceed legislative spending 2. The section hereby incorporates terms and provisions of the federally approved HCBS waivers. To the extent that the terms of the federally approved waiver are inconsistent with the provisions of this section, the waiver(s) shall control. 8.7100.C Financial Eligibility 1. Members shall meet the Medicaid Assistance eligibility criteria for Long Term Care as stated at Section 8.100.

The Applicant’s income must be less than 300% of the current Supplemental Security Income Federal Benefit Rate and countable resources less than $2,000 for a single person or $3,000 for a couple.
Spousal impoverishment rules set forth at § 1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special HCBS waiver group. In the case of a participant with a community spouse, the state shall use spousal post-eligibility rules as set forth at §1924 of the Act.

Spousal impoverishment rules do not apply to people in the Medicaid Buy-In 4. The HCBS waiver programs provide services both for individuals eligible only for Medicaid and for individuals who are dually eligible for both Medicare and Medicaid.

a. Individuals may be eligible to participate in the adult HCBS waiver programs through the Medicaid Buy-in Program for Working Adults with Disabilities if all listed eligibility criteria listed at 8.100.6.P are met. 8.7100.D Level of Care and Target Group 1. Individuals shall be referred to the Case Management Agency for an initial HCBS eligibility determination. The Long-Term Services and Supports Level of Care (LOC) eligibility determination screen is used to determine an individual's need for institutional Level of Care.

The state-prescribed Assessment instrument shall measure six defined Activities of Daily Living (ADLs) and the need for supervision for behavioral, executive or cognitive dysfunction. ADLs include bathing, dressing, toileting, mobility, transferring, and eating.
Level of Care Assessments and Reassessments shall be performed by Case Management Agencies and utilize the same instrument in determining the Level of Care for the waiver as for State Plan institutional care.
The individual also must be at risk of placement in an Institution within one month, but for the availability of Waiver Services. See individual waiver program for specific Level of Care requirements.
For initial Level of Care eligibility determinations, the Professional Medical Information Page (PMIP) shall be completed by a treating medical professional who verifies the individual’s qualifying diagnoses or conditions. .
The individual must require Long-Term Services and Supports to remain in their own home, in the Family residence, or in the community.
To utilize HCBS Waiver Benefits, the individual must choose to receive services in their home or community.
The cost of HCBS Waiver Services shall not be greater than the cost of placement in an Institution and the individual’s safety and health can be assured in the community within the federally approved capacity and the aggregate cost containments of the enrolled waiver program.
The Case Management Agency shall certify HCBS waiver eligibility only for those individuals:

a. Determined by the Case Management Agency to meet the target group designation for one or more waiver programs detailed in the Target Group Criteria section of each HCBS waiver program at Section 8.7101.

b. Determined by a Level of Care Assessment to require the Level of Care available in an Institution according to Section 8.401; or c. A length of stay shall be assigned by the Case Management Agency for approved admissions according to guidelines at Section 8.402. 8.7100.E Receiving HCBS Waiver Services 1. Only Members who receive HCBS Waiver Services as defined at Section 8.7500, or who have agreed to accept HCBS services when eligibility criteria have been met are eligible for an HCBS waiver program.

a. Case Management is not a waiver service and shall not be used to satisfy this requirement.

b. Desire or need for home health services or other Medicaid State Plan services that are not identified as HCBS Waiver Services shall not satisfy this eligibility requirement.

HCBS waiver program Members who have received no HCBS Waiver Services for one calendar month shall be discontinued from the program.
Members may not be simultaneously enrolled in more than one HCBS waiver. 8.7100.F Institutional Status 1. Members who are residents of Institutions are not eligible for HCBS Waiver Services while residing in such Institutions.
A Member enrolled in an HCBS waiver and who is admitted to a hospital may not receive HCBS Waiver Services while residing in the hospital. If the Member resides in the hospital for a continuous period of one month or more, the Case Manager shall terminate the Member from the HCBS waiver program.
A Member enrolled in an HCBS waiver and who is admitted to a nursing facility or ICF-IID may not receive HCBS Waiver Services while in the nursing facility or Intermediate Care Facilities for Individuals with Intellectual Disabilities, except as provided below:

a. If Medicaid pays for all or part of the nursing facility care or Intermediate Care Facilities for Individuals with Intellectual Disabilities, or if the Case Manager verifies that a Long-Term Services and Supports Level of Care Eligibility Determination Screen has been completed for the nursing facility or Intermediate Care Facilities for Individuals with Intellectual Disabilities placement, the Case Manager must terminate the Member from the HCBS waiver program.

b. A Member enrolled in an HCBS waiver who enters a nursing facility for HCBS respite care shall not be required to obtain a Long-Term Services and Supports Level of Care Eligibility Determination Screen and shall not be terminated from the HCBS waiver program.

c. Nothing in this section is intended to create a right to receive respite care services pursuant to the Waiver Benefit if respite care services are not included in the waiver. 8.7100.G Provisions for Compliance with Federal Cost Effectiveness 1. The Department of Health Care Policy and Financing shall conduct periodic aggregate cost effectiveness analyses per federal requirements and in partnership with the Centers for Medicare and Medicaid. 8.7100.H Maintenance of HCBS Waiver Eligibility 1. The Member shall maintain eligibility by meeting General Eligibility and waiver program-specific requirements set forth herein subject to the following:

a. Reevaluation of the Member to verify Medicaid, financial, and program eligibility is required within twelve months following any previous Assessment. The Continued Stay Review will follow the same procedures set forth at Section 8.401.11-.17(H).

b. The Member must receive at least one HCBS waiver service each calendar month.

c. The Member must not be simultaneously enrolled in any other HCBS waiver program.

d. The Member must not be residing in an Institution, correctional facility, or other Institution. 8.7100.I Waiting List 1. Individuals who are determined eligible for a HCBS Waiver Services, who cannot be served within the capacity limits of the federally-approved waiver, shall be eligible for placement on the waiting list for a HCBS waiver for which they applied. A separate waiting list shall be maintained for each waiver.

a. The Department shall maintain the waiting list.

b. The date of initial determination of eligibility for an HCBS waiver shall determine the individual’s position on the waiting list.

c. As openings become available within the capacity limits of the federal waiver, individuals shall be considered for services based on the criteria in order of priority as follows:

i. Individuals being Deinstitutionalized from nursing facilities or Intermediate Care Facilities for Individuals with Intellectual ii. Individuals being discharged from a hospital who, without Waiver Services, would be discharged to an Institution at a greater cost to Medicaid.

iii. Individuals, currently receiving long-term home health benefits, whose services could be delivered at a lower cost through a Waiver Benefit.

iv. Members with high Long-Term Services and Supports Level of Care Eligibility Determination Screen scores who are at imminent risk of Institutional placement.

d. Individuals denied program enrollment shall be informed of their appeal rights in accordance with Section 8.057. 8.7100.J Termination 1. The Department shall discontinue a Member’s enrollment in an HCBS waiver when one of the following occurs:

a. The Member no longer meets the HCBS Waiver Benefit criteria, b. The Member dies, c. The Member enrolls in another HCBS waiver program or is admitted for a long-term stay beyond one month in an Institution, or i. The Member does not receive an HCBS waiver service during a full one-month period, or ii. The Member voluntarily withdraws from the HCBS waiver program. 8.7101 HCBS Waiver Program-Specific Member Eligibility 8.7101.A [Intentionally omitted] 8.7101.B Children's Extensive Support Waiver (HCBS-CES)

Target Group Criteria 2. To be eligible for the HCBS-CES waiver, an individual shall meet the Target a. Is unmarried and under 18 years of age.

b. Has a Developmental Disability (which includes a Developmental Delay if under five years of age) and requires long term services and supports to remain in the Family home.

c. Meets Intermediate Care Facilities for Individuals with Intellectual Disabilities Level of Care as determined by the Level of Care Screen.

d. Resides in an eligible HCBS-CES waiver setting, defined as:

i. Residing with biological or adoptive Parent(s), or Legal Guardian, ii. Residing in an out-of-home placement and can return home with the provision of HCBS-CES Waiver Services with the following 1) The Case Manager shall work with the residential caregiver to develop a transition plan that includes timelines and identified services or supports requested during the time the Member is not residing in the Family home. The Case Manager shall submit the transition plan to the Department for approval prior to the start of services.

iii. Meets the definition of disability set forth at 42 U.S.C. § 423(d).

iv. Meets the HCBS-CES waiver Member eligibility criteria:

The individual demonstrates a behavior or has a medical condition that requires direct human intervention, more intense than a verbal reminder, redirection, or brief observation of status, at least once every two hours during the day and on a weekly average of once every three hours during the night. The behavior or medical condition must be considered beyond what is typically age appropriate and due to one or more of the following conditions:

a) A significant pattern of self-endangering behavior or medical condition which, without intervention will result in a life-threatening condition or situation, b) A significant pattern of serious aggressive behavior toward self, others, or property, or c) Constant vocalizations such as screaming, crying, laughing, or verbal threats which cause emotional distress to caregivers. The term constant is defined as on the average of 15 minutes each waking hour.

For purposes of this subsection 6, Significant Pattern is defined as a behavior or medical condition that is harmful to self or others as evidenced by actual events occurring within the past six (6) months.
To remain eligible for Waiver Services, the annual Reassessment must demonstrate that in the absence of the existing interventions or preventions provided as Waiver Services, the intensity and frequency of the behavior or medical condition would return to a level that would meet the criteria listed above.

Medicaid Eligibility Groups Served in the Waiver a. HCBS-CES Waiver Services are available to eligible Individuals in the i. SSI recipients ii. Optional state plan recipients 4. Other a. Individuals who are determined eligible for HCBS-CES Waiver Benefits who cannot be served within the capacity limits of the federally approved waiver, shall be eligible for placement on a waiting list maintained by the 8.7101.C Children’s Habilitation Residential Program Waiver (HCBS-CHRP)
Target Group Criteria 2. To be eligible for the HCBS-CHRP waiver, an individual shall meet the Target a. Is under 21 years of age.

b. Has Extraordinary Needs that put the individual at risk or in need of out-ofhome placement as identified in one of the two following manners:

i. Meets Intermediate Care Facilities for Individuals with Intellectual Disabilities Level of Care as determined by the Level of Care Screen, and 1) has been determined to have a Developmental Disability as determined pursuant to Section 8.607or if under five years of age, a Developmental Delay, or ii. Has a Serious Emotional Disturbance (SED) as defined in Section 8.7100.A as documented in a format prescribed by the Department, and the individual under 21 years old either 1) meets Nursing Facility Level of Care as determined by the Level of Care Screen or, 2) as documented in a format prescribed by the Department, the individual experienced inpatient psychiatric care, was at risk of inpatient psychiatric care, or was determined to require inpatient psychiatric care.

Medicaid Eligibility Groups Served in the Waiver 4. HCBS-CHRP Waiver Services are available to eligible Members in the following a. Children for whom foster care maintenance payments are being made by the County Departments of Human/Social Services and who otherwise meet eligibility criteria.

b. Individuals who meet the criteria set forth at 42 CFR §435.217.

Other a. An Assessment of the level of support needed shall be completed upon determination of eligibility and shall determine the level of reimbursement for Habilitation and per diem Respite services.

b. Individuals determined eligible for benefits under the HCBS-CHRP waiver, who cannot be served within the capacity limits of the federally approved waiver, shall be eligible for placement on a waiting list maintained by the 8.7101.D Children with Complex Health Needs Waiver (HCBS-CwCHN)

Target Group Criteria:
To be eligible for the HCBS-CwCHN waiver, an individual shall meet the Target a. Is under 19 years of age, b. Meets a Level of Care, as determined by the state prescribed Level of Care Assessment instrument defined in 8.401.16, furnished in one of the i. Nursing Facility Ii. Hospital 1. To meet Hospital Level of Care for CwCHN, a member must either:

a. Have a diagnosis of a Life-Limiting Illness (i.e. a lifelimiting medical condition or set of life-limiting medical conditions) as certified by a licensed medical professional and documented as prescribed by the Department upon enrollment.

Or:

b. One of the following conditions applies to the participant, documented as prescribed by the Department upon initial enrollment:

i. Technologically dependent for life or healthsustaining functions, OR ii. Complex medication regimen or medical interventions to maintain or improve health status, OR iii. Need of ongoing assessment or intervention to prevent serious deterioration of health status or medical complications that place life, health, or development at risk.

Medicaid Eligibility Groups Served in the Waiver:
HCBS-CwCHN Waiver Services are available to eligible individuals in the a. Meets federal SSI disability definition and/or is an SSI recipient b. Optional State Plan recipients 5. Waiting List a. Individuals who are determined eligible for benefits under the HCBS- CwCHN Waiver , and who cannot be served within the capacity limits of the federally approved waiver, shall be eligible for placement on a waiting list maintained by the Department.

b. A child on the waiting list shall be prioritized for enrollment in the waiver if they meet any of the following criteria:

i. Have been in a hospital for one month or longer and require Waiver Services in order to be discharged from the hospital.

ii. Are on the waiting list for an organ transplant.

iii. Are dependent upon mechanical ventilation or prolonged intravenous administration of nutritional substances.

iv. Have received a terminally ill prognosis from their physician.

Other a. To be eligible for the CwCHN waiver, the income and resources of the child shall not exceed 300% of the current maximum Social Security Insurance (SSI) standard maintenance allowance. 8.7101.E Persons with Brain Injury Waiver (HCBS-BI)
Target Group Criteria 2. To be eligible for the HCBS-BI waiver, an individual shall meet the Target Group a. Is determined to have a Brain Injury that occurred prior to the individual’s 65th birthday.

i. Brain Injury is defined as an injury to the brain of traumatic or acquired origin which results in residual physical, cognitive, emotional, and/or behavioral difficulties of a non-progressive nature and is limited to the to the broad diagnoses found within the most current version of the ICD.

b. Is 16 years of age or older.

c. Meets Nursing Facility Level of Care;

d. Meets Hospital Level of Care and as evidenced by:

i. The individual shall have been:

Referred to the Case Management Agency while receiving inpatient care in an acute care or rehabilitation hospital for the treatment of the individual’s Brain Injury; or 2) A comprehensive functional Assessment using the Longterm Services and Supports Level of Care Screen results in at least the minimum scores required by Section 8.7202.E, demonstrating a functional need for nursing facility Level of Care.

ii. The individual shall require goal-oriented therapy with medical management by a physician.

iii. The individual shall not be therapeutically managed in a community-based setting without significant supervision and structure, specialized therapy, and support services.

Medicaid Eligibility Groups Served in the Waiver 4. HCBS-BI Waiver Services are available to eligible Members in the following State Plan eligibility groups:

a. SSI recipients b. Optional state plan recipients c. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as described in 42 U.S.C §1902 1396a(a)(10)(A)(ii)(XIII))

d. Working individuals with disabilities who buy into Medicaid TWWIIA Basic Coverage Group as provided in 42 U.S.C. § 1396a(a)(10)(A)(ii)(XV of the Act)

Other a. Persons determined eligible for HCBS-BI services that cannot be served within the capacity limits of the HCBS-BI waiver shall be eligible for placement on a waiting list maintained by the Department. 8.7101.F Community Mental Health Supports Waiver (HCBS-CMHS)
Target Group Criteria 2. To be eligible for the HCBS-CMHS waiver, an individual shall meet the Target a. Is experiencing a severe and persistent mental health need that requires assistance with one or more ADLs. For purposes of this subsection, a person experiencing a severe and persistent mental health need is defined as one who:

i. Is 18 years of age or older with a severe and persistent mental health need, ii. Currently has or at any time during the one-year period prior to Assessment had a diagnosed mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders (DSM -5):

Has a disorder that is episodic, recurrent, or has persistent features, but may vary in terms of severity and disabling effects; and 2) Has resulted in functional impairment which substantially interferes with or limits one or more major life activities, and iii. A severe and persistent mental health need does not include:
Intellectual or developmental disorders; or 2) Substance use disorder without a co-occurring diagnosis of a severe and persistent mental health need.

b. Meets Nursing Facility Level of Care.

c. A length of stay shall be assigned by the Utilization Review Contractor (URC) for approved admissions, according to guidelines at Section 8.402.30.

Medicaid Eligibility Groups Served in the Waiver 4. HCBS-CMHS Waiver Services are available to eligible Members in the following a. SSI recipients b. Optional state plan recipients c. Working individuals with disabilities who buy into Medicaid BBA Working Disabled Group as described in described in 42 U.S.C § 1396a(a)(10)(A)(ii)(XIII)

d. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1396a(a)(10)(A)(ii)(XV) of the Act 8.7101.G Elderly, Blind, And Disabled Waiver (HCBS-EBD)

Target Group Criteria 2. To be eligible for the HCBS-EBD waiver, an individual shall meet the Target a. Is determined by the Case Management Agency to meet the target group definition for functionally impaired elderly, or the target group definition for physically disabled or blind adult.

b. Meets the minimum and/or if applicable maximum age for individuals served in each subgroup c. Aged: Be 65 years of age or older i. Physically Disabled or Blind: Be 18-64 years of age (Those participants who are physically disabled who reach the age of 65 shall automatically get classified as Aged with no break in services), and/or ii. HIV/AIDS: Be 18 years of age or older.

d. Meets Nursing Facility Level of Care.

Medicaid Eligibility Groups Served in the Waiver 4. HCBS-EBD Waiver Services are available to eligible Members in the following a. SSI recipients b. Optional state plan recipients c. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as described in §1396a (a)(10)(A)(ii)(XIII))

d. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1396a (a)(10)(A)(ii)(XV) of the Act 5. Other a. HCBS-EBD Members that enter a nursing facility or hospital may not receive HCBS-EBD Waiver Services while residing in the nursing facility or hospital unless prior authorization has been received from the i. HCBS-EBD Members admitted to a nursing facility or hospital for one calendar month or longer shall be discontinued from the HCBS-EBD program.

ii. HCBS-EBD Members entering a nursing facility for Respite Care as an HCBS-EBD service shall not be discontinued from the HCBS- EBD program.

b. Individuals determined eligible for HCBS-EBD services that cannot be served within the capacity limits of the HCBS-EBD waiver shall be eligible for placement on a waiting list. 8.7101.H Complementary and Integrative Health Waiver (HCBS-CIH)

Target Group Criteria 2. To be eligible for the HCBS-CIH waiver, an individual shall meet the Target Group a. Is 18 years of age or older.

b. Has a qualifying condition of a spinal cord injury (traumatic or nontraumatic), multiple sclerosis, a Brain Injury, spina bifida, muscular dystrophy, or cerebral palsy with the Inability for Independent Ambulation directly resulting from one of these conditions as defined by broad diagnoses related to each condition within the most current version of the ICD at the time of Assessment.

c. Be unable to ambulate independently as a result of the qualifying condition as identified by the Case Manager through the Level of Care Screen process. A person is considered unable to ambulate independently if:

i. The individual does not walk, and requires use of a wheelchair or scooter in all settings, whether or not they can operate the wheelchair or scooter safely, on their own; or ii. The individual does walk, but requires the use of a walker or cane in all settings, whether they can use the walker or cane safely, on their own; or iii. The individual does walk but requires “touch” or “stand-by” assistance to ambulate safely in all settings.

d. Meets Hospital Level of Care or Nursing Facility Level of Care.

Medicaid Eligibility Groups Served in the Waiver a. HCBS-CIH Waiver Services are available to eligible individuals in the i. SSI recipients ii. Optional state plan recipients iii. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as described in 42 U.S.C § 1396a(a)(10)(A)(ii)(XIII)).

iv. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1396a(a)(10)(A)(ii)(XV) of the Act 4. Other a. Persons determined eligible for HCBS-CIH services that cannot be served within the capacity limits of the HCBS-CIH waiver shall be eligible for placement on a waiting list. 8.7101.I Supported Living Services Waiver (HCBS-SLS)

Target Group Criteria 2. To be eligible for the HCBS-SLS waiver, an individual shall meet the Target a. Has an intellectual or Developmental Disability b. Is 18 years of age or older.

c. Meets the Intermediate Care Facilities for Individuals with Intellectual Disabilities Level of Care.

d. Does not require 24-hour supervision on a continuous basis which is reimbursed as an HCBS-SLS service.

e. Resides in an eligible HCBS-SLS setting. An SLS setting is the individual's residence, which is defined as the following:

i. A living arrangement, which the individual owns, rents, or leases in their own name, ii. The home where the individual lives with the Member’s Family or legal Guardian, or iii. A living arrangement of no more than three persons receiving HCBS Waiver Services residing in one household, unless they are all Members of the same family.

Medicaid Eligibility Groups Served in the Waiver 4. HCBS-SLS Waiver Services are available to eligible Members in the following a. SSI recipients b. Optional state plan recipients c. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as described in 42 U.S.C § 1396a(a)(10)(A)(ii)(XIII)).

d. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1396a(a)(10)(A)(ii)(XV) of the Act 5. Other a. Enrollment in the HCBS-SLS waiver may be limited when utilization of the HCBS-SLS waiver program is projected to exceed legislative pending b. When the HCBS-SLS waiver reaches capacity for enrollment, an individual determined eligible for a waiver shall be placed on a waiting list.

c. As openings become available in the HCBS-SLS waiver program in a designated service area, individuals shall be considered for services in order of placement on the local Case Management Agency’s waiting list regarding an appropriate match to services and supports. Exceptions to this requirement shall be limited to situations in which:

i. An emergency greatly endangers the health, safety, and welfare of the individual or others and the emergency cannot be resolved in another way. For the purposes of this subsection, emergencies are defined as follows:

Homelessness: the individual does not have a place to live or is in imminent danger of losing their place of abode.
Abusive or Neglectful Situation: the individual is experiencing ongoing physical, sexual, or emotional abuse or neglect in their present living situation and their health, safety or wellbeing are in serious jeopardy.
Danger to Others: the individual's behavior or psychiatric is such that others in the home are at risk of being hurt by them. Sufficient supervision cannot be provided by the current caretaker to ensure the safety of persons in the 4) Danger to Self: an individual's medical, psychiatric, or behavioral challenges are such that they are seriously injuring/harming themselves or are in imminent danger of doing so.

d. The Legislature has appropriated funds specific to individuals or to a specific class of persons.

e. If an eligible individual is placed on a waiting list for SLS Waiver Services, a written notice, including information regarding the Member appeals process, shall be sent to the individual and/or his/her legal Guardian in accordance with the provisions of Section 8.057, et seq. 8.7101.J Developmental Disabilities Waiver (HCBS-DD)

Target Group Criteria 2. To be eligible for the HCBS-DD waiver, an individual shall meet the Target Group a. Has an intellectual or Developmental Disability.

b. Requires access to 24-hour services and supports to meet daily living needs that allow them to live safely and participate in the community.

c. Is 18 years of age or older.

d. Meets Intermediate Care Facilities for Individuals with Intellectual Disabilities Level of Care.

The State may limit the number of Members enrolled in the HCBS-DD waiver at any point in time during a waiver year. When the HCBS-DD waiver reaches capacity for enrollment, an individual determined eligible for the waiver shall be eligible for placement on a waiting list.

a. The state reserves capacity for the following purposes:

i. Emergency in which positions are reserved for individuals whose names are on the waiting list, who are experiencing a Crisis, and require immediate assistance to ensure their health and safety, ii. 18-21 Transition in which positions made available for children who are adopted through the Colorado Child Welfare system, reach an age at which they are no longer eligible for foster care, the HCBS- Children's Extensive Supports waiver, or the HCBS-Children's Habilitation Residential Program waiver in order to continue access to services that will allow them to continue living safely in the community without interruption, and iii. Deinstitutionalization for Nursing Facility, Intermediate Care Facilities for Individuals with Intellectual Disabilities, and State Mental Health Institutes in which positions are made available for individuals who have requested to transition from one of these settings to a community setting, and iv. Waitlists. As vacancies occur in waiver enrollments, the state shall enroll the next individual on the waiting list based on the statewide order of the selection date.

Medicaid Eligibility Groups Served in the Waiver 5. HCBS-DD Waiver Services are available to eligible Members in the following a. SSI recipients b. Optional state plan recipients c. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as Medicaid as described in 42 U.S.C § 1396a(a)(10)(A)(ii)(XIII))

d. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as described in 42 U.S.C. § 1396a(a)(10)(A)(ii)(XV) of the Act 6. Other a. The Member shall maintain eligibility by meeting the General Eligibility and waiver program-specific requirements set forth herein and maintaining residence in a GRSS or IRSS setting.

b. Enrollment in the HCBS-DD waiver may be limited when utilization of the HCBS-DD waiver program is projected to exceed legislative pending c. When the HCBS-DD waiver reaches capacity for enrollment, an individual determined eligible for a waiver shall be placed on a waiting list.

d. As openings become available in the HCBS-DD waiver program, individuals shall be considered for services in order of placement on the statewide waiting list. Exceptions to this requirement shall be limited to situations in which:

Homelessness: the individual does not have a place to live or is in imminent danger of losing their place of abode.
Abusive or Neglectful Situation: the individual is experiencing ongoing physical, sexual, or emotional abuse or neglect in their present living situation and their health, safety or wellbeing are in serious jeopardy.
Danger to Others: the individual's behavior or psychiatric is such that others in the home are at risk of being hurt by them. Sufficient supervision cannot be provided by the current caretaker to ensure the safety of persons in the 4) Danger to Self: an individual's medical, psychiatric, or behavioral challenges are such that they are seriously injuring/harming themselves or are in imminent danger of doing so.
Loss or Incapacitation of Primary Caregiver: a person’s primary caregiver is no longer in the person’s primary residence to provide care; or the primary caregiver is experiencing a chronic, long-term, or life-threatening physical or psychiatric condition that significantly limits the ability to provide care; or the primary caregiver is age 65 years or older and continuing to provide care poses an imminent risk to the health and welfare of the person or primary caregiver; or, regardless of age and based on the recommendation of a professional, the primary caregiver cannot provide sufficient supervision to ensure the person’s health and welfare.

e. The Legislature has appropriated funds specific to individuals or to a specific class of persons.

f. If an eligible individual is placed on a waiting list for DD Waiver Services, a written notice, including information regarding the Member appeals process, shall be sent to the individual and/or his/her legal Guardian in accordance with the provisions of Section 8.057, et seq. 8.7200 Case Management Agency Requirements 8.7200.A Colorado Case Management System 1. The Colorado Case Management System consists of Case Management agencies representing defined service areas throughout the state, for the

purpose of providing assistance to persons in need of long-term services & support, including but not limited to Home and Community-Based Services. 8.7200.B Definitions 1. Assessment means a comprehensive evaluation with the individual seeking services and appropriate supports (such as Family Members, advocates, friends and/or caregivers), chosen by the individual, conducted by the Case Manager, with supporting diagnostic information from the individual’s medical provider to determine the individual’s level of functioning, service needs, available resources, and potential funding resources.

Case Management Agency is defined in Section 8.7100.A.8 3. Case Management Agency Defined Service Area means one or more counties that have been designated as a geographic region in which one Agency serves as the Case Management Agency for persons in need of Home and Community- Based Waiver Services or Long Term Services and Supports.
Case Management Activities means the Assessment of an individual seeking or receiving Long-Term Services and Supports’ needs, the development and implementation of a Person-Centered Support Plan for such individual, Referral and related activities, the coordination and monitoring of long-term service delivery, the evaluation of service effectiveness, and the periodic Reassessment of such individual’s needs and collaboration with other entities impacting the Members’ HCBS, health and welfare.

a. Case Management Activities means all activities performed by a Case Management Agency reimbursed through contracts and Targeted Case Management.

i. Administrative Case Management includes activities that are reimbursed through contracts with the Department of Health Care Policy and Financing.

ii. Targeted Case Management refers to coordination and planning services provided with, or on behalf of, an individual Member.

Targeted Case Management is a state plan benefit and is reimbursed through direct billing, not contract payments.

Case Manager means an employee of a Case Management Agency, as defined at Section 8.7100.A.8, who performs the required Case Management Activities.
Colorado General Assembly means the legislature of the State of Colorado, comprising both the state senate and the state house of representatives.
Community Centered Board (CCB) means a private for-profit or not-for-profit organization that is an administrator of locally generated funding pursuant to § 25.5-10-206(6), C.R.S. and acts as a resource for persons with an Intellectual and Developmental Disability or a child with a Developmental Delay.
Complaint means any statement received by an individual or Member as it relates to unsatisfactory services provided through the Case Management Agency to include, but not limited to: general business functions, administration, State General Fund program functions, and Case Management functions.

Complaints regarding activities outside the scope of work for the Case Management Agency are excluded from this definition.

Conflict-Free Case Management means Members enrolled in any Long-Te r m Services and Supports programs and/or Home and Community-Based Services waivers must receive direct Home and Community-Based Services and Case Management from separate entities.
Conflict-Free Case Management Waiver means the Case Management Agency may provide direct services to Members for whom it provides Case Management 11. Corrective Action Plan means a written plan by the Case Management Agency, which includes a detailed description of actions to be taken to correct noncompliance with waiver requirements, regulations, and direction from the Department, and which sets forth the date by which each action shall be completed and the persons responsible for implementing the action.
Critical Incident means an actual or alleged event that creates the risk of serious harm to the health or welfare of a Member; including events that may endanger or negatively impact the mental and/or physical well-being of an individual.

Critical Incidents include, but are not limited to, injury/illness; abuse/neglect/exploitation; damage/theft of property; medication mismanagement; lost or missing person; criminal activity; unsafe housing/displacement; or death.

Defined Service Area means the geographical area the Department determines shall be served by a Case Management Agency.
Department means the Colorado Department of Health Care Policy and Financing, the Single State Medicaid Agency.
Home and Community-Based Services (HCBS) Waivers is as defined in Waiver Eligibility Requirements Section 8.7100 et seq.
In-Reach Counseling is a service designed to engage and provide institutionalized population Members with information regarding housing, transition, and other community-based services available to support them living in the community; and to answer any questions that may arise either in a group setting or individually 17. Intellectual and Developmental Disability has the same meaning set forth in

Section 25.5-6-403 (3.3)(a), C.R.S and Section 8.7100.A.40.

Information Management System (IMS) means an automated data management system approved by the Department to enter Case Management information for each individual seeking or receiving long-term services as well as to compile and generate standardized or custom summary reports.
Intake, Screening and Referral means the initial contact with individuals by the Case Management Agency and shall include, but not be limited to, a preliminary screening in the following areas: an individual's need for Long-Term Services and Supports; an individual's need for Referral to other programs or services; an individual's eligibility for financial and program assistance; and the need for a comprehensive Functional Needs Assessment of the individual seeking services.
Long-Term Services and Supports (LTSS) means the services and supports used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine daily activities. Long term Services and Supports includes but is not limited to long term care such as nursing facility care as part of the standard Medicaid benefit package and Home and Community- Based Services provided under waivers granted by the Federal government.
Long Term Services and Supports Level of Care Eligibility Determination Screen (Level of Care Screen) means a comprehensive evaluation with the individual seeking services and appropriate support persons (such as Family Members, friends, and or caregivers) to determine an Applicant or Member’s eligibility for Long-Term Services and Supports based on their need for institutional Level of Care as determined using the Department’s prescribed Assessment instrument as outlined in Section 8.7202.E.
Long Term Services and Supports (LTSS) Program means any of the following: publicly funded programs, Medicaid Nursing Facility Care, Program for All- Inclusive Care for the Elderly (PACE) (where applicable), Hospital Back-up (HBU) and Adult Long-Term Home Health (LTHH).

a. [Intentionally omitted]

b. Developmental Disabilities (HCBS-DD)

c. Home and Community-Based Services for the Elderly, Blind and Disabled (HCBS-EBD)

d. Home and Community-Based Services Complementary and Integrative Health (HCBS-CIH)

e. Home and Community-Based Services for Persons with a Brain Injury (HCBS-BI)

f. Home and Community-Based Services Community Mental Health Supports (HCBS-CMHS)

g. Home and Community-Based Services for Children with Complex Health Needs (HCBS-CwCHN), and h. Home and Community-Based Services Supported Living Services (HCBS- SLS)

i. Children’s Extensive Support Waiver (HCBS-CES)

j. Children’s Habilitative Residential Program (HCBS-CHRP)

Member means any person enrolled in the state medical assistance program, the children’s basic health plan, HCBS waiver program, or State General Funded 24. Member Identified Team means the people, agencies or representatives a Member selects to participate to support in their long-term care programs, processes and procedures including but not limited to their service planning or other waiver program processes and procedures. Members may choose specific people or agencies and may select which portions of their program they want the team to be involved with. Members may revoke or change this team at any time.

“Member Identified Team” applies to all waivers and replaces Interdisciplinary Team in former rules applicable to people with Intellectual and Developmental 25. Pre-Admission Screening and Resident Review (PASRR) is as defined in Section 8.401.18.

Person-Centered Case Management means Case Management services that offer people dignity, compassion and respect while facilitating Assessments and planning that support people to recognize and develop their own strengths and abilities to enable them to live an independent and fulfilling life.
Person-Centered Support Planning means the process of working with the Member and people chosen by the individual to identify goals, needed services, individual choices and preferences, and appropriate service providers based on the individual seeking or receiving services’ Assessment and knowledge of the individual and of community resources. Support Planning informs the individual seeking or receiving services of his or her rights and responsibilities.
Post Reintegration Survey is a series of questions found in the Department’s prescribed system that Case Managers ask Members at their next contact or within ninety (90) days of transitioning back into the community, to gain the Member’s perspective on the transition process. It is the final step in the Rapid Reintegration process.
Rapid Referral is the Person-Centered process that occurs when an Individual, who is seeking admission to a nursing facility, is interested in, or does not oppose living in the community, and is experiencing unstable housing and/or requiring additional supported services, is then assigned to a Transition Coordination Agency for transition coordination.
Rapid Reintegration is the Person-Centered process that occurs when an Individual who is seeking admission to a nursing facility, is interested in, or does not oppose, living in the Community, and has stable housing receives services as described in the Rapid Reintegration Plan.
Rapid Reintegration Barrier Questions is a series of questions in the Department's prescribed system that Case Managers complete during the Rapid Reintegration initiation process. These questions will identify and document barriers that may affect the member’s transition back to the community. Based on responses the Case Manager will either complete a Rapid Referral or a Rapid Reintegration Plan.
Rapid Reintegration Plan is a written Person-Centered plan developed for the

purpose of rapidly transitioning a Member from a nursing facility into the 33. Reassessment means a periodic reevaluation with the Member, their chosen supports, and Case Manager, to re-determine the individual’s level of functioning, service needs, available resources and potential funding resources.

State General Fund (SGF) Programs means programs funded solely through the Colorado State General Fund. Those include but are not limited to: State Supported Living Services (State-SLS) at Section 8.7202.V.4, Specialized Nursing Care Services,and Family Support Services Program (FSSP) at Section 8.7561.
Target Group Criteria means the factors that define a specific population to be served through an HCBS waiver. Target Group Criteria can include physical or behavioral disabilities, chronic conditions, age, or diagnosis, and May include other criteria such as demonstrating an exceptional need.
Transition Coordination Agency (TCA) means a public or private not-for-profit or for-profit Agency that meets all applicable state and federal requirements and is certified by the Department to provide coordination services for those transitioning from facility-based care to community-based care pursuant to a Provider Participation Agreement with the state department.
Transition Escalation is an increase in the severity or seriousness of an issue, typically tied to whether the applicant or Member’s case is, or has been, impacted by the actions taken or not taken by the member’s transition team.
Waiver Benefit means covered benefits offered in addition to or as an alternative to state plan benefits as authorized by 42 U.S.C. § 1396n(c) and include the Waiver Benefits described in Section 8.7101 for the following programs:

Children’s Extensive Support Waiver (HCBS-CES); Children's Habilitation Residential Program Waiver (HCBS-CHRP); Children With Complex Health Needs Waiver (CwCHN); Persons With Brain Injury Waiver (HCBS- BI);Community Mental Health Supports Waiver (HCBS-CMHS); Elderly, Blind and Disabled Waiver (HCBS-EBD); Complementary and Integrative Health Waiver (HCBS-CIH; Supported Living Services Waiver (HCBS -SLS);and Developmental Disabilities Waiver (HCBS-DD). 8.7200.C Legal Basis 1. Pursuant to Section 25.5-6-1701, C.R.S., the State Department is authorized to provide for a statewide Case Management system. 8.7200.D Case Management Agency Defined Service Areas 1. Case Management Agency Defined Service Areas shall meet the following 2. Counties composing a multi-county service area shall be contiguous.

A single county may be designated as a Defined Service Area provided the county serves a monthly average of 400 or more individuals for receiving Long- Term Services and Supports.
Multi-county service areas shall also be required to serve a minimum number of individuals Members of 400.
Case Management services shall be provided to Members by the Case Management Agency awarded the contract for the Member’s county of residence.
Each Case Management Agency shall have an exceptions process and policy for serving Members outside of their Defined Service Area and for Members to request to be served by an Agency outside their service area. Each Case Management Agency shall submit the exceptions process and policy to the Department for approval by a method determined by the Department and shall review the process and policy with the Community Advisory Committee and Governing Body at least once per contract period.
When a Member in a Case Management Agency’s defined serve area requests to transfer to a Case Management Agency outside the Member’s Defined Service Area, the Case Management Agencies shall coordinate the transfer in accordance with transfer rules 8.7202.M. Case Management Agencies shall provide a report on their process and the number of Members served outside their Defined Service Area upon Department request. 8.7200.E Case Management Agency Selection and Contracting 1. Case Management Agency Competitive Procurement Process 2. The Department shall select Case Management Agencies in accordance to applicable requirements of Title 24, Articles 101-112, C.R.S., and 1 CCR 101-9.
Case Management Agency Contract a. Case Management Agency shall be bound to all requirements identified in the contract between the Agency and the Department including but not limited to quality assurance standards and compliance with the Department’s rules and federal regulation applicable for Case Management Agencies and for all Long-Term Services and Supports programs. 8.7201 Case Management Agency Overall Requirements 8.7201.A Administration of a Case Management Agency 1. The Case Management Agency shall be required in their mission statement, bylaws, articles of incorporation, and contracts, to comply with all regulations which govern the Case Management Agency, and to comply with the following standards:

a. The Case Management Agency shall serve individuals in need of Long- Term Services and Supports as defined in Section 8.7100.A.48 b. The Case Management Agency shall have the capacity to accept funding from multiple sources;

c. The Case Management Agency may subcontract with individuals, for-profit entities and not-for-profit entities to provide Case Management Agency Targeted Case Management and administrative Case Management Activities up to the limitations established in the Case Management Agency contract. Subcontractors must abide by the terms of the Case Management Agency contract with the Department and are obligated to follow all applicable federal and state statutes and regulations. The Case Management Agency is responsible for subcontractor performance.

d. The Case Management Agency may receive funds from public or private foundations and corporations; and e. The Case Management Agency shall be required to publicly disclose all sources and amounts of revenue as described in Section 25.5-6-1708 CRS.

The Case Management Agency shall fulfill all functions of a Case Management Agency and Case Manager as described in these rules.
The Case Management Agency shall:

a. Not provide guardianship services for any individual applying for Long- Term Services and Supports or Member enrolled in a Long-Term Services and Supports program.

b. Maintain, or have access to, information about public and private state and local services, supports and resources and shall make such information available to the individual, Member and/or persons inquiring upon their behalf.

c. Be separate from the delivery of direct services and supports paid for by any payer for the same individual they provide Case Management, unless otherwise approved by the Department through a Conflict Free Case Management Waiver and except pursuant to Section 8.7202.W when the Case Management Agency is acting as the Organized Health Care Delivery System, or approved by the Department through a Conflict Free Case Management Waiver and in accordance with Section 25.5-6-1703(6)

d. Establish and maintain working relationships through Memorandum of Understanding processes and procedures with community-based resources, supports, and organizations, hospitals, service providers, and other organizations that assist in meeting the individuals’ and Members’ needs including but not limited to local Regional Accountable Entities, Behavioral Health Administration, Aging and Disability Resource Centers, counties, schools, and Medical Assistance sites as necessary for individual and Member support.

e. Maintain a website that at a minimum contains contact information for the Case Management Agency, the ability for electronic communication, hours of operation, available resources, program options, services provided, and the transparency documentation required in Section 25.5-6-1708 C.R.S.

f. Provide Case Management services without Discrimination on the basis of race, religion, political affiliation, gender, national origin, age, sexual orientation, gender expression or disability.

The Department may grant a Case Management Agency a Conflict Free Case Management waiver (CFCMW) to provide direct services and Case Management in the event that no other willing and qualified providers are available for the capacity of Member services necessary.

a. Applications for this waiver shall be received and evaluated in the manner in which has been communicated by the Department.

b. The Department may grant a Case Management Agency a Conflict-Free Case Management Waiver (formerly known as a rural exception) to provide specific direct services within their Defined Service Area to ensure access to these services in rural and frontier areas across Colorado.

c. The Case Management Agency shall:

i. Submit a formal application (found on the Department website) for a Conflict-Free Case Management Waiver.

ii. The Department shall provide formal notification to the Case Management Agency within 10 business days of the receipt of the application. The Department shall notify Applicants of their approval or denial within 90 days of receipt of the application.

iii. If the Applicant submits a response to the Case Management Agency Request for Proposal (RFP), the Department shall notify the Agency of approval or denial prior to the delivery of intent to award letters to RFP Respondents or within 90 day of receipt of the application whichever occurs first.

iv. If the Conflict-Free Case Management Waiver application is denied, the Department will coordinate with the Case Management Agency for a transition period, if necessary.

v. If a Case Management Agency requires a waiver between Case Management Agency contract cycles, the Case Management Agency must submit the application for the Conflict Free Case Management Waiver and maintain the documentation for the next RFP submission.

If the Conflict-Free Case Management Waiver application is approved, the Department will coordinate with the Case Management Agency for next steps in implementation and execution, if necessary.
If the Conflict-Free Case Management Waiver application is denied, the Department will coordinate with the Case Management Agency for a transition period within their contract period, if necessary.

vi. A Case Management Agency that is granted a Conflict-Free Case Management Waiver shall provide an annual report to the Department subject to Department approval that includes but will not be limited to:

a summary of individuals participating in direct services and Case Management;
how the Case Management Agency has ensured informed consent and/or choice, if other providers exist in the Defined Service Area; and 3) how the Case Management Agency continues to support the recruitment of willing and qualified providers in their Defined Service Area.
how the direct service provider functions and Case Management Agency functions are administratively separated (including staff) with safeguards in place to ensure a distinction between direct services and Case Management exists as a protection against conflict of interest.

vii. If a new service provider(s) becomes available in the area, the Case Management Agency may continue to provide direct services until the Department has determined that the alternate provider(s) is capable of meeting all needs in that service area.

viii. If other service providers are available in the area, the Case Manager must document the offering of choice of provider and/or that no provider had capacity to serve new Members in the ix. To ensure conflict of interest is being mitigated by the Case Management Agency, the Department will conduct annual quality reviews that will include but not be limited to, reviews of documentation of Members’ choice of provider and informed consent for services. 8.7201.B Case Management Agency Governing Body 1. Each Case Management Agency shall assemble a governing body or board of directors that complies with requirements in Section 25.5-6-1708 C.R.S.

a. The Case Management Agency shall maintain all meeting agendas, minutes, and documents that are required to be posted on the Case Management Agency’s website for at least three months after posting.

b. The Case Management Agency shall maintain all contracts, financial statements, and 990s that are required to be posted on the Case Management Agency’s website on its website for at least three calendar years after posting.

c. The Case Management Agency shall not screen or divert any email that is sent to a member of the board of directors or governing body of a Case Management Agency. The Case Management Agency shall ensure that all emails addressed to a member of the board of directors or governing body are delivered to that member.

i. In the event a member of the board of directors or governing body is unable to access a computer or needs assistance with email, the Case Management Agency shall provide appropriate assistance, including providing emails in alternative formats upon request or mailing correspondence through the U.S. postal d. The Department shall maintain a website form for community members to make anonymous Complaints regarding the Case Management Agency compliance with the transparency requirements in C.R.S. 25.5-6-1708.

The Case Management Agency and its governing body shall comply with the Department’s direction for responding to all Complaints.

The Case Management Agency governing body function shall include but not be limited to:

a. Financial oversight and solvency b. Ensuring accountability and the provision of high quality Case Management c. Ensuring a working Community Advisory Committee convenes at least quarterly d. Resolving disputes between individuals, Members and Case Management Agency that are elevated to the governing body and e. Developing and presenting the Long-Range Plan annually to the Department f. Ensuring adherence to all state and federal regulations and contractual obligations and requirements. 8.7201.C Community Advisory Committee 1. The Case Management Agency shall establish and maintain a community advisory committee for the purpose of providing public input for Case Management Agency operations.

The Community Advisory Committee Responsibilities shall include:

a. Monthly review of Case Management Agency Complaint log b. Receiving Complaints from the community regarding the Case Management Agency via open forum at their meetings c. Supporting Case Management Agency in resolving Complaints with Members, including Referral to the Department’s escalation process d. Making recommendations to the Case Management Agency about policies and procedures, and e. Providing public input and guidance to the Case Management Agency in the review of service delivery policies and procedures, marketing strategies, resource development, overall Case Management Agency operations, service quality, individual Member satisfaction, resolution of Complaints at the local level and other related professional problems or issues.

Community Advisory Committee Membership a. The Case Management Agency shall demonstrate efforts to recruit and support members of the Community Advisory Committee who represent the characteristics of the community as it relates to diversity of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, abilities, and disabilities, and socio-economic status.

b. The membership of the Community Advisory Committee shall include regional representation from, but not be limited to, at least one of each of i. The Defined Service Area’s county commissioners, area agencies on aging, medical professionals, physical and/or intellectual disability professionals, ombudsmen, human service agencies, county government officials, mental/behavioral health professionals, and ii. Regional representation from one or more Long-Term Services and Supports Members or Family Members of individuals receiving Long-Term Services and Supports including Members with I/DD and/or Members with disabilities.

Members shall be given priority of selection over Family iii. The Case Management Agency shall make every effort to recruit and maintain a majority of members or people with lived experience on the Community Advisory Committee over professionals as outlined in 8.7201.C.3.b.i-ii. If the Case Management Agency is unable to maintain this majority, the Case Management Agency shall submit the attempts at recruitment with their annual report to the Department.

c. The Community Advisory Committee shall have a membership count and quorum based on the number of people served. The quorum must include a majority of Members or people with lived experience.

i. Case Management Agencies serving 400-2000 people will have a committee membership count of 5 minimum with a quorum of 3.

ii. Case Management Agencies serving 2001-7000 people will have a committee membership of 7 minimum with a quorum of 4.

iii. Case Management Agencies serving 7001 or more people will have a committee membership of 9 with a quorum of 5.

d. In the event a Community Advisory Committee is comprised of greater than the minimum number of committee members, the quorum shall be a simple majority.

i. If the quorum is not reached, the meeting may continue but the committee must abstain from final recommendation votes until the quorum is met.

The Community Advisory Committee shall function only as an advisory body providing recommendations to the Case Management Agency and Case Management Agency governing body and shall have no decisionmaking power.
The Case Management Agency shall train the Community Advisory Committee members in confidentiality, mandatory reporting and disability cultural competency.
The Community Advisory Committee shall maintain public notices in accordance with confidentiality requirements of the following: meetings, meeting minutes, and documentation of actions taken in response to recommendations and Complaints. Public notices of meetings shall be made available online and by request for increased equitable access.
The Community Advisory Committee shall provide options for equitable access to meetings including live, online audiovisual access to meetings.
The Community Advisory Committee shall report to the Case Management Agency governing body quarterly on all Case Management complaints trends and documentation of actions taken in response to recommendations and complaints. These reports shall be made public.
The Community Advisory Committee shall provide reports to the Department and its committees upon request. These reports shall be made public.
The Community Advisory Committee may be combined in purpose or name with other Case Management Agency committees in the Case Management Agency Defined Service Area so long as it meets the above

purpose, criteria and reporting requirements.

The Case Management Agency must provide an annual summary of the Community Advisory Committee’s activities over the prior year in its Long Range Plan and presentation to the Department 8.7201.D Case Management Agency Complaint Process for Individuals and Members 1. Every Case Management Agency shall use the Department prescribed Case Management Agency Complaint log and have procedures setting forth a process for the timely resolution of Complaints received from a Member, Parent(s) of a minor, Guardian and/or other Legally Authorized Representative, as appropriate.

The Case Management Agency shall not take any action that affects the future provision of appropriate services or supports based on the receipt of a Complaint from a Member or their Parent, Guardian or representative.

The procedure shall be provided, orally and in writing and in the communication method of the member’s or guardian’s choosing, to all Members, the Parents of a minor, Guardian and/or other Legally Authorized Representative, as appropriate, at the time of admission, at any time changes to the procedure occur and as part of the annual service planning process.
The Case Management Agency shall make all Complaint procedures available on their public facing website.
The Complaint procedure shall include, at a minimum, the following:

a. Contact information for a person within the Case Management Agency who will receive Complaints.

b. Identification of support person(s) who can assist the individual or Member in submitting a Complaint.

c. An opportunity to find a mutually acceptable solution. This could include the use of mediation if both parties voluntarily agree.

d. Timelines for resolving the Complaint.

e. Escalation of the Complaint to the Agency director or designee for consideration if the Complaint cannot be resolved at a lower level. This may include the Department escalation process, if necessary.

f. Assurances that no Member shall be coerced, intimidated, threatened, or retaliated against because the Member has exercised his or her right to file a Complaint or has participated in the Complaint process.

g. Review of redacted Complaint log and resolutions with the Community Advisory Committee.

The Department shall review the Complaint procedure and logs annually to ensure appropriate resolution of Complaints and provide feedback and follow up to Case Management Agency as necessary.
If an Agency goes without Complaints for more than two years, the Department shall require the Case Management Agency to complete a statistically valid customer satisfaction survey each year for each of the following two years.
The Department shall maintain a website form for community Members to make anonymous Complaints regarding the Case Management Agency. 8.7201.E Personnel System 1. The Case Management Agency shall have a system that complies with all rules, regulations, and Department communications for recruiting, retaining, hiring, evaluating, and terminating Case Management Agency employees including but not limited to a. Colorado Bureau of Investigations criminal history background check b. Colorado Adult Protective Services data system checks, and c. Verification of compliance with applicable state regulations.
Case Management Agency employment policies and practices shall comply with all federal and state affirmative action and civil rights requirements.
The Case Management Agency shall maintain a current job description for each employment position. 8.7201.F Staffing Patterns 1. Each Case Management Agency shall assure adequate staffing levels and infrastructure, including maintaining caseload sizes or ratios as set forth in contract, to effectively manage the Case Management Agencies’ s caseload to ensure timely delivery of high-quality services. This includes at least one full-time Case Manager to provide Case Management functions and administrative support, and, as needed, additional Case Managers, case aids, supervisors, and other staff.
Within their staffing patterns, Case Management Agencies shall publicly post its policies and procedures and provide choice of Case Manager to Members served in their Defined Service Area and shall clearly communicate to each individual and Member the steps for requesting a new Case Manager.
Case Management Agencies shall maintain staffing patterns in accordance with Department prescribed best practices for Long-Term Services and Supports Case Manager-level caseloads for all Targeted Case Management Activities and shall comply with all contractual requirements.

a. Case Management Agency shall not exceed the best practice standards for HCBS waiver or CFC caseload sizes without written approval from the 4. Case Management Agencies shall ensure staff have access to statutes and regulations relevant to the provision of authorized services.

For each individual Members, Case Management Agencies shall assign one (1) primary Case Manager or point of contact who ensures Case Management services are provided on behalf of the Member or individual across all programs.

Case Management Agencies must maintain a best practice standard in their policies and procedures for notification of a Member when a new Case Manager is assigned to a Member.

Case Management Agencies shall ensure persons who are employed by the Agency meet the requirements of these regulations.
Case Management Agencies shall verify and document that Case Managers who are employed meet minimum requirements and qualifications.
Case Management Agencies and their staff shall avoid situations that create the potential for a real or perceived conflict of interest. If a situation that may involve potential conflict of interest cannot be avoided, staff shall notify affected parties of possible the conflict of interest and policies and procedures in place to ensure protection of the Member or individual’s rights. 8.7201.G Case Management Agency Communication and Documentation 1. The Case Management Agency shall:

a. Comply with all reporting and billing policies and procedures established by the Department, document individual and Member records within the Department’s prescribed systems and adhere to the system requirements provided by the Department for these systems.

b. Have access to Member eligibility, Prior Authorization Request (PAR), and claims data reporting provided through a data query application, program eligibility determination, Financial Eligibility determination, Person- Centered Support Planning, service authorization, Critical Incident reporting and follow-up, monitoring of health and welfare, monitoring of services, information and Referral services provided by the Agency, Complaint trends and resolutions, resource development and fiscal accountability.

c. Maintain individual and Member records within the Department’s prescribed systems for the purposes of individual and Member information management.

d. Maintain accurate and detailed documentation of all Case Management and State General Fund Program activities required by the Case Management Agency Contract and these rules.

e. Maintain accurate and detailed supporting documentation in the Department’s prescribed system within ten (10) business days of all activities as required through the Case Management Agency Contract and these rules to substantiate claims for reimbursement.

f. Provide supporting documentation not already residing within the Department’s prescribed systems to the Department upon request.

g. Correct one hundred percent (100%) of data errors, discovered by the Department, and confirm the accuracy of the data it enters into the Department prescribed system within ten (10) Business Days of notification from the Department of an error.

h. Provide information and reports as required by the Department including, but not limited to, data and records necessary for the Department to conduct operations.

The Case Management Agency shall have adequate phone and computer hardware and software for communication with Members, individuals, employees and stakeholders, compatible with the Information Management System with such capacity and capabilities as prescribed by the Department to manage the administrative requirements necessary to fulfill the Case Management Agency responsibilities.
The Case Management Agency shall have adequate staff support to maintain a computerized information system in accordance with the Department's 8.7201.H Case Management Agency Individual and Member Recordkeeping 1. The Case Management Agency shall complete and maintain all required records in the Information Management System in accordance with program requirements and Department training or communication and shall maintain individual records at the Agency level for any additional documents associated with the individual seeking or enrolled in a Long-Term Services and Supports program or service.
The Case Manager shall use the Information Management System for purposes of documentation of all case activities, monitoring of service delivery, and service effectiveness. If applicable, the individual's Legally Authorized Representative shall be identified in the record, with a copy of appropriate documentation.
The Case Management Agency may accept physical or digital signatures on Department forms. If the individual is unable to sign a form requiring his/her signature because of a medical condition, any mark the individual is capable of making shall be accepted in lieu of a signature. If the individual is not capable of making a mark or performing a digital signature, the physical or digital signature of a Guardian or other Legally Authorized Representative shall be accepted.
The case records shall include:

a. Information identifying the individual, including the individual’s state Medicaid identification number, date of birth (DOB), social security number (SSN) if applicable, address and phone number;

b. Forms required by the Department for the specific program in which the individual is enrolled; and c. Documentation of all Case Management activity;

d. Any communication accommodations necessary for the Member or Guardian.

The Department shall examine the Case Management Agency’s documentation practices when monitoring the Case Management Agency’s performance.
Records pertaining to persons seeking or receiving services shall be maintained in accordance with these rules and other applicable federal and state regulations and accreditation standards. Where no superseding regulation or policy applies, records may be purged and destroyed per Agency policy.
A Case Management Agency shall designate an employee who shall be responsible for the record at all times during the examination of the record by entities other than employees of that Agency.
Records shall be made available for review at the Agency to authorized persons within a reasonable period of time as negotiated by the Agency and the party seeking access.
At no time may a person examining a record remove anything from it or otherwise make changes in it, except as delineated below:

a. If the person seeking or receiving services, Parent of a minor, Guardian or other Legally Authorized Representative, if within the scope of his/her

authority, objects to any information contained in the record, he/she may submit a request for changes, corrections, deletions, or other modifications.

b. The person seeking or receiving services, Parent of a minor, Guardian or other Legally Authorized Representative shall sign and date the request.

c. The Agency administrator shall make the final determination regarding the request and shall notify the requesting party of the decision.

d. If the Agency administrator denies the request, then the requestor has the right to have a statement regarding their request entered into the record.

Records or portions of records may be photocopied or otherwise duplicated only in accordance with written Agency procedures, and any fee for duplication shall be reasonable pursuant to section 24-72-205, C.R.S.
The Case Management Agency shall provide a Member one free copy of any information contained in their record upon request.
The Case Management Agency shall maintain records for seven (7) years after the date a Member discharges from a waiver program, including all documents, records, communications, notes and other materials related to services provided and work performed. 8.7201.I Confidentiality of Information 1. The Case Management Agency shall protect the confidentiality of all records of individuals seeking and receiving services required by Section 26-1-114(3)(a)(I), C.R.S. and 45 C.F.R., Parts 160 and 165, Subparts A and C (HIPAA). Release of information forms obtained from the individual must be signed, dated, and kept in the Member’s record. Release of information forms shall be renewed at least annually, or with the new Provider Agency whenever there is a change of provider. Fiscal data, budgets, financial statements and reports which do not identify individuals by name or Medicaid ID number, and which do not otherwise include Protected Health Information, are subject to disclosure pursuant to the Colorado Open Records Act, Title 24, Article 72, Part 2, C.R.S.
Identifying information regulated by this rule is any information which could reasonably be expected to identify the individual seeking or receiving services or their Family or contact persons, including, but not limited to, name, Social Security number, Medicaid Member identification number, household number or any other identifying number or code, street address, and telephone number, photograph or digital image, or any distinguishing mark. Identifying numbers assigned and used internally within a single Agency shall be excluded from this

regulation.

At the time of eligibility determination and enrollment, the individual, parent of a minor, Guardian and/or other person acting as an advisor to the person shall be advised of the type of information collected and maintained by the Agency, and to whom and when it is routinely disclosed.
This rule applies to confidential information in any format including, but not limited to, individual records, correspondence or other written materials, verbal communication, photographs, and electronically stored data.
The records and all other documentation or correspondence concerning individuals seeking or receiving services are the property of the Agency which is responsible for maintaining and safeguarding their contents.
All written authorizations referenced within this chapter must be:

a. Signed and dated;

b. For a specified time period;

c. Specific as to the information or photograph or digital image to be disclosed and the intended use of such information or photograph; and, d. Specific as to whom it will be disclosed.

Authorizations may be revoked in writing or verbally at any time by the person who provided the authorization.
Disclosure of confidential information shall be limited to:

a. The individual seeking or receiving services, Parent of a minor, or Guardian.

b. Persons or entities presenting written authorization signed by the person seeking or receiving services, Parent of a minor, or Guardian.

c. The Legally Authorized Representative of the person seeking or receiving services as defined in Section 8.7001.A.7, if access to confidential information is within the scope of their authority.

d. Qualified professional personnel of community centered boards, regional centers and other service agencies including boards of directors and Human Rights Committee Members to the extent necessary for the acquisition, provision, oversight, or Referral of services and supports.

e. The Department or its designees as deemed necessary by the Executive Director to fulfill the duties prescribed by Title 25.5, Article 10 of Colorado Revised Statutes.

f. To the extent necessary, qualified professional personnel of authorized external agencies whose responsibility it is to license, to accredit, to monitor, to approve or to conduct other functions as designated by the Executive Director of the Department.

g. Physicians, psychologists, and other professionals providing services or supports to a person in an emergency situation which precludes obtaining consent in such an instance:

i. Documentation of this access shall be entered into the person's ii. This documentation shall contain the date and time of the disclosure, the information disclosed, the names of the persons by whom and to whom the information was disclosed, and the nature of the emergency.

h. The court or persons authorized by an order of the court, issued after a hearing, notice of which was given to the person, Parents of a minor or legal Guardian, where appropriate, and the custodian of the information.

i. Other persons or entities authorized by law; and, j. The entity designated as the protection and advocacy system for Colorado pursuant to 42 U.S.C. § 604 when:

i. A Complaint has been received by the protection and advocacy system from or on behalf of a person with a Developmental Disability; and, ii. Such person does not have a legal Guardian or the state or the designee of the state is the legal Guardian of such person.

Nothing in this regulation should be taken to mean that a person or entity who is authorized to access confidential information regarding an individual per Section 8.606.2.A is authorized to access any and all confidential information available regarding that individual. Disclosure of confidential information must be limited to the information which is necessary to perform the duties of that person or entity requiring access. The individual seeking or receiving services, Parent of a minor, or Guardian may access any and all aspects of that person's record. The Legally Authorized Representative of an individual may access those aspects of a person's record that are within the scope of their authority. 8.7201.J Preservation of Member Rights 1. Case Management Agencies shall have policies and procedures that assure the preservation of Member rights contained in Sections 25.5-10-216 through 240, C.R.S. and 8.7001.

a. The Case Management Agency shall assure the protection of the rights of Members as defined by the Department under applicable programs, including but not limited to Section 8.7001.

b. The Case Management Agency shall assure that the following rights are preserved for all individuals served by the Case Management Agency, whether the individual is a recipient of a state-administered program or a private pay individual:

i. The individual and/or the individual’s Legally Authorized Representative, as necessary, is fully informed of the individual’s rights and responsibilities;

ii. The individual and/or the individual’s Legally Authorized Representative participates in the development and approval of, and is provided a copy of, the individual’s Person-Centered Support Plan;

iii. The individual and/or the individual’s Legally Authorized Representative selects service providers from among available qualified and willing providers;

iv. The individual and/or the individual’s Legally Authorized Representative has access to a uniform Complaint system provided for all individuals served by the Case Management Agency; and v. The individual who applies for or receives publicly funded benefits and/or the individual’s Legally Authorized Representative has access to a uniform appeal process, which meets the requirements of Section 8.057, when benefits or services are denied or reduced and the issue is appealable.

Members shall have the right to read or have Case Management Agency explain any rules or regulations adopted by the Department and policies and procedures of the Case Management Agency pertaining to such persons' activities, services and supports, or to obtain copies of Title 25.5 Article 10, C.R.S., rules, policies or procedures at no cost or at a reasonable cost in accordance with Section 24-72- 205, C.R.S..
Case Management Agencies shall inform Members, Parents of minors, Guardians and other Legally Authorized Representatives of the rights provided in Title 25.5 Article10, C.R.S., and:

a. Case Management Agencies shall provide a written and verbal summary of rights and a description of how to exercise them, at the time of eligibility determination, at the time of enrollment, and when substantive changes to services and supports are considered through the Individualized Planning b. The information shall be provided in a manner that is easily understood, verbally and in writing, in the native language of the individual, or through other modes of communication as may be necessary to enhance understanding for the Member.

c. Case Management Agencies shall provide assistance and ongoing instruction to Members in exercising their rights.

Case Management Agencies shall ensure that no individual, Member, their Family Members, Guardian or other Legally Authorized Representatives, are retaliated against in their receipt of Case Management services, direct services or supports or otherwise as a result of attempts to advocate on their own behalf.
Case Management Agency employees and Contractors must be made aware of the rights of Members and procedures for safeguarding these rights. 8.7201.K Member Access to Case Management Agency 1. Case Management Agencies shall have policies and procedures that assures compliance with all federally mandated requirements for access to services.

a. In accordance with the Americans with Disabilities Act (ADA), 42 U.S.C. 12101 et seq. there shall be no physical or programmatic barriers which prohibit individual participation, b. The Case Management Agency shall not require Members to come to the Agency's office in order to receive Case Management Agency services.

c. The Case Management Agency shall comply with nondiscrimination requirements, as defined by federal and Department rules and outlined in contract.

d. Case Management Agency functions shall be provided in a personcentered model of Case Management service delivery.

e. Case Management Agencies shall complete a Level of Care Screen when it is requested by the Member or individual in accordance with Member rights, even if the Case Management Agency staff does not believe the individual will be deemed eligible.

f. The Case Management Agency shall have office location(s) and building office hours in accordance with written requirements in Case Management Agency contract and in accordance with Americans with Disabilities Act (ADA), 42 U.S.C. 12101 et seq. 8.7201.L Incident Reporting 1. Case Management Agencies shall have a written policy and procedure for the timely reporting, recording and reviewing of Incidents occurring on the Case Management Agency property or care which shall include, but not be limited to:

a. Allegations of abuse, mistreatment, neglect, or exploitation;

b. Serious Illnesses and injuries to a person receiving services that require intervention that is above and beyond basic first aid;

c. Lost or missing persons receiving services;

d. Medical emergencies involving Members that require intervention that is above and beyond basic first aid or that are not screened out by medical professionals;

e. Hospitalization of Members;

f. Death of Members; g Errors in medication administration; and, h. Stolen personal property belonging to a Member.

Reports of Incidents shall include, but not be limited to:

a. Name of the person reporting;

b. Name of the Member who was involved in the Incident;

c. Name of persons involved or witnessing the Incident;

d. Type of Incident;

e. Description of the Incident;

f. Date and place of occurrence;

g. Duration of the Incident;

h. Description of the action taken in response to the incident;

i. Whether the Incident was observed directly or reported to the Case Management Agency;

j. Names of persons notified;

k. Follow-up action taken or where to find documentation of further follow-up; and, l. Name of the person responsible for follow-up.

Case Management Agencies shall ensure all staff are trained to identify Critical Incident Reporting criteria according to the Agency’s written policy and procedure and Department requirements.
Case Management Agencies shall ensure staff are trained to identify Incidents that are required to be reported to Colorado Department of Public Health and Environment (CDPHE).
Incidents meeting Critical Incident Reporting criteria, including but not limited to, Allegations of mistreatment, abuse, neglect and exploitation, and injuries which require emergency medical treatment or result in hospitalization or death shall be reported by the Case Management Agency in the Department's prescribed system within 24 hours or 1 business day of being reported.
The Case Management Agency shall place in the Member’s record reports of Incidents not meeting Critical Incident Reporting criteria.
The Case Management Agency shall provide records of Incidents not meeting Critical Incident Reporting criteria to the Department upon request.
Case Management Agencies shall review and analyze information from Incident reports to identify trends and problematic practices which may be occurring in specific services and shall take appropriate action to report Complaints as necessary. 8.7201.M Mistreatment, Abuse, Neglect, and Exploitation 1. Pursuant to Section 25.5-10-221, C.R.S., all Case Management Agencies shall prohibit mistreatment, abuse, neglect, or exploitation of any individual and or 2. Case Management Agencies shall have written policies and procedures for handling cases of alleged or suspected mistreatment, abuse, neglect, or exploitation of any individual and or Member. These policies and procedures must be consistent with state law and:

a. Definitions of mistreatment, abuse, neglect, or exploitation must be consistent with state law and these rules;

b. Provide a mechanism for monitoring to detect instances of mistreatment, abuse, neglect, or exploitation. Monitoring is to include, at a minimum, the review of:

i. Incident reports;

ii. Verbal and written reports of unusual or dramatic changes in behavior(s) of Members; and, iii. Verbal and written reports from Members, advocates, families, Guardians, and friends of Members.

c. Provide procedures for reporting, reviewing, and collaborating with Adult/Child Protection Services, and law enforcement entities/representatives for investigating all allegations of mistreatment, abuse, neglect, or exploitation;

d. Ensure that appropriate disciplinary actions up to and including termination, and appropriate legal recourse are taken against employees and Contractors who have engaged in mistreatment, abuse, neglect, or exploitation;

e. Shall procure a memorandum of understanding (MOU) with local Adult/Child Protection Services, and Law Enforcement, and Provider Agencies outlining roles and responsibilities as well as outline standard practices for reporting and mitigating risk for Members.

f. Ensure that employees and Members receiving services and Contractors are made aware of applicable state law and Agency policies and procedures related to mistreatment, abuse, neglect or exploitation;

g. Require immediate reporting by employees and Contractors according to Agency policy and procedures and to the Agency administrator or his/her designee;

h. Require reporting of allegations within 24 hours of learning of the Incident to appropriate authorities, recording in Information Management System, reporting to the Parent of a minor, Guardian, or other Legally Authorized Representative, and Case Management Agency;

i. Require timely reporting of Critical Incident Report follow-up and reporting of actions taken by caregivers, Provider Agencies, DHS, and Law Enforcement to protect the Member receiving services. Case Management Agencies shall ensure prompt action to protect the safety, as well as, mental and physical health of the Member. Such action may include any action that would protect the Member(s) receiving services if determined necessary and appropriate by the Provider Agency or Case Management Agency pending the outcome of the investigation. Actions may include, but are not limited to, removing the Member from his/her residential and/or day services setting and removing or replacing staff;

j. Require advocating for Referral to victim support and protective orders for Members as applicable to the mistreatment, abuse, neglect, or exploitation. Provide necessary victim supports;

k. Require prompt reporting of the allegation to appropriate authorities in accordance with statutory requirements and pursuant to Section 8.7201.M.3;

l. Ensure Human Rights Committee review of all allegations; and, m. Ensure that no individual is coerced, intimidated, threatened or retaliated against because the individual, in good faith, makes a report of suspected mistreatment, abuse, neglect or exploitation or assists or participates in any manner in an investigation of such allegations in accordance with

Section 8.7201.M.3.

Case Management Agencies shall develop relationships with local authorities required to investigate mistreatment, abuse, neglect, and exploitation. All alleged Incidents of abuse, mistreatment, neglect, or exploitation shall be thoroughly investigated in a timely manner using the specified investigation procedures.

However, such procedures must not be used in lieu of investigations required by law or which may result from action initiated pursuant to Section B, above.

a. Within 24 hours of becoming aware of the Incident, a Critical Incident report shall be made available to the Agency administrator or designee and the Case Management Agency.

b. The Agency shall maintain a written administrative record of all such investigations including:

i. The Incident report and preliminary results of the investigation;

ii. A summary of the investigative procedures utilized;

iii. The full investigative finding(s);

iv. The actions taken; and, v. The Human Rights Committee review of the investigative report and the action taken on recommendations made by the committee.

c. The Agency shall ensure that appropriate actions are taken when an allegation against an employee or Contractor is substantiated, and that the results of the investigation are recorded, with the employee's or Contractor's knowledge, in the employee's personnel or Contractor's file. 8.7202 Functions of A Case Management Agency 8.7202.A Case Management Services Overview 1. Functions of the Case Manager a. Ongoing Case Management and Targeted Case Management b. Case management services are provided for Members and individuals accessing Home and Community-Based services. Case Management services shall include, but not be limited to, the following tasks, activities, requirements, and responsibilities: 8.7202.B Intake, Screening, and Referral 1. The Intake, Screening and Referral function of a Case Management Agency shall include, but not be limited to, the following activities:

a. The Case Management Agency shall verify the individual’s demographic information collected during the intake;

b. The completion of the Intake, Screening and Referral functions using the Department’s Information Management System to determine Applicant needs and eligibility for Long-Term Services and Supports and non- Long- Term Services and Supports services, information and Referral assistance to Long-Term Services and Supports and other services and supports, as needed;

c. Level of Care eligibility determination as applicable;

d. Referring to and facilitation of the Medicaid Financial Eligibility application 2. The Case Management Agency must maintain, or have access to, information about public and private state and local services, supports and resources and shall make such information available to the Member, individual and/or persons inquiring upon their behalf.

The Case Management Agency shall coordinate the completion of the Financial Eligibility determination by:

a. Verifying the individual’s current Financial Eligibility status; or b. Referring the individual to the county department of social services of the individual’s county of residence for application and support with completing an application in accordance with Section 8.100.3.A.7; or c. Providing the individual with Financial Eligibility application form(s) for submission, with required attachments, to the county department of social services for the county in which the individual resides; and d. Conducting and documenting follow-up activities to complete the Functional Eligibility determination and coordinate the completion of the Financial Eligibility determination.

In compliance with standards established by the Department, Case Management Agencies may ask referring agencies to complete and submit an intake and screening form to initiate the process.

a. Case Management Agencies shall not delay the completion of an intake screen based on the use of this form.

b. Case Management Agencies shall accept Referrals for Long-Te r m Services and Supports including but not limited to the following modalities:

i. Intake Screen form ii. Phone calls iii. County DHS Referrals and communication iv. In person requests for Long-Term Services and Supports v. Medical Assistance sites 5. The Case Manager shall perform a screening to determine whether a Functional Eligibility Assessment is needed; The individual shall be informed of the right to receive an Assessment if the individual disagrees with the Case Manager's decision.

The Case Manager shall identify potential payment source(s), including the availability of private funding resources; including but not limited to trusts, thirdparty insurance, and/or private community funding.
The Case Manager shall implement the use of a Case Management Agency procedure for prioritizing urgent inquiries.
When an individual with Intellectual and Developmental Disabilities cannot be safely served in a community setting due to challenging behavior, including behavior that presents a danger to self or others, or behavior which results in significant property destruction and community placement options have been unsuccessful and exhausted, the Case Management Agency shall make a Referral to the Regional Centers and shall comply with the Regional Centers admission policy. 8.7202.C Nursing Facility Admission and Discharge 1. For Members in HCBS Programs who are already determined to be at the nursing facility Level of Care and seeking admission into a nursing facility, the Case Management Agency shall:

a. Provide information about community-based services to the individual to determine if they desire to live in the community with additional support and if the individual indicates interest to live in the community, document preference in the Department’s Information Management System.

b. Coordinate the admission date with the facility.

c. Complete the Pre-Admission Screening and Resident Review (PASRR)

Level 1 Screen, and if there is an indication of a mental illness or Developmental Disability, submit to the Department or its agent to determine whether a Pre-Admission Screening and Resident Review (PASRR) Level 2 evaluation is required.

d. Maintain the Level 1 Screen in the individual’s case file regardless of the outcome of the Level 1 Screen; and e. If appropriate, assign the remaining HCBS length of stay towards the nursing facility admission if the completion date of the most recent Level of Care screen is not six (6) months old or older.

The Case Manager and the nursing facility shall complete the following activities for discharges from nursing facilities:

a. The nursing facility shall contact the Case Management Agency in the district where the nursing facility is located to inform the Case Management Agency of the discharge if placement into home or community-based services is being considered.

b. The nursing facility and the Case Management Agency Case Manager shall coordinate the discharge date.

c. When placement into HCBS Programs is being considered, the Case Management Agency shall determine the remaining length of stay.

i. If the end date for the nursing facility is indefinite, the Case Management Agency shall assign an end date not beyond one (1) year from the date of the most recent Level of Care Screen.

ii. If the Level of Care Screen was conducted within the preceding twelve (12) months, the Case Management Agency shall generate a new certification page that reflects the end date that was assigned to the nursing facility.

iii. If no Level of Care Screen was completed within the preceding twelve (12) months, the Case Management Agency shall complete a new Level of Care Screen. The Assessment results shall be used to determine Level of Care and the new length of stay.

iv. The Case Management Agency shall send a copy of the Level of Care Screen certification page to the eligibility enrollment specialist at the county department of social services.

v. Within 2 business days of financial approval, the Case Management Agency shall outreach the Member to review available service options.

vi. The Case Management Agency shall submit the HCBS Prior Authorization Request to the Department or its fiscal agent.

If the individual is being discharged from a hospital or other institutional setting, the discharge planner shall contact the Case Management Agency for Assessment by emailing or faxing the initial intake and screening form.
The Case Manager shall view and document the current Personal Care Boarding Home license, if the individual lives, or plans to live, in a Congregate Facility as defined at Section 8.7100.A.12..
A Case Manager may determine that an individual is eligible to receive Waiver Services while the individual resides in a nursing facility when the individual meets the eligibility criteria as established at Sections 8.400 , and 8.7100 and the individual requests to transition out of the nursing facility.
If the individual has been evaluated with the Level of Care Screen and has been assigned a length of stay that has not lapsed, the Case Management Agency Case Manager is not required to conduct another review when the transition is requested unless a change in condition has occurred since the most recent Level of Care Screen. 8.7202.D Determination of Developmental Delay and Intellectual and Developmental Disability 1. A determination of developmental delay or intellectual and developmental disability does not constitute a determination of eligibility for services or supports.

The Case Management Agency shall determine whether a person has a developmental delay or intellectual and developmental disability and, therefore, may be eligible to receive services and supports pursuant to Sections 25.5.6- 1702(3) and 1704, C.R.S., in accordance with criteria prescribed by the 2. Eligibility for Medicaid funded programs specific to persons with developmental delays or intellectual and developmental disabilities shall be determined pursuant to the Colorado Department of Health Care Policy and Financing's Medical Assistance rules (10 C.C.R. 2505-10 Section 8.100).

The developmental delay or intellectual and developmental disability determination shall be made by case management agency staff having the minimum qualifications outlined in 10 CCR 2505-10 Section 8.7203.A(1)-(5)
A Request for Developmental Disability Determination of a developmental delay or intellectual and developmental disability shall be submitted to the Case Management Agency in the defined service area where the person resides, including temporary residences, such as incarceration, hospitalization, or foster care placement within the state, in the form and manner prescribed by the 5. At the time of request, the Case Management Agency shall:

a. Provide the applicant with all required forms and a list of the minimum required documents and information necessary for the determination of intellectual or developmental disability or developmental delay determination; and, b. Provide the applicant with information on where to obtain testing for the level of intellectual functioning and adaptive behavior, if requested. The responsibility for obtaining such assessments shall be with the applicant, parent(s) of a minor and/or legally authorized representative.

The applicant, parent(s) of a minor and/or legally authorized representative shall provide all documentation and information necessary for the determination of developmental delay or intellectual and developmental disability within ninety (90) calendar days of the request.

a. The Case Management Agency may request additional documentation and/or information, as needed, to complete the determination of developmental delay or intellectual and developmental disability.

b. The applicant, parent(s) of a minor and/or legally authorized representative may have additional assessments completed and submitted to the Case Management Agency for consideration.

If the applicant, parent(s) of a minor and/or legally authorized representative has not provided the documentation and information necessary for the determination within ninety (90) calendar days of the request, the Case Management Agency shall:

a. Close the request and notify the applicant in writing according to the procedures established at Section 8.7202.D(13); or, b. The Case Management Agency may, at the request of the applicant, parent of a minor and/or legally authorized representative extend the deadline for providing the necessary documentation and information by up to an additional ninety (90) calendar days.

i. In no case shall the deadline for providing the necessary documentation and information exceed one hundred eighty (180) calendar days.

ii. The Case Management Agency shall provide a written update to the applicant no less than every ninety (90) calendar days until a determination of developmental delay or intellectual and developmental disability is completed or the request is closed.

iii. If the extended deadline for providing the necessary documentation and information has expired and there is still insufficient information to make a determination of developmental delay or intellectual and developmental disability, the Case Management Agency shall close the request and notify the applicant and/or legally authorized representative in writing according to the procedures established at Section 8.7202.D(13).

For all applicants, the Case Management Agency shall enter into the Department's prescribed Information Management System and shall permanently maintain a written and/or electronic record of the developmental delay or intellectual and developmental disability determination in a form and manner prescribed by the Department. The record, at a minimum, shall include:

a. The name of the applicant;

b. The applicant's date of birth;

c. The date of the determination of developmental delay or intellectual and developmental disability; and d. A description of the rationale for the developmental delay or intellectual and developmental disability determination including, at minimum, assessment scores and diagnoses;

All information and assessments used to determine a developmental delay or intellectual and developmental disability shall be current so as to accurately represent the applicant's abilities at the time of determination.

a. Assessments of adaptive behavior shall have been completed within three (3) years of the request.

b. Assessments of intellectual functioning shall have been completed as i. If an individual is between five (5) and eighteen (18) years of age, at least one intellectual assessment shall have been completed to determine the individual's impairment of general intellectual functioning; or, ii. If an individual is eighteen (18) years of age or older and there is only one intellectual assessment available to determine the individual's impairment of general intellectual functioning, the assessment shall have been completed when the individual was at least eighteen (18) years of age and shall have been completed within ten (10) years of the request; or, iii. If there is historical pattern of consistent scores, based on two (2) or more intellectual assessments, that demonstrate an impairment of general intellectual functioning, the assessments may be used regardless of the individual's age at the time of determination.

c. An established neurological condition shall be documented as follows:

i. A diagnosed neurological condition shall be determined by a MD, DO, PA, APN, psychologist, neuropsychologist, or other qualified medical professional practicing within the scope of their license; or, ii. If a specific diagnosis is not possible, a written statement from a MD, DO, PA, APN, psychologist, neuropsychologist, or other qualified medical professional, practicing within the scope of their license, may be used as long as there is a documented effort to determine a diagnosis and the available assessment information reasonably supports a conclusion that a neurological impairment is present.

iii. The effects of mental illness or physical or sensory impairment must be considered to determine the extent to which such impairments are the sole contributing factor to the impairment of general intellectual functioning or limitations to adaptive behavior.

iv. The established neurological condition documentation must be signed by the MD, DO, PA, APN, psychologist, neuropsychologist, or other qualified medical professional practicing within the scope of their license.

The Case Management Agency shall make the determination of developmental delay or intellectual and developmental disability within thirty (30) calendar days of the receipt of all information and documentation required to make a determination.
The date of the developmental delay or intellectual and developmental disability determination shall be the date that all documentation and information required for the determination of a developmental or intellectual and developmental disability was received by the Case Management Agency.
If a delay to the determination of a developmental delay or intellectual and developmental disability is due to the actions or inactions of the Case Management Agency, the original date of request shall be used.
The Case Management Agency making the developmental delay or intellectual and developmental disability determination shall, in writing, notify the applicant, parent(s) of a minor and/or their legally authorized representative, and other such persons as designated by the applicant, of the decision. Such notification shall:

a. Be mailed to the person within seven (7) calendar days of the date of determination decision;

b. Be provided in such alternative means of communication as to reasonably ensure that the information has been communicated in an understandable form; and, c. For persons determined to have a developmental delay or intellectual and developmental disability, contain an explanation of the process that will occur -and notice that, at a minimum, a Person-Centered Support Plan shall be developed upon enrollment into a developmental disability program;

d. For persons determined not to have a developmental delay or intellectual and developmental disability or persons whose request is closed without the determination of a developmental delay or intellectual and developmental disability, state the reasons for the determination or closure, and provide a written Long-Term Care Notice of Action form in accordance with the provisions of Section 8.057 regarding the applicant's right to appeal the decision to the Office of Administrative Courts.

Applicants determined not to have a developmental delay or intellectual and developmental disability may request a new determination at any time upon receipt of new or missing required information, and a new request date shall be established.
A determination of developmental delay or intellectual and developmental disability shall be accepted by other Case Management Agencies, service agencies and regional centers.
A determination of developmental delay or intellectual and developmental disability shall be permanent and shall not require renewal or review unless:

a. The Member Identified Team determines that developmental disability services are no longer needed due to improvement in a person's condition and recommends a redetermination; or, b. Information from a new evaluation becomes available which demonstrates sufficient improvement in a person's condition such that the determination should be reviewed. 8.7202.E Level of Care Determination 1. The Level of Care Screen shall be used to establish a Member’s Level of Care.

At the time of completing the Level of Care Screen, unless the individual opposes community living, the Case Manager shall provide information on communitybased services to the individual to determine if they desire to live in the community with additional support.
The Case Management Agency shall complete the Level of Care Screen within the following time frames:

a. For an individual who is not being discharged from a hospital or a nursing facility, the individual Assessment shall be completed and documented in the Department prescribed technology system within 10 working days after receiving confirmation that the Medicaid application has been received by the county department of social services, unless a different time frame specified below applies.

b. The Case Management Agency shall complete and document the Assessment within five (5) working days after notification by the nursing facility for a resident who is changing pay source (Medicare/private pay to Medicaid) in the nursing facility, the Case Management Agency shall complete and document the Assessment within five (5) working days after notification by the nursing facility.

c. For a resident who is being admitted to the nursing facility from the hospital, the Case Management Agency shall complete and document the Assessment, including a Pre-Admission Screening and Resident Review (PASRR) Level 1 Screen within two (2) working days after notification.

i. For Pre-Admission Screening and Resident Review (PASRR) Level 1 Screen regulations, Section 8.401.18 d. For an individual who is being transferred from a nursing facility to an HCBS program or between nursing facilities, the Case Management Agency shall complete and document the Assessment within five (5) working days after notification by the nursing facility.

e. For an individual who is being transferred from a hospital to an HCBS program, the Case Management Agency shall complete and document the Assessment within two (2) working days after notification from the hospital.

Under no circumstances shall the start date for Functional Eligibility based on the Level of Care Screen be backdated by the Case Manager.
The Case Management Agency shall complete and document the Level of Care Screen for Long-Term Services and Supports Programs, in accordance with

Section 8.401.1. Under no circumstances shall late PAR revisions be approved by the State or its agent.

The Case Management Agency shall assess the individual’s functional status face-to-face in the location where the person currently resides. Upon Department approval, Assessment may be completed by the Case Manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the Case Manager or individual (e.g. natural disaster, pandemic, etc.).
The Case Management Agency shall conduct the following activities when completing a Level of Care Screen of an individual seeking services:

a. Obtain diagnostic information in the manner prescribed by the Department from the individual’s medical provider for individuals in nursing facilities, ICF-IID, or HCBS waivers.

b. Determine the individual’s functional capacity during an assessment, with observation of the individual and family, if appropriate, in his or her residential setting and determine the functional capacity score in each of the areas identified in Section 8.401.1.

c. Determine the length of stay for individuals seeking/receiving nursing facility care using the Nursing Facility Length of Stay Assignment Form in accordance with Section 8.402.15.

d. Determine the need for Long-Term Services and Supports on the Level of Care Screen during the assessment.

e. For HCBS Programs and admissions to nursing facilities from the community, the original Level of Care Screen and Person-Centered Support Plan copy shall be sent to entities or persons of the Member’s choosing. If changes to the individual’s condition occur which significantly change the payment or services amount, a copy of the Person-Centered Support Plan must be sent to the Provider Agency, and a copy is to be maintained in the Member’s record.

f. When the Case Management Agency assesses the individual’s functional capacity on the Level of Care Screen, it is not an Adverse Action that is directly appealable. The individual’s right to appeal arises only when an individual is denied enrollment into a Long-Term Services and Supports Program by the Case Management Agency based on the Level of Care Screen for Functional Eligibility. The appeal process is governed by the provisions of Section 8.057.

The Case Management Agency shall conduct the following activities at the conclusion of the Level of Care Screen for nursing facility admission if the individual expresses a desire to live in, or does not oppose to living in the community with additional support:

a. Complete the Rapid Reintegration Barrier Questions within the Department’s Prescribed System at the completion of the Level of Care Screen.

i. If the Member is determined to have unstable housing, additional support needed beyond a thirty (30) day resolution, or transition support is needed, the Case Manager will complete a Rapid Referral to the Transition Coordination Agency within two (2) business days from completion of the level of care.

ii. If the Member has HCBS, stable housing, no transition support is needed, and is able to transition to the community within thirty (30) days, the Case Manager will complete the Rapid Reintegration Plan. The Rapid Reintegration Plan will consist of a series of questions that will identify any additional support that can be resolved by the case manager, the date on which the reintegration is intended to occur and updated to include the date the reintegration occurred once completed.

b. Refer the Member/ Individual to community resources, as needed.

c. If the individual does not meet financial eligibility requirements, the Case Manager will submit an escalation ticket to Transition Escalation as instructed by the Department.

d. If the Member declines a referral to the Transition Coordination Agency or Rapid Reintegration Plan, the Case Manager shall:

i. advise the Member to follow the nursing facility transition process;

ii. educate the Member about In Reach counseling, if they become interested in living in the community in the future; and document in the Departments Information Management System the reason for declination. Once documented, the Rapid Reintegration Plan stops and is no longer applicable.

e. For any Member that goes through the Rapid Reintegration process, the Case Manager will complete a post reintegration survey with the Member at their next contact or within ninety (90) days, this is the final step in the Rapid Reintegration process.

f. If a Member transitioned from the Nursing Facility to the community or they request to end the Rapid Reintegration Plan, the Case Manager will close the Rapid Reintegration plan in the Department’s Prescribed 8.7202.F Needs Assessment 1. Needs Assessment a. The Case Manager shall continually identify individuals’ strengths, needs, and preferences for services and supports as they change or as indicated by the occurrence of Critical Incidents.

b. The Case Manager shall complete a new Level of Care Screen during an in-person Reassessment annually, or more frequently if warranted by the individual’s condition or if required by the rules of the Long-Term Services and Supports Program in which the individual is enrolled. Upon Department approval, Reassessment may be completed by the Case Manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the Case Manager or individual (e.g., natural disaster, pandemic, etc.).

Reassessment a. The Case Manager shall commence a regularly scheduled Reassessment at least one (1) but no more than three (3) months before the required completion date. The Case Manager shall complete a Reassessment of a Member within twelve (12) months of the initial individual assessment or the most recent Reassessment. A Reassessment shall be completed within 10 days if the individual’s condition changes or if required by program criteria.

b. The Case Manager shall update the information provided at the previous Level of Care Screen in the Department prescribed system within five business days of completion of the Assessment.

c. Reassessment shall include, but not be limited to, the following activities:

i. Assess the individual’s functional status face-to-face, in the location where the person currently resides. Upon Department approval, Assessment may be completed by the Case Manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the Case Manager or individual (e.g., natural disaster, pandemic, etc.).

ii. Review Person-Centered Support Plan, service agreements and provider contracts or agreements;

iii. Evaluate effectiveness, appropriateness and quality of services and iv. Verify continuing Medicaid eligibility, other financial and program eligibility;

v. Annually, or more often if indicated, complete a new Person- Centered Support Plan and service agreements;

vi. Inform the individual’s medical provider of any changes in the individual’s needs;

vii. Maintain appropriate documentation, including type and frequency of Long-Term Services and Supports the individual is receiving for certification of continued program eligibility, if required by the program;

viii. Refer the individual to community resources as needed and develop resources for the individual if the resource is not available within the individual’s community; and ix. Submit appropriate documentation for authorization of services, in accordance with program requirements.

x. In order to assure quality of services and supports and the health and welfare of the individual, the Case Manager shall ask for permission from the individual to observe the individual’s residence as part of the Reassessment process, but this shall not be compulsory of the individual.

d. The Case Management Agency shall be responsible for completing Reassessments of Members receiving care in a nursing facility. A Reassessment shall be completed if the nursing facility determines there has been a significant change in the resident's physical/medical status, if the individual requests a Reassessment or if the Case Manager assigns a definite end date. The nursing facility shall be responsible to send the Case Management Agency a Referral for a new Assessment as needed.

At the time of completing the Reassessment, unless the individual opposes community living, the Case Manager shall provide options counseling on community-based services to the individual to determine if they desire to live in the community with additional support. 8.7202.G Waitlist Management 1. When the total capacity for enrollment or the total appropriation authorizations by the Colorado General Assembly has been met, the Department shall maintain one statewide waiting list for individuals eligible for the HCBS-DD waiver.

a. The Department of Health Care Policy and Financing shall maintain at least two categories of the one waitlist to include statuses of: As Soon As Available or Safety Net.

i. As Soon As Available (ASAA) means the individual has requested enrollment as soon as available.

ii. Safety Net (SN) means the individual does not currently need or want adult services, but requests to be on the waiting list in case a need arises. This category includes individuals who are not yet eligible for adult programs due to not having reached their 18th birthday.

b. Date Specific in a waitlist means the individual does not need services at this time but has requested enrollment at a specific future date. This category includes individuals who are not yet eligible for adult programs due to not having reached their 18th birthday.

The name of an individual eligible for the HCBS-DD waiver program shall be placed on the waiting list by the Case Management Agency making the eligibility determination if the Member meets DD waiver target criteria.
When an individual is placed on the waiting list for HCBS-DD Waiver Services, a written Notice of Action shall be sent to the individual or the individual’s legal Guardian that includes information regarding individual rights and the Member’s right to appeal pursuant to Section 8.057 et seq.
The placement date used to establish an individual’s position on a waiting list shall be:

a. The date on which the individual was initially determined to have a Developmental Disability by the Case Management Agency; or b. The fourteenth (14) birth date if a child is determined to have a Developmental Disability by the Case Management Agency prior to the age of fourteen.

As openings become available in the HCBS-DD Waiver program in a Defined Service Area, that Case Management Agency shall report that opening to Health Care Policy and Financing.
Individuals whose names are on the waiting list shall be considered for enrollment to the HCBS-DD waiver in order of placement date on the waiting list.

Exceptions to this requirement shall be limited to:

a. An emergency situation where the health and safety of an individual or others is endangered, and the emergency cannot be resolved in another way and if the individual meets DD waiver Target Criteria. Individuals at risk of experiencing an emergency are defined by the following criteria:

i. Homeless: the individual will imminently lose their housing as evidenced by an eviction notice; or their primary residence during the night is a public or private facility that provides temporary living accommodations; or they are experiencing any other unstable or non-permanent housing situation; or they are discharging from prison or jail; or they are in the hospital and do not have a stable housing situation to go to upon discharge.

ii. Abusive or neglectful situation: the individual is experiencing ongoing physical, sexual or emotional abuse or neglect in the individual’s present living situation and the individual’s health, safety or well-being is in serious jeopardy.

iii. Danger to others: the individual's behavior or psychiatric condition is such that others in the home are at risk of being hurt by the individual and sufficient supervision to ensure safety of the individual in the community cannot be provided by the current caretaker.

iv. Danger to self: the individual's medical, psychiatric or behavioral challenges are such that the individual is seriously injuring/harming themself or is in imminent danger of doing so.

v. Loss or Incapacitation of Primary Caregiver: the individual’s primary caregiver is no longer in the individual’s primary residence to provide care; or the primary caregiver is experiencing a chronic, long-term, or life-threatening physical or psychiatric condition that significantly limits the ability to provide care; or the primary caregiver is age 65 years or older and continuing to provide care poses an imminent risk to the health and welfare of the individual or primary caregiver; or, regardless of age and based on the recommendation of a professional, the primary caregiver cannot provide sufficient supervision to ensure the individual’s health and welfare.

Enrollments are reserved to meet statewide priorities that may include:

a. An individual who is eligible for the HCBS-DD Waiver and is no longer eligible for services in the foster care system due to an age that exceeds the foster care system limits, b. Individuals who reside in long-term care institutional settings who are eligible for the HCBS DD Waiver and have requested to be placed in a community setting, c. Members enrolled in a Home and Community-Based Services CES or CHRP waivers who are under 18 years of age and are eligible for the HCBS-DD waiver.

d. Individuals who are in an emergency situation.

Enrollments shall be authorized for individuals based on the criteria set forth by the General Assembly in appropriations when applicable.

a. An individual shall accept or decline the offer of enrollment within 30 calendar days from the date the enrollment was offered. Reasonable effort, such as a second notice or phone call, shall be made to contact the individual, family, legal Guardian, or other interested party.

b. Upon a written request of the individual, family, legal Guardian, or other interested party the Case Management Agency may grant an additional 30 calendar days to accept or decline an enrollment offer. The delineation reason shall be recorded in the Department’s Information Management System within 10 business days.

c. If an individual does not respond to the offer of enrollment within the time set forth in subsection 2 and/or 3 above, the offer is considered declined and the individual shall maintain their position on the waiting list as determined by their placement date but will be moved to safety net status until the Member is willing or able to accept an enrollment. The Member may notify their Case Management Agency of their desire to move back to a status of As Soon As Available (ASAA) when they would be ready to accept an enrollment into the DD waiver.

d. The Case Management Agency shall record all waiting list communications, enrollments, and declinations in the Department's Information Management System within 10 business days.

e. The Case Management Agency shall record an annual waiting list review within the Department's Information Management System within 10 business days or as directed by the Department. 8.7202.H Telehealth and Delivery 1. Members eligible to use HCBS Telehealth are those enrolled in the waivers and services as defined in this rule at Section 8.7100.

The Case Management Agency shall ensure the use of HCBS Telehealth is the choice of the Member through the Person-Centered Support Planning process by indicating the Member’s choice to receive HCBS Telehealth in the Department prescribed IT system.
Through the Person-Centered Support Planning process, the Case Management Agency shall identify and address the benefits and possible detriments to Members choosing to use HCBS Telehealth for service delivery.
HCBS Telehealth delivery must be prior authorized and documented in the Member’s Person-Centered Support Plan.
Telehealth as a service delivery method for authorized HCBS Waiver Services, shall not interfere with any individual rights or be used as any part of a Rights Modification plan. 8.7202.I Utilization Review 1. The Case Manager shall complete a Utilization Review at quarterly monitoring and as needed.
The Case Manager shall immediately report, to the appropriate Agency, any information which indicates an overpayment, incorrect payment or mis-utilization of any public assistance benefit and shall cooperate with the appropriate Agency in any subsequent recovery process, in accordance with Section 8.076. 8.7202.J Person-Centered Support Coordination 1. Service and support coordination shall be the responsibility of the Case Management Agencies. Service and support coordination shall be provided in partnership with the Member receiving services, the Parents of a minor, and legal Guardians.

a. The Member shall designate a Member Identified Team which may include but not be limited to: a LTSS Representative, family members, or individuals from public and private agencies to the extent such partnership is requested by the Member.

Service and support coordination shall assist the Member Determine the individual’s functional capacity to ensure:

a. A Person-Centered Support Plan is developed, utilizing necessary information for the preparation of the Person-Centered Support Plan and using the Member Identified Team process;

b. Facilitating access to and provision of services and supports identified in the Person-Centered Support Plan;

c. The coordination and continuity of services and supports identified in the Person-Centered Support Plan for continuity of service provision; and d. The Person-Centered Support Plan is reviewed periodically, as needed, to determine the results achieved, if the needs of the Member are accurately reflected in the Person-Centered Support Plan, whether the services and supports identified in the Person- Centered-Support Plan are appropriate to meet the person's needs, and what actions are necessary for the plan to be successfully implemented.

Person-Centered Support Plan Development a. The Case Manager shall work with individuals to design and update Person-Centered Support Plans that address individuals’ goals and assessed needs and preferences;

b. The Case Manager shall share a copy of the completed Person-Centered Support Plan with all providers that are providing services under the plan within 15 working days after the plan is completed or updated.

Remediation a. The Case Manager shall identify, resolve, and to the extent possible, establish strategies to prevent Critical Incidents and problems with the delivery of services and supports.
The Case Manager shall develop the Person-Centered Support Plan for individuals not residing in nursing facilities within fifteen (15) working days after determination of program eligibility.
The Case Manager shall:

a. Address the functional needs identified through the individual Assessment in the Person-Centered Support Plan;

b. Offer informed choices to the individual regarding the services and supports they receive and from whom, as well as the documentation of services needed, including type of service, specific functions to be performed, duration and frequency of service, type of provider and services needed but that may not be available;

c. Support Members in provider selection to the degree and extent that the Member or Family requests or requires for successful placement with a direct service provider;

d. Include strategies for solving conflict or disagreement within the process, including clear conflict-of-interest guidelines for all planning participants;

e. Reflect cultural considerations of the individual and be conducted by providing information in Plain Language and in a manner that is accessible to individuals with disabilities and individuals who have limited English proficiency;

b. Formalize the Person-Centered Support Plan agreement, including appropriate physical or digital signatures, in accordance with program requirements;

c. Contain prior authorization for services, in accordance with program directives;

d. Contain prior authorization of Adult Long-Term Home Health Services, pursuant to Sections 8.520.8;

e. Include a method for the individual to request updates to the plan as needed;

f. Include an explanation to the individual of procedures for lodging Complaints against Case Management Agencies and providers;

g. Include an explanation to the individual of Critical Incident procedures; and h. Explain the appeals process to the individual.

The Case Manager shall provide necessary information and support to ensure that the individual directs the process to the maximum extent possible and is enabled to make informed choices and decisions and shall ensure that the development of the Person-Centered Support Plan:

a. Occurs at a time and location convenient to the Member;

b. Is led by the individual, the individual’s Parent’s (if the individual is a minor), and/or the individual’s Legally Authorized Representative;

c. Includes people chosen by the individual;

d. Addresses the goals, needs and preferences identified by the individual throughout the planning process;

e. Includes the arrangement for services by contacting service providers, coordinating service delivery, negotiating with the provider and the individual regarding service provision and formalizing provider agreements in accordance with program rules; and f. Includes Referral to community resources as needed and development of resources for the individual if a resource is not available within the individual’s community.

Prudent purchase of services:

a. The Case Manager shall arrange services and supports using the most cost-effective methods available in light of the individual’s needs and preferences.

b. When family, friends, volunteers or others are available, willing and able to support the individual at no cost, these supports shall be utilized before the purchase of services, providing these services adequately meet the individual’s needs.

c. When public dollars must be used to purchase services, the Case Manager shall encourage the individual to select the lowest-cost provider of service when quality of service is comparable.

d. The Case Manager shall assure there is no duplication in services provided by Long-Term Services and Supports programs and any other publicly or privately funded services.

Individuals and/or their Guardians and other Legally Authorized Representatives, as appropriate, who enroll in HCBS Waiver Services or CFC Services shall have the freedom to choose from qualified Provider Agencies in accordance with

Section 8.7400, as applicable.

Case Managers shall follow all documented rules, regulations, policies and operational guidance in these rules and set forth by the Department for Case Management and Home and Community-Based Services.
Case Managers shall support Members in identifying qualified Provider Agencies and assist them in determining the best fit for their needs and service plan approvals, including but not limited to: setting up tours, communicating with potential providers about the Member’s needs or soliciting entrance to programs on behalf of the Member, depending on Member preferences and needs.
Case Managers shall follow all documented policy and operational guidance from the Department for Case Management services including but not limited to:

a. Home modification b. Vehicle modification c. Organized Health Care Delivery System d. Consumer-Directed Attendant Supports Services e. In-Home Support Services f. Nursing Facilities g. Transition Services h. Long Term Home Health i. Private Duty Nursing 8.7202.K Monitoring 1. Case Management Agencies shall be responsible to monitor the overall provision of services and supports authorized by Case Managers to ensure the rights, health, safety and welfare of Members, quality services, and that service provision practices promote Member’s ability to engage in self-determination, self-representation, and self-advocacy. Monitoring is required for all waivers in accordance with federal waiver requirements and §§ 25.5-6-1701 — 25.5-6- 1709. §§ 25.5-6-1702(3)

Monitoring activities shall include but not be limited to the following:

a. Case Managers shall monitor service providers and the delivery of services and supports identified within the Person-Centered Support Plan and the Prior Authorization Request (PAR) for potential rights violations, risks to health, safety and welfare; changed needs, issues with utilization or provision of services, quality of service deliver, or issues with statutory or legal compliance. This may include, but is not limited to:

i. Reviewing and following up on Incident reports, individualized service plans, Rights Modifications, and other provider documentation ii. Observing the environment(s) where services are being provided iii. Contacting Provider Agency staff about service provision and Member satisfaction iv. Contacting Members and/or their Legally Authorized Representative about service provision and Member satisfaction b. The Case Manager shall contact service provider(s) to perform monitoring no less frequently than every 6 months.

c. The Case Manager shall, at a minimum, perform quarterly monitoring contacts with the Member, as defined by the Member’s certification period start and end dates.

i. At a minimum, Member monitoring contacts shall include the 1) A review of the Member’s Level of Care Screen, Needs Assessment and Person-Centered Support Plan, with the Member, to determine whether their Level of Care or needs have changed, or needs are not being met.

A review of the Member’s service utilization to determine whether services are being delivered/utilized as outlined in the Person-Centered Support Plan /Prior Authorization Request (PAR).
An evaluation of the Member’s satisfaction with services, to include whether service provision practices promote selfdetermination, self-representation, and self-advocacy and are person-centered.
An evaluation of the Member’s health, safety and welfare, including respect for individual rights.
A review of the Member’s goals, choices and preferences a) An in-person monitoring contact is required at least one (1) time during the Person-Centered Support Plan certification period not to include the annual Long-Term Services and Supports Level of Care Reassessment. The Case Manager shall ensure the one (1) required in-person monitoring contact occurs, with the Member physically present, in the Member’s place of residence or location of services. Case Managers shall contact service providers and Members to coordinate the monitoring.

ii. The Case Manager shall contact service provider(s) to perform monitoring no less frequently than every six (6) months.

iii. Upon Department approval in advance, contact may be completed by the Case Manager at an alternate location, via the telephone or using virtual technology methods.

iv. Such approval may be granted for situations in which in- person face-to-face meetings would pose a documented safety risk to the Case Manager or individual (e.g. natural disaster, pandemic, etc.).

The Case Manager shall perform three monitoring contacts each certification period in addition to the one required inperson monitoring. The three additional monitoring contact shall be either in-person, on the phone, or through other technological modality based on the Member preference of engagement. Additional monitoring contacts may also be performed based on any Critical Incident Reports or other needs that arise throughout the service plan year.

v. Contacts shall be directly with the Member and/or their Legally Authorized Representative.

vi. Contacts shall be bidirectional, i.e., questions and responses, conversation between the Case Manager and the Member and/or their Legally Authorized Representative; letters, emails or voicemails to the Member and/or their Legally Authorized Representative shall not constitute a monitoring contact for purposes of this requirement.

The Case Manager shall take appropriate action to remediate any risks or issues identified during monitoring activities regarding the rights, health, safety and welfare of the Member or service provision or utilization.

a. The identified issue(s) shall be documented in the Information Management System.

b. The action(s) taken to remediate identified issue(s) shall be documented in the Information Management System.

The following criteria may be used by the Case Manager to determine the individual’s level of Case Management involvement needed:

a. Member preference;

b. Availability and level of involvement of family, volunteers, or other c. Overall level of physical capabilities;

d. Mental status or cognitive capabilities;

e. Duration of disabilities or conditions;

f. Length of time supports have been in place;

g. Stability of providers/unpaid supports;

h. Whether the Member is in a Crisis or acute situation;

i. The Member’s perception of need for services;

j. The Member’s familiarity with navigating the system/services;

k. The Member’s move to a new housing alternative; and l. Whether the individual was discharged from a hospital or Nursing Facility. 8.7202.L Critical Incident Reporting 1. Case Managers shall report Critical Incidents within 24 hours of notification within the Information Management System.

Critical Incident reporting is required when the following occurs a. Injury/Illness;

b. Missing Person;

c. Criminal Activity;

d. Unsafe Housing/Displacement;

e. Death;

f. Medication Management Issues;

g. Other High-Risk Issues;

h. Allegations of Abuse, Mistreatment, Neglect, or Exploitation;

i. Damage to the Consumer’s Property/Theft.

Allegations of abuse, mistreatment, neglect and exploitation, and injuries which require emergency medical treatment or result in hospitalization or death shall be reported immediately to the Agency administrator or designee.
Case Managers shall comply with mandatory reporting requirements set forth at Sections 18-6.5-108, 19-3-304, and 26-3.1-102, C.R.S.
Each Critical Incident Report must include:

a. Incident type i. Mistreatment, Abuse, Neglect or Exploitation (MANE) as defined at

Section 19-1-103, 26-3.1-101, 16-22-102 (9), and 25.5-10-202 ii. Non-Mane: A Critical Incident, including but not limited to, a category of criminal activity, damage to a consumer’s property, theft, death, injury, illness, medication management issues, missing persons, unsafe housing or displacement, other high risk issues.

b. Date and time of Incident;

c. Location of Incident, including name of facility, if applicable;

d. Individuals Involved;

e. Description of Incident, and f. Resolution of Incident, if applicable.

The Case Manager shall complete required follow up activities and reporting in the Information Management System within assigned timelines.
The Case Manager shall be responsible to report suspected crimes against a Member to protective services. In the event, at any time throughout the Case Management process, the Case Manager suspects an individual to be a victim of mistreatment, abuse, neglect, exploitation or a harmful act, the Case Manager shall immediately refer the individual to the protective services section of the county department of social services of the individual's county of residence and/or the local law enforcement agency. The Agency shall ensure that employees and Contractors obligated by statute, including but not limited to,

Section 19-13-304, C.R.S., (Colorado Children's Code), Section 18-6.5-108, C.R.S., (Colorado Criminal Code - Duty To Report A Crime), and Section 26-3.1- 102, C.R.S., (Human Services Code - Protective Services), to report suspected abuse, mistreatment, neglect, or exploitation, are aware of the obligation and reporting procedures. 8.7202.M Case Management Agency Transfers 1. Case Management Agencies shall complete the following procedures in the event a Member transfers from one Case Management Agency Defined Service Area to another Case Management Agency Defined Service Area.

Transfer activities shall include, at minimum, a. Initial contact by the originating Case Management Agency with the receiving Case Management Agency in the Case Management Agency Defined Service Area of the Member.

b. Determination of transfer date.

i. Determination of transfer date shall not be delayed based on receipt of mailed, electronic, or paper records.

c. Necessary access and permissions in all appropriate Department prescribed systems.

d. Both agencies, sending and receiving, must verify and document transfer request sent and transfer request received.

e. All transfer activities shall be documented and recorded in the Department’s prescribed system.

f. The originating Case Management Agency shall notify the originating county department of social services eligibility enrollment specialist of the individual’s plan to transfer and the transfer date, and the eligibility enrollment specialist shall comply with the transfer requirements set forth in Section 8.100.3.C. The receiving Case Management Agency shall coordinate the transfer with the eligibility enrollment specialist of the receiving county.

The transferring Case Management Agency shall contact the receiving Case Management Agency by telephone or email and give notification that the individual is planning to transfer, negotiate a transfer date and provide all information necessary to ensure that the receiving Case Management Agency is able to meet the individual's needs.
Both agencies, sending and receiving, shall verify and document the transfer request sent and transfer request received.
The transferring Case Management Agency shall notify the originating county department of social services eligibility enrollment specialist of the individual’s plan to transfer and the transfer date, and eligibility enrollment specialist shall follow rules described in Section 8.100.3.C. The receiving Case Management Agency shall coordinate the transfer with the eligibility enrollment specialist of the new county.
Prior to transfer, the transferring Case Management Agency shall make available to the receiving Case Management Agency the individual’s case records in the 7. If the individual is moving from one Case Management Agency Defined Service Area to another Case Management Agency Defined Service Area to enter an Alternative Care Facility or Nursing Facility, the transferring Case Management Agency shall forward copies of the individual’s records to the facility prior to the individual’s admission to the facility, in accordance with Section 8.7202.M.
To ensure continuity of services and supports, the originating Case Management Agency and the receiving Case Management Agency shall coordinate the arrangement of services prior to the individual’s relocation to the receiving Case Management Agency’s defined service area and within ten (10) working days after notification of the individual’s relocation.
If a failure of Case Management Agency transfer results in a break in payment authorization, the Case Management Agencies shall be subject to Payment Liability as outlined in 10 CCR 2505-10 8.7202.Z.
The receiving Case Management Agency shall complete a face-to-face meeting with the individual in the individual’s residence and a case summary update within ten (10) working days after the individual’s relocation, in accordance with Assessment procedures for individuals served by Case Management Agencies.

Upon Department approval, the meeting may be completed using virtual technology methods or may be delayed. Such approval may be granted for situations in which in-person observation would pose a documented safety risk to the Case Manager or individual (e.g., natural disaster, pandemic, etc.)

The receiving Case Management Agency shall review the Person-Centered Support Plan and the Level of Care Screen and change or coordinate services and providers as necessary. The originating Case Management Agency shall not close out the case until face-to-face contact is verified.
If indicated by changes in the Person-Centered Support Plan, the receiving Case Management Agency shall revise the Person-Centered Support Plan and prior authorization forms as identified during the review.
Within thirty (30) calendar days of the individual’s relocation, the receiving Case Management Agency shall forward to the Department, or its fiscal agent, revised forms as required by the Member’s approved publicly funded program(s). 8.7202.N Case Management Agency Member Exceptions Process 1. Members, and their Legally Authorized Representative, may request to be served by a Case Management Agency outside of their defined service area with the approval of the Case Management Agency outside their defined service area and Department oversight.
The Case Management Agency must be willing and able to incur all costs to meet all regulatory and contractual requirements for the Members served outside their defined service areas. The Department does not provide additional funding for any travel costs incurred by a Case Management Agency that is serving a Member enrolled in any HCBS Waiver or State General Fund programs outside of the Agency's approved Defined Service Area.
The Case Management Agency must be willing and able to perform monitoring and follow up in the same manner and frequency as required for a Member within the defined service area. The Department shall not allow an exception to inperson Assessments or monitoring visit requirements based solely on travel time.
Case Management Agency policies and procedures must outline how the Case Management Agency plans to ensure all regulatory and contractual requirements can be met for Members receiving Case Management services from a Case Management Agency outside their defined service area.
The Case Management Agency shall follow the process approval and reporting requirements set forth by the Department for Members being served outside their defined service area.
If a person requires a transfer to a new Case Management Agency for any reason, both Case Management Agencies must follow the transfer process in

Section 8.7202.M to maintain Member eligibility and services.

Case Management Agencies shall have a policy and procedure to grant Members a choice of Case Manager at their Agency. 8.7202.O State General Fund Transfers 1. When an individual enrolled in, or on the waiting list for, State General Fund program and moves to another Case Management Agency’s defined service area and wishes to transfer their State General Fund program, the following procedure shall be followed:
All transfer activities outlined in 8.7202.M shall apply to State General Fund Programs.

a. The originating Case Management Agency shall send the State General Fund Individual Person-Centered Support Plan to the receiving Case Management Agency, where the receiving Case Management Agency shall determine if appropriate State General Fund funding is available or if the individual will need to be placed on a waiting list by reviewing the State General Fund Individual Person-Centered Support Plan in the Department’s prescribed system. The receiving Case Management Agency decision of service availability will be communicated in the following way:

b. The receiving Case Management Agency shall notify the individual seeking transfer of its decision by the individual’s preferred method, no later than ten (10) business days from the date of the request; and c. The receiving Case Management Agency shall notify the originating Case Management Agency of its decision by U.S. Mail, phone call or email of its decision no later than ten (10) business days from the date of the request.

i. The decision shall clearly state:

The receiving Case Management Agency’s decision 2) The basis of the decision; and 3) The contact information of the assigned Case Manager or waiting list manager.

ii. The originating Case Management Agency shall contact the individual requesting the transfer no more than 5 days from the date the decision was received to:

Ensure the individual understands the decision; and 2) Support the individual in making a final decision about the transfer.

d. After the transfer, there shall be a transfer meeting in-person when possible, or by phone if geographic location or time does not permit, within fifteen (15) business days of when the notification of service determination is sent out by the receiving Case Management Agency. The transfer meeting must include but is not limited to the transferring individual and the receiving Case Manager. Any additional attendees must be approved by the transferring individual.

e. The receiving Case Management Agency must ensure that:

i. The transferring individual meets his or her primary contact of the receiving Case Management Agency.

ii. The individual is informed of the date when Services and Supports will be transferred, when Services and Supports will be available, and the length of time the Supports and Services will be available.

iii. The receiving Case Management Agency Case Manager shall have an in-person meeting with the individual to review and update the Person-Centered Support Plan, prior to the Supports and Services being authorized. Upon Department approval, contact may be completed by the Case Manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the Case Manager or individual (e.g. natural disaster, pandemic, etc.). 8.7202.P Informed Consent for Rights Modifications 1. The Case Manager is responsible for following the HCBS Settings Final Rule, as codified at Section 8.7001.B, and shall ensure compliance with all requirements of Section 8.7001.B, and shall obtain, maintain, and distribute a signed Informed Consent for any Rights Modification pursuant to Section 8.7001.B.4 per Department requirements as set forth in rule, other issuances, and trainings.

The Case Manager shall arrange for meetings to discuss proposed Rights Modifications consistent with the timelines in Sections 8.7001.B.4.g-h..
Before requesting or obtaining Informed Consent, the Case Manager shall make the offers required under 8.7001.B.4.d.i to the Member and record the Member’s responses in the Department prescribed Information Management System.
The Case Management Agency’s Case Manager is responsible for obtaining Informed Consent and other documentation supporting any Rights Modifications, maintaining these materials in the prescribed Department system as a part of the Person-Centered Support Plan, and distributing them to any providers implementing the Rights Modifications. 8.7202.Q Human Rights Committees 1. Each Case Management Agency shall establish at least one Human Rights Committee (HRC) as a third party mechanism to safeguard the rights of members in waivers targeted to individuals with Intellectual and Developmental Disabilities. The Human Rights Committee is an advisory and review body to the administration of each Case Management Agency.
The Human Rights committee shall be constituted as required by Section 25.5- 10-209(2)h, C.R.S.
If a consultant to the Case Management Agency, regional center, or Provider Agency serves on the Human Rights Committee, procedures shall be developed related to potential conflicts of interest.
The Case Management Agency shall orient members regarding the duties and responsibilities of the Human Rights Committee.
The Case Management Agency shall provide the Human Rights Committee with the necessary staff support to facilitate its functions.
Each Provider Agency shall make referrals as required in rules and regulations for review by the Human Rights Committee(s) in the manner required by 7. The recommendations of the Human Rights Committee shall become a part of the Case Management Agency’s record as well as a part of the individual's master record.
The Human Rights Committee shall develop operating procedures which include, but are not limited to, Human Rights Committee responsibilities for the committee's organization, Department required universal documents, the review process, mitigation of potential conflicts of interest, and provisions for recording dissenting opinions of committee members in the committee's recommendations.
The Human Rights Committee shall establish and implement operating and review procedures to determine that the practices of the Case Management Agency is in compliance with Section 25.5-10, C.R.S., are consistent with the mission, goals and policies of the Department, and Case Management Agency and ensure that:

a. Informed Consent is obtained when required from the person receiving services, the Parent of a minor, or the Guardian or other Legally Authorized Representative as appropriate;

b. Modifications of the rights of members occurs only within procedural safeguards as stipulated in Section 8.7001 and that continued modification of such rights is reviewed by the individual, their Guardian or other Legally Authorized Representative, and the rest of the Member Identified Team at a frequency decided by the team, but not less than every six months;

c. Psychotropic medications and other prescribed medications used for the

purpose of modifying the behavior of Members receiving services through the Intellectual and Developmental Disability waivers are used in accordance with the requirements of Section 8.7416, and are monitored by the Human Rights Committee on a regular basis; and, d. Allegations of mistreatment, abuse, neglect and exploitation are investigated, and the investigation report is reviewed.

RESEARCH

a. Any experimental research performed by or under the supervision of the Case Management Agency, the Community Centered Board, service agency or Regional Center shall be governed by policies/procedures which shall:

i. Require adherence to ethical and design standards in the conduct of research;

ii. Require review by the Human Rights Committee;

iii. Address the adequacy of the research design;

iv. Address the qualifications of the individuals responsible for coordinating the project;

v. Address the benefits of the research in general;

vi. Address the benefits and risks to the participants;

vii. Address the benefits to the agency;

viii. Address the possible disruptive effects of the project on agency operations;

ix. Require obtaining informed consent from participants, their guardians or the parents of a minor. Such consent may be given only after consultation with:

a. The member selected team; and, b. A developmental disabilities professional not affiliated with the service agency from which the person receives services;

x. Require procedures for dealing with any potentially harmful effects that may occur in the course of the research activities.

b. No person shall be subjected to experimental research or hazardous treatment procedures if the person implicitly or expressly objects to such procedures or such procedures are prohibited. 8.7202.R Denials/Discontinuations/Adverse Actions 1. Individuals seeking or receiving services shall be denied or discontinued from services provided pursuant to publicly funded programs for which the Case Management Agency provides case management services if they are determined ineligible for any of the reasons below. Individuals shall be notified of any of the adverse actions and appeal rights as follows:

a. Financial Eligibility i. The eligibility enrollment specialist from the county department of social services shall issue to the Member a Long Term Care Waiver Program Notice of Action (LTC-803) regarding denial or discontinuation of services for reasons of Financial Eligibility which shall inform the individual of appeal rights in accordance with Section 8.057.

ii. If the individual or Member is found to be financially ineligible for HCBS or Long-Term Services and Supports benefits, the Case Management Agency shall issue to the Member a Long Term Care Waiver Program Notice of Action (LTC-803) that informs the individual of their appeal rights in accordance with Section 8.057.

The Case Manager shall not attend the appeal hearing for a denial or discontinuation based on Financial Eligibility, unless subpoenaed, or unless requested by the Department.

b. Functional Eligibility and Target Group i. The Case Management Agency shall notify the individual of the denial or discontinuation and appeal rights by sending the Long- Term Care Waiver Program Notice of Action and shall attend the appeal hearing to defend the denial or discontinuation, when:

The individual does not meet the Functional Eligibility requirement for HCBS waiver and Long-Term Services and Supports Programs or nursing facility admissions or CFC Level of Care requirements outlined in Section 8.7604; or 2) The individual does not meet the Target Group Criteria as specified by the HCBS waivers; or 3) The individual failed to submit the required paperwork, documents or any other part of the eligibility criteria and/or application within 90 days from Level of Care Screen.

c. Receipt of Services i. The Case Management Agency shall notify the individual of the denial or discontinuation and appeal rights by sending the Long- Term Care Waiver Program Notice of Action and shall attend the appeal hearing to defend the denial or discontinuation, when:

The individual has not received an HCBS Waiver service for one calendar month,;
The individual does not keep or schedule an appointment for Assessment or monitoring two (2) times in a one month consecutive period as required by these regulations.

d. Institutional Status i. The Case Management Agency shall notify the individual of denial or discontinuation by sending the Long-Term Care Waiver Program Notice of Action when the Case Manager determines that the individual does not meet the following program eligibility 1) The individual is not eligible to receive HCBS services while a resident of a nursing facility, hospital, or other Institution; or 2) The individual who is already a recipient of program services enters a hospital for treatment, and hospitalization continues for thirty (30) days or more.

The Long-Term Care Waiver Program Notice of Action shall be completed in the Information Management System for all applicable programs at the time of initial eligibility, when there is a significant change in the individual’s payment or services, an adverse action, and at the time of discontinuation.
In the event the individual appeals a denial or discontinuation action, except for reasons related to Financial Eligibility, the Case Manager shall attend the appeal hearing to defend the denial or discontinuation action.
The Case Management Agency shall provide the Long-Term Care Waiver Program Notice of Action form to Applicants and individuals within 11 business days regarding their appeal rights in accordance with Section 8.057 et seq. when a. The individual or Applicant is determined to not have a Developmental Disability, b. The individual or Applicant is found ineligible for Long-Term Services and Supports.

c. The individual or Applicant is determined eligible or ineligible for placement on a waiting list for Long-Term Services and Supports, d. An adverse action occurs that affects the individual’s or Applicant’s waiver enrollment status, e. The individual or Applicant voluntarily withdraws.

The Case Management Agency shall appear and defend its decision at the Office of Administrative Courts as described in Section 8.057 et seq. when the Case Management Agency has made a denial or adverse action against an individual.
The Case Management Agency shall notify the providers in the individual’s service plan within one (1) business day of the discontinuation or adverse action.
The Case Manager shall notify all providers on the Person-Centered Support Plan no later than within one (1) business day of discontinuation or adverse action.
The Case Manager shall follow procedures to close the individual’s case in the Information Management System within one (1) business day of discontinuation for all CFC or HCBS Programs 9. The Case Management Agency shall notify the County Department of Human/Social Services income maintenance technician within ten (10) business days of an adverse action that affects Medicaid Financial Eligibility.
The Case Management Agency shall notify the county eligibility enrollment specialist of the appropriate county department of social services:

a. At the same time it notifies the individual seeking or receiving services of the adverse action;

b. When the individual has filed a written appeal with the Case Management Agency; and c. When the individual has withdrawn the appeal or a final Agency decision has been entered.

The Applicant or individual shall be informed of an adverse action if the individual or Applicant is determined ineligible and the following:

a. The individual or Applicant is detained or resides in a correctional facility, b. The individual or Applicant enters an institute for mental health with a duration that continues for more than thirty (30) days.

The Case Management Agency shall refer individuals to the Medicaid Buy-In program who do not qualify for waivers due to Financial Eligibility.
Case Management Agencies shall document in the Information Management System all voluntary withdrawals from all programs. 8.7202.S Case Management Support to Members and Families Receiving Services Related to Dispute Resolution with Provider Agencies 1. Every Case Management Agency shall have procedures which comply with requirements as set forth in these rules and Section 25.5-10- 212, C.R.S., for resolution of disputes between Members or individuals and Provider Agencies involving individuals or Members. This dispute resolution does not supersede or negate the requirement for a Long Term Care Waiver Program Notice of Action (LTC-803). Case Management Agency dispute resolution procedures shall include but not limited to the following circumstances:

a. The individual or Member is no longer eligible for services or supports;

b. Services or supports are to be terminated; or, c. Services set forth in the Person-Centered Support Plan are to be changed or reduced, or denied.

The procedure shall contain an explanation of the process to be used by Members or Applicants for services or Parents of a minor, Guardians and/or other Legally Authorized Representatives in the event that they are dissatisfied with the decision or action of the regional center or Provider Agency.
The dispute resolution procedure shall be stated in writing, in English.

Interpretation in native languages other than English and through such modes of communication as may be necessary for the Member’s accommodation needs shall be made available upon request.

a. The procedure shall be provided, orally and in writing, to all Members or Applicants for services and Parents of a minor, Guardian, and/or other Legally Authorized Representative at the time of application, at the time the individualized plan is developed, any time changes in the plan are contemplated, and upon request by the above named persons.

b. The procedure shall state that use of the dispute resolution procedure shall not prejudice the future provision of appropriate services or supports to the individual in need of and/or receiving services.

c. The procedure shall state that an individual shall not be coerced, intimidated, threatened or retaliated against because that individual has exercised his or her right to file a Complaint or has participated in the dispute resolution process.

The procedure of the Case Management Agency shall stipulate that notice of action proposed as defined in Section 8.7202.R shall be provided to the Member/Applicant, and to the person's Parents if a minor, Guardian and/or other Legally Authorized Representative at least fifteen (15) days prior to the date actions enumerated in Section 8.7202.S.1 become effective. The above named persons may dispute such action(s) by filing a Complaint with the Agency initiating the action. Upon such Complaint, the procedures set forth by the Case Management Agency shall be initiated.
The procedure of the Case Management Agency shall provide the opportunity for resolution of any dispute through an informal negotiation process which may be waived only by mutual consent. Mediation by the Case Manager could be considered as one means to informal negotiation if both parties voluntarily agree to this process.
The opportunity for resolution of a dispute through informal negotiation shall include the scheduling of a meeting of all parties or their representatives within fifteen (15) days of the receipt of the Complaint.
After opportunities for informal negotiation of the dispute have been attempted or mutually waived, either party may request that the dispute resolution process set forth by the Case Management Agency and the following provisions shall be initiated. Parent(s) or Guardian of a minor, age birth to three years, may utilize the dispute resolution process specified under the requirements of the Procedural Safe Guards for early intervention services pursuant to the Individuals with Disabilities Education Act.
The dispute resolution procedures of the Case Management Agency shall, at a minimum, afford due process by providing for:

a. The opportunity of the parties to present information and evidence in support of their positions to an impartial decision maker. The impartial decision maker may be the director of the Agency taking the action or their designee. The impartial decision maker shall not have been directly involved in the specific decision at issue;

b. Timely notification of the meeting (at least ten days prior) to all parties unless waived by the objecting parties;

c. Representation by counsel, Legally Authorized Representative, or another individual if the objecting party desires;

d. The opportunity to respond to or question the opposing position;

e. Recording of the proceeding by electronic device or reporter;

f. Issuance of a written decision setting forth the reasons therefore within fifteen (15) days of the meeting;

g. Notification that if the dispute is not resolved, the objecting party may request that the Executive Director of the Department or their designee review the decision; and, h. Notification to the Department by the Case Management Agency of all disputes proceeding and the decision issued.

The dispute resolution procedure of the Department shall be as follows:

a. A request to the Executive Director of the Department to review the outcome of the dispute resolution process shall be submitted to the Department within fifteen (15) working days from which the written decision was postmarked;

b. The request for review shall also contain a statement of the matters in dispute and all information or evidence which is deemed relevant to a thorough review of the matter. The Case Management Agency shall be afforded the opportunity to respond within fifteen (15) working days;

c. The Executive Director of the Department or designee shall have the right to additional information and may request oral argument or a hearing if deemed necessary by the Executive Director or designee to render a decision;

d. The Executive Director of the Department or designee shall be de novo and a decision shall be rendered within ten (10) working days of the submission of all relevant information; and, e. The decision of the Executive Director of the Department shall constitute Final Agency Action regarding dispute.

No Member may be terminated from services or supports during the dispute resolution process unless the Department determines an emergency situation, as meeting the criteria set forth in Section 8.7000.A.4 exists. 8.7202.T Disputes between Department and Case Management Agency 1. The following shall apply in the event that the terms of the Case Management Agency requirements and responsibilities in these rules for Targeted Case Management Activities are disputed by either party:

a. The Case Management Agency shall notify the Director of the Office of Community Living of the circumstances of the dispute.

b. The parties shall informally meet at a mutually agreeable time to attempt resolution.

c. If the dispute cannot be resolved through this informal process, then the formal process at Section 8.7202 shall be used.

d. The Case Management Agency shall submit a written request for formal dispute resolution to the Department.

i. The request shall state the specific grounds for the dispute.

ii. It shall include all available exhibits, evidence, arguments, and documents believed to substantiate the protest, and the relief requested.

e. The Department may request additional information deemed necessary to resolve the dispute.

f. Within fifteen (15) working days following the receipt of written materials and additional requested information, the Department shall respond to the request by issuing a written decision, which shall be inclusive of the reasons for the decision.

g. A copy of the documentation presented or considered, the decision made and the contract shall be maintained in the Department’s files.

h. The Department's decision shall represent final Agency action on the disputed issue.

i. Notwithstanding the dispute, the Case Management Agency shall honor all contractual obligations entered into in its contract with the Department. No Agency shall have its contract terminated pending resolution of a contractual dispute, unless an emergency order is necessary for the preservation of public health, safety or welfare, as determined pursuant to

Section 8.7000.A.4.

j. Nothing in this procedure shall prohibit the Department from initiating corrective action based on evidence presented in the request for Departmental intervention or during its review.

k. Disputes related to administrative Case Management Activities must follow the process outlined in the Case Management Agency contract. 8.7202.U Continuous Quality Improvement of the Case Management Agency 1. To ensure the Case Management Agency is completing Case Management Activities according to requirements, the Department shall conduct performance reviews and evaluations of the Case Management Agency.

The Department may work with the Case Management Agency in the completion of any performance reviews and evaluations, and/or the Department may complete any or all performance reviews and evaluations independently, at the Department’s sole discretion.
The Case Management Agency shall provide all information necessary, as determined by the Department for the Department to complete performance reviews and evaluations, upon the Department’s request.
The Case Management Agency shall perform internal oversight of their Agency work product to ensure Case Management Activities described in rule and contract are performed as required.
The Department shall make the results of any performance reviews and evaluations available to the public and publicly post the results of any performance reviews and evaluations.
The Department may recoup funding as a result of any performance review and evaluation where payment was rendered for services not complete and/or not in alignment with federal and/or state regulations or Contract.
A Case Management Agency may be placed on corrective action requiring remediation based on the result of any performance review or evaluation.
Case Management Agencies shall allow access by authorized personnel of the Department, and/or its Contractors, for the purpose of reviewing documents and systems relevant to the provision of Case Management services and supports funded by the Department and shall cooperate with the Department in the evaluation of such services and supports.
Case Management Agency Satisfaction Survey a. At least annually, the Case Management Agency shall survey a random sample of Members to determine their level of satisfaction with services provided by the Agency. The Case Management Agency shall have a written policy and procedure for completing the Member satisfaction survey.

b. The random sample of individuals shall constitute forty (40) individuals or ten percent (10%) of the Case Management Agency’s average monthly caseload, whichever is higher.

c. The individual satisfaction survey shall conform to guidelines provided by the Department, including multiple survey formats and shall be ADA compliant.

d. The results of the individual satisfaction survey shall be made available to the Department upon request and shall be utilized for the Case Management Agency’s quality assurance and resource development efforts.

e. The Case Management Agency shall assure that consumer information regarding HCBS waiver programs is available for all individuals at the local level.

f. The Survey results shall be provided to the Community Advisory Committee for review regarding actions necessary to respond to quality concerns or issues and community engagement. 8.7202.V Provision of State Program Services 1. The Case Management Agency is responsible for the administration of state plan Long-Term Services and Supports programs including: State Supported Living Services (State-SLS), OBRA-SS, and Family Support Services Program (FSSP), in accordance with Medical Services Board regulations, and the Case Management Agency contract, and all the requirements associated with these programs including, but not limited to: Family Support Council development and maintenance, rates for State SLS and monitoring of services, and the PASSR 2. Family Support Program a. Case Management for State General Fund program support is the coordination of services provided for individuals with an Intellectual and Developmental Disability or Developmental Delay that consists of facilitating enrollment, assessing needs, locating, coordinating, and monitoring needed FSSP funded services, such as medical, social, education, and other services to ensure nonduplication of services, and monitoring to ensure the effective and efficient provision of services across multiple funding sources.

b. At minimum, the Case Manager is responsible for:

i. Determining initial and ongoing eligibility for the FSSP;

ii. Assisting Applicants with the Assessment;

iii. The development and annual Reassessment of the Family Support Plan (FSP); and iv. Ensuring service delivery in accordance with the FSP, and v. Coordinating with the Family Support Council as needed 3. OBRA-SS State General Fund Program a. Case Management Agencies shall follow all contractual obligations, rules and regulations pertaining to OBRA-SS at 42 CFR 483.

State Supported Living Services State General Fund Program a. The Case Manager shall coordinate, authorize, and monitor services based on the approved State-SLS Person-Centered Support Plan.

b. The Case Manager shall complete monitoring activities in compliance with 8.7557.D.4.

c. The Case Management Agency Case Manager shall assist individuals to gain access to other resources for which they are eligible and to ensure individuals secure long-term support as efficiently as possible.

d. The Case Management Agency Case Manager shall provide all State-SLS documentation upon the request from the Department.

e. Referrals to the State-SLS program shall be made through the Case Management Agency in the defined service area the individual resides in.

Home Care Allowance program a. Case Management Agencies shall contract with the Colorado Department of Human Services to administer the Home Care Allowance program.

b. The Case Managers shall complete all requirements for Home Care Allowance in accordance with 9 C.C.R. 2503-5; and with any applicable contract(s). 8.7202.W Organized Health Care Delivery System (OHCDS)

The Organized Health Care Delivery System for waivers is the Case Management Agency as designated by the Department in accordance with

Section 25.5 -10-209, C.R.S.

The Organized Health Care Delivery System is the Medicaid provider of record for a Member whose services are delivered through the Organized Health Care Delivery System.
The Organized Health Care Delivery System shall maintain a Medicaid provider agreement with the Department to deliver Waiver Services according to the current federally approved waiver.
The Organized Health Care Delivery System may contract and/or employ for delivery of approved Waiver Services for the Organized Health Care Delivery 5. The Organized Health Care Delivery System shall:

a. Ensure that the Contractor and/or employee meets minimum provider qualifications as set forth in the applicable HCBS waiver;

b. Ensure that services are delivered according to the applicable HCBS waiver definitions and as identified in the Member’s Service Plan;

c. Ensure that any subcontractor maintains sufficient documentation to support the claims submitted; and d. Monitor the health and safety of HCBS waiver Members receiving services from a subcontractor and report concerns for health and welfare to the proper authorities.

The Organized Health Care Delivery System is authorized to subcontract and negotiate reimbursement rates with providers in compliance with all federal and state regulations regarding administrative, claim payment and rate setting requirements. The Organized Health Care Delivery System shall:

a. Establish reimbursement rates that are consistent with efficiency, economy and quality of care;

b. Establish written policies and procedures regarding the process that will be used to set rates for each service type and for all providers;

c. Ensure that the negotiated rates are sufficient to promote quality of care and to enlist enough providers to provide choice to individuals or Members;

d. Negotiate rates that are in accordance with the Department’s established fee for service rate schedule and the Department’s procedures:

i. Manually priced items that have no maximum allowable reimbursement rate assigned, nor a Manufacturer’s Suggested Retail Price (MSRP), shall be reimbursed at the lesser of the submitted charges or the sum of the manufacturer's invoice cost, plus 13.56 percent.

d. Collect and maintain the data used to develop provider rates and ensure data includes the costs for allowable services provided to Members to address the individual and stakeholders’ needs, that are allowable activities within the HCBS waiver service definition and that supports the established rate;

e. Maintain documentation of provider reimbursement rates and provide the documentation to the Department, and Centers for Medicare and Medicaid Services (CMS); and f. Report by August 31 of each year, the names, rates and total payment made to the subcontractors 8.7202.X Member and Individual Documentation and Recordkeeping 1. Documentation includes:

a. Documentation of the Member’s choice of services, providers, nursing home placement, or other services, including a signed statement of choice from the Member;

b. Documentation that the individual or Member was informed of the right to free choice of providers from among all the available and qualified providers for each needed service, and that the individual understands his/her right to change providers;

c. Except when a individual or Member is residing in an alternative care facility, documentation to include a process, developed in coordination with the Member, the Member’s Family or Guardian and the Member’s physician, by which the Member may receive necessary care if the Member’s Family or service provider is unavailable due to an emergency situation or to unforeseen circumstances. The individual and the individual’s Family or Guardian shall be duly informed of these alternative care provisions at the time the service plan is initiated.

Case Managers shall support Members in determining their per diem payment obligation pursuant to Section 8.509.31.E. Case Managers shall inform Members residing in an Alternative Care Facility of their individual payment obligation on a form prescribed by the state at the time of the first Assessment visit; by the end of each plan period; or within ten (10) working days whenever there is a significant change in the diem payment amount.

a. Significant change is defined as a change of fifty dollars ($50) or more.

b. Copies of individual payment forms shall be kept in the individual files at the Case Management Agency and shall not be mailed to the State of its agent except as required for a Prior Authorization Request, pursuant to

Section 8.509.31(G)], or if requested by the state for monitoring purposes.

All Case Management documentation shall meet all of the following standards:

a. Records shall be objective and understandable;

b. Records shall be prepared at the time of the activity or no later than five (5) business days from the time of the activity;

c. Records shall be dated according to the date of the activity, including the year;

d. Records shall be entered into the Department’s Information Management System;

e. Records shall identify the person creating the documentation;

f. Entries must be concise and include all pertinent information;

g. Information must be kept together, in a logical organized sequence, for easy access and review;

h. The source of all information shall be recorded, and the record shall clarify whether information is observable and objective fact or is a someone’s judgment or conclusion;

i. All persons and agencies referenced in the documentation must be identified by name and by relationship to the Member;

j. All forms prescribed by the Department shall be completely and accurately filled out by the Case Manager; and, k. If the Case Manager is unable to comply with any of the regulations specifying the time frames within which Case Management Activities are to be completed, due to circumstances outside the Case Management Agency’s control, the circumstances shall be documented in the case 4. Documentation of Contacts and Case Management Activities in the Department Prescribed Information Management System.

All case documentation must be entered into the Department’s Information Management System within five (5) business days from the date of activity.
The Case Manager shall use the Department-prescribed Information Management System for purposes of documentation of all Case Management Activities, monitoring of service delivery, and service effectiveness. If applicable, the individual's Legally Authorized Representative or Long-Term Services and Supports Representative or both shall be identified in the case record, with a copy of appropriate documentation.
The Case Management Agency may accept physical or digital signatures on Department forms. If the individual is unable to sign a form requiring his/her signature because of a medical condition, any mark the individual is capable of making will be accepted in lieu of a signature. If the individual is not capable of making a mark or performing a digital signature, the physical or digital signature of a Guardian or other Legally Authorized Representative shall be accepted. 8.7202.Y Communication 1. The Case Management Agency’s Case Manager shall be responsible for ensuring materials, documents, and information used to conduct Case Management Activities are adapted to the cultural background, language, ethnic origin and preferred means of communication of the individual.
In addition to any communication requirements specified elsewhere in these rules, the Case Manager shall be responsible for the following communications:

a. The Case Manager shall inform the eligibility enrollment specialist of any and all changes affecting the participation of a Member in Case Management Agency-served programs, including changes in income, within one (1) working day after the Case Manager learns of the change.

The Case Manager shall provide the eligibility enrollment specialist with copies of the certification page of the approved Level of Care Screen form.

b. If the individual has an open adult protective services (APS) or child protective services (CPS) case at the county department of social services, the Case Manager shall keep the individual’s APS or CPS worker informed of the individual’s status and shall participate in mutual staffing of the individual’s case.

c. The Case Manager shall report to the Colorado Department of Public Health and Environment (CDPHE) any Congregate Facility which is not licensed.

d. The Case Manager shall inform all Alternative Care Facility individuals of their obligation to pay the full and current State-prescribed room and board amount, from their own income, to the Alternative Care Facility e. Within five working days of receipt of the approved Prior Authorization Request (PAR) form, from the fiscal agent, the Case Manager shall provide copies to all the HCBS providers in the Person-Centered Support f. The Case Manager shall coordinate with the Regional Accountable Entity and Behavioral Health Administration along with other community partners involved with the Members’ services and supports.

g. The Case Manager shall notify the Utilization Review Contractor (URC), on a form prescribed by the Department, within 30 calendar days, of the outcome when a Member is not Diverted.

h. Case Managers shall maintain communication with Members, Family Members, providers and other necessary parties within minimum standards for returned communication as described in contract. 8.7202.Z Targeted Case Management Activity Billing and Payment Liability 1. Billing:

a. Claims are reimbursable only when supported by the following documentation:

i. The name of the individual;

ii. The date of the activity;

iii. The nature of the activity including whether it is direct or indirect contact with the individual;

iv. The content of the activity including the relevant observations, Assessments, findings;

v. Outcomes achieved, and as appropriate, follow up action;

vi. For HCBS waiver or CFC programs, documentation required pursuant to Sections 8.519 and 8.760.

b. Claims are subject to a post-payment review by the Department. If the Department identifies an overpayment or a claim reimbursement not in compliance with requirements, the amount reimbursed shall be subject to reversal of claims, recovery of the amount reimbursed, or the Case Management Agency may be subject to suspension of payments.

c. Targeted Case Management services consist of facilitating enrollment; locating, coordinating, and monitoring Long-Term Services and Supports services; and coordinating with other non waiver or non-CFC funded services, such as medical, social, educational, and other services to ensure non-duplication of services and monitor the effective and efficient provision of services across multiple funding sources. The individual does not need to be physically present for this service to be performed if it is done on the individual’s/Member’s behalf.

d. TCM services provided to Members enrolled in HCBS waiver programs or CFC are to be reimbursed based on the Department's TCM Fee Schedule.

e. TCM providers shall record what documentation exists in the log notes and enter necessary documentation into the Department prescribed system as required by the Department.

i. Case Management Agencies shall document all targeted Case Management services and meet the following criteria:

All targeted Case Management services must be documented in the Department’s system within 10 business days of the activity and prior to submitting a claim for 2) Documentation must be specific to the Member and clearly and concisely detail the activity completed.
Documentation must specify the Member’s preference for inperson or virtual for monitoring contacts in adherence with Department direction and requirements.
The use of mass email communication, robotic and/or automatic voice messages cannot be used to replace the Case Management Agencies required Case Management services or any billable targeted Case Management service.

e. Reimbursement rates shall be published prior to their effective date in accordance with Federal requirements at 42 C.F.R. § 447.205(d) and shall be based upon a market-based research and standards.

f. TCM services may not be claimed prior to the first day of enrollment into an eligible program nor prior to the actual date of eligibility for Medicaid benefits.

Exclusions a. Case Management services provided to any individuals enrolled in the following programs are not billable as Targeted Case Management services as specified in Section 8.7202.Z:

i. Persons enrolled in a Home and Community-Based Services waiver or CFC not included as an eligible HCBS service as described in Sections 8.7000-8.7100 and 8.7500.

ii. Persons residing in a Class I nursing facility.

iii. Persons residing in an Intermediate Care Facility for the Intellectually Disabled (ICF-ID).

Payment Liability a. Failure to prepare the service plan and prior authorization or failure to submit the service plan forms in accordance with Department policies and procedures shall result in the reversal and recovery of reimbursement for services authorized retroactive to the first date of service. The Case Management Agency and/or providers may not seek reimbursement for these services from the Member.

b. If the Case Management Agency causes an individual enrolled in HCBS Waiver Services to have a break in payment authorization, the Case Management Agency shall ensure that all services continue and shall be solely financially responsible for any losses incurred by Provider Agencies until payment authorization is reinstated. 8.7202.AA Support Levels and Algorithms 1. Definitions a) Algorithm means a formula that establishes a set of rules that precisely defines a sequence of operations. An Algorithm is used to assign Members into one of six Support Levels in the Home and Community Based Services-Developmental Disabilities (HCBS-DD) and Home and Community Based Services-Supported Living Services (HCBS-SLS) waivers.

b) Respondent means a person participating in the Support Level Assessment who has knowledge of the Member’s skills and abilities in various areas of their lives. The Member may be their own Respondent by themselves or with support for the Support Level Assessment. For Respondents who are not the Member, they must have recently observed the Member directly in one or more places such as home, work, or in the c) Interviewer means an individual formally trained in the administration and implementation of the Support Level Assessment by a Department approved trainer using the Department approved curriculum.

d) Support Level means a numeric value determined using an Algorithm that places Members into groups with other Members who have similar overall support needs.

e) Virtual Meeting Platform means a form of communication that enables individuals in different physical locations to use their mobile or internet connected devices to meet in the same virtual room.

Support Level Assessments a) Since 2007, the Supports Intensity Scale (SIS-A) Assessment was required for enrollment into the HCBS-DD and HCBS-SLS waivers and used to determine a Member’s Support Level.

i) The Department will discontinue use of the Supports Intensity Scale (SIS-A) Assessment to determine Support Levels for initial enrollments into the HCBS-DD and HCBS-SLS waivers after June 30, 2025.

ii) Supports Intensity Scale (SIS-A) Assessment Support Levels will continue to be utilized for those Members who have them assigned prior to July 1, 2025.

b) Effective July 1, 2025, the Interim Support Level Assessment (ISLA) will replace the Supports Intensity Scale (SIS-A) Assessment used for initial HCBS-DD and HCBS-SLS enrollments to determine the Member’s Support Level.

i) The Interim Support Level Assessment (ISLA) will be used until the Department fully implements the Colorado Single Assessment (CSA) and Person-Centered Budget Algorithm (PCBA) for Resource Allocation across all HCBS waivers.

c) SIS-A and ISLA Support Levels will be used simultaneously after July 1, 2025; however, a single Member shall never have both a SIS-A and ISLA Support Level simultaneously.

d) The Case Management Agency shall conduct a Support Level Assessment for a Member at the time of initial enrollment into HCBS-DD and HCBS-SLS.

i) Interviewers conducting Support Level Assessments shall be trained and qualified to perform the assessments.

ii) The Interviewer conducting the Support Level Assessment shall not also act as a Respondent for the same assessment.

iii) The Case Management Agency shall:

(1) Notify the Member, their Legal Guardian, or their Legally Authorized Representative, if applicable, of the requirement for and the right to participate in the Support Level (2) Support and encourage the Member to participate in the Support Level Assessment.

(a) If the Member chooses not to participate in the Support Level Assessment, the Case Management Agency shall document their choice in the Member’s record on the Department prescribed Information Management System; and, (b) Assist the Member or other Member Identified Team members to identify who will participate on their behalf (family, friends, unpaid support, etc.) and document their choice in the Department prescribed (3) Assist the Member to identify other Respondents (Legal Guardian, family, friends, unpaid support, etc.) whom they choose to participate in the Support Level Assessment.

(4) Allow the Member to complete the Support Level Assessment as the only Respondent if they choose.

(5) Document the Member’s selection of Respondents or choice to be the only Respondent in the Department prescribed (6) Follow person-centered practices by accommodating the Member’s preference in completing the Support Level Assessment via in-person, in the Member’s home, at an alternate location, or by virtual meeting platform.

(7) Inform the Member, their Legal Guardian, or their Legally Authorized Representative, if applicable, of the purpose of the Support Level Assessment, the Complaint Process, and the Support Level Review Process.

(8) Provide a copy of the completed Support Level Assessment to the Member within 30 calendar days of the assessment.

(a) The Case Management Agency shall document provision of a copy of the Support Level Assessment to the Member, their Legal Guardian, or their Legally Authorized Representative, if applicable, in the Department prescribed Information Management 2) Support Levels a) A Support Level reflects the assessed support needs of a Member and is required for a Member enrolled in the Home and Community-Based Services-Developmental Disabilities (HCBS-DD) or the Home and Community-Based Services-Supported Living Services (HCBS-SLS)

b) The Support Level is used as a factor for Day Habilitation, Supported Employment, and Residential Habilitation services to determine the rate paid to Providers.

c) A Member shall be assigned into one of six Support Levels according to their overall support needs and based upon the standardized Algorithm for HCBS-DD or HCBS-SLS.

i) The Supports Intensity Scale (SIS-A) Assessment converts subscale raw scores for each section into standard scores for each section, which are used in the Algorithm for Supports Intensity Scale (SIS-A) Assessment Support Levels.

ii) Supports Intensity Scale (SIS-A) Assessment Algorithm factors:

(a) Standard scores from Section 2: Parts A (Home Living Activities), B (Community Living Activities), and E (Health and Safety Activities) (ABE) from the SIS-A, (b) Total scores from Section 1A: Exceptional Medial Support Needs score from the SIS-A, (c) Total scores from Section 1B: Exceptional Behavioral Support Needs score from the SIS-A, and (d) Whether the Member presents as a safety risk, defined in

Section 8.7100.A Definitions, as follows:

(i) In HCBS-DD, Extreme Safety Risk to Others or Extreme Safety Risk to Self.

(ii) In HCBS-SLS, Extreme Safety Risk to Others.

iii) Supports Intensity Scale (SIS-A) Assessment Algorithm Formula Table SIS-A Support Level 1 Subgroup 1A: ∑ 2ABE ≤ 25; 1A ≤ 1 AND 1B ≤ 2 Subgroup 1B: ∑ 2ABE ≤ 25; 1A ≤ 2 AND 1B 3-5 Subgroup 1C: ∑ 2ABE ≤ 25; 1A 3-4 AND 1B 3-5 SIS-A Support Level 2 Subgroup 2A: ∑ 2ABE 26-30; 1A ≤ 1 AND 1B ≤ 2 Subgroup 2B: ∑ 2ABE 26-30; 1A ≤ 2 AND 1B 3-5 Subgroup 2C: ∑ 2ABE 26-30; 1A 3-4 AND 1B 3-5 Subgroup 1D: ∑ 2ABE ≤ 25; 1A 5-6 Subgroup 1G: ∑ 2ABE ≤ 25; 1B 6-9 Subgroup 2D: ∑ 2ABE 26-30; 1A 5-6 Subgroup 2G: ∑ 2ABE 26-30; 1B 6-9 Subgroup 3A: ∑ 2ABE 31-33; 1A ≤ 1 AND 1B ≤ 2 Subgroup 3B: ∑ 2ABE 31-33 1A ≤ 2 AND 1B 3-5 SIS-A Support Level 3 Subgroup 1H: ∑ 2ABE ≤ 25; 1B 10-13 Subgroup 2H: ∑ 2ABE 26-30; 1B 10-13 Subgroup 3C: ∑ 2ABE 31-33; 1A 3-4 AND 1B 3-5 Subgroup 3D: ∑ 2ABE 31-33; 1A 3-6 Subgroup 3G: ∑ 2ABE 31-33; 1B 6-9 Subgroup 4A: ∑ 2ABE ≥ 34; 1A ≤ 1 AND 1B ≤ 2 Subgroup 4B: ∑ 2ABE ≥ 34 1A ≤ 2 AND 1B 3-5 SIS-A Support Level 4 Subgroup 1E: ∑ 2ABE ≤ 25; 1A 7-8 Subgroup 1F: ∑ 2ABE ≤ 25; 1A ≥ 9 Subgroup 1I: ∑ 2ABE ≤ 25; 1B 14-15 Subgroup 1J: ∑ 2ABE ≤ 25; 1B ≥ 16 Subgroup 2E: ∑ 2ABE 26-30; 1A 7-8 Subgroup 2I: ∑ 2ABE 26-30; 1B 14-15 Subgroup 2J: ∑ 2ABE 26-30; 1B ≥ 16 Subgroup 3E: ∑ 2ABE 31-33; 1A 7-8 Subgroup 3H: ∑ 2ABE 31-33; 1B 10-13 Subgroup 4C: ∑ 2ABE ≥ 34; 1A 3-4 AND 1B 3-5 Subgroup 4G: ∑ 2ABE ≥ 34; 1B 6-9 SIS-A Support Level 5 Subgroup 2F: ∑ 2ABE 26-30; 1A ≥ 9 Subgroup 3I: ∑ 2ABE 31-33; 1B 14-15 Subgroup 3J: ∑ 2ABE 31-33; 1B ≥ 16 Subgroup 4D: ∑ 2ABE ≥ 34; 1A 3-6 Subgroup 4E: ∑ 2ABE ≥ 34; 1A 7-8 Subgroup 4H: ∑ 2ABE ≥ 34; 1B 10-13 Subgroup 4I: ∑ 2ABE ≥ 34; 1B 14-15 Group 5A: Extreme Safety Risk to Others AND 1b ≤ 11 SIS-A Support Level 6 Subgroup 4J: ∑ 2ABE ≥ 34; 1B ≥ 16 Subgroup 3F: ∑ 2ABE 31-33; 1A ≥ 9 Subgroup 4F: ∑ 2ABE ≥ 34; 1A ≥ 9 Group 6A: Extreme Safety Risk to Self AND Extreme Safety Risk to Others AND 1b ≥ Group 6B: Extreme Safety Risk to Others AND 1b ≥ 12 Extreme Safety Risk to Self – this factor acts to increase the level otherwise determined by the above criteria. Level 1 increases to level 3, level 2 increases to level 4, level 3 increases to level 4, level 4 increases to level 5. Subgroup 6A outlines the conditions in which level 5 may increase to level 6.

Extreme Safety Risk to Others – this factor acts to increase the level otherwise determined by the above criteria. Level 1 increases to level 5, level 2 increases to level 5, level 3 increases to level 5, and level 4 increases to level 6. Subgroup 6B outlines the conditions in which level 5 may increase to level 6.

iv) The Interim Support Level Assessment (ISLA) converts subscale raw scores for into scale scores for each section, which are used in the Algorithm for Interim Support Level Assessment (ISLA)

Support Levels.

v) Interim Support Level Assessment (ISLA) Algorithm factors:

(1) Functioning (ADLs and IADLs), and (2) Health (Medical), and, (3) Psychosocial (Behavior and Mental Health), and, (4) Memory and Cognitive, and, (5) Social Environment and Safety; and, (6) Whether the Member presents as a safety risk, defined in

Section 8.7100.A Definitions, as follows:

(a) In the HCBS-SLS waiver, Extreme Safety Risk to Others.

(b) In the HCBS-DD waiver, Extreme Safety Risk to Others or Extreme Safety Risk to Self.

vi) Interim Support Level Assessment (ISLA) Algorithm Formula Table is posted on the Department’s website and can be found at (link).

vii) The results of the Algorithm are used to assign Members to Support Levels one through six; with a Support Level one indicating a minimal need for supports and a Support Level six indicating a significantly higher need for supports.

(1) In HCBS-DD, the Department may assign a Support Level seven (7) reimbursement rate for Residential Habilitation and/or Day Habilitation services provided to a Member with extraordinary overall needs.

(2) These Support Level seven (7) requests must be initiated by the Member, their Legal Guardian, or their Legally Authorized Representative, if applicable, and submitted by the Case Management Agency to the Department for review.

viii) For HCBS-SLS, the Support Level will determine the Service Plan Authorization Limit (SPAL), defined at Section 8.7200.B, and the rate of reimbursement for Day Habilitation and Supported Employment Service.

(1) The HCBS-SLS SPAL will remain in place for already established Support Plan certifications that end after July 1, 2025.

(a) The HCBS-SLS SPAL shall not apply to Support Plan Continued Stay Reviews held after July 1, 2025.

(2) For Members newly enrolling in HCBS-SLS and Community First Choice (CFC) on or after July 1, 2025, the SPAL shall not apply.

(3) The SPAL is posted on the Department’s webpage.

ix) For HCBS-DD, Support Level determines the rate of reimbursement for Supported Employment Services, Day Habilitation, and Residential Habilitation Services.

x) Specific scores from the Member's Support Level Assessment shall be used in addition to Risk Factor scores to calculate the Member's Support Level in HCBS-DD and HCBS-SLS.

(1) The Case Management Agency in consultation with the Member Identified Team shall make a determination whether a Member meets the definition of Extreme Safety Risk to Others or Extreme Safety Risk to Self through the following process:

(a) The Case Manager shall:

(i) Document the Member Identified Team discussion of the Rights Modification identifying the line of-sight supervision and/or secured, controlled setting justification, in the Member’s record on the Department prescribed Information Management System; and, (ii) Follow the Rights Modification process outlined in Section 8.7001.B.4.

(b) The Case Manager Supervisor shall:

(i) Verify the Member meets safety risk criteria, (ii) Verify the signed Informed Consent for the Rights Modification is in the Member’s record on the Department prescribed Information Management System; and, (iii) Document that the Member meets the Extreme Safety Risk to Others or Extreme Safety Risk to Self definition(s) in the Department prescribed Information Management System.

(iv) The Case Management Agency shall review the status of the Member’s Safety Risk Factors at least annually or when significant changes occur, to ensure that the Member continues to meet the definition(s).

(c) At the point a Member no longer meets the definition(s) of Extreme Safety Risk to Others or Extreme Safety Risk to Self, their status must be changed in the Department prescribed Information Management System which will auto-calculate to the Member’s current Algorithm Support Level and the Member’s Person-Centered Support Plan shall be updated to reflect the removal of the Risk Factor and any changes in related, identified support needs within 10 business days of the definition(s) no longer being met or, in cases where Section 8.7202.AA.C(xiii)(4)(b)(i-iii), applies, within 10 business days of receipt of approval or denial of the Support Level Review request.

(d) For cases in which a Member’s behavior does not satisfy a Safety Risk Factor definition but the Member’s needs continue to be substantially higher than those typical of their assigned Support Level (without adjustments for risk factors) and a Rights Modification continues to be in place, the Member Identified Team may consider a Support Level Review request, as outlined in Section 8.7202.5, as a part of the person-centered support planning and Rights Modification processes.

(i) If the Member Identified Team determines a Support Level Review request is needed, the Case Management Agency shall submit a Support Level Review request with input from the Member Identified Team which includes, but is not limited to, detailed information from the Person-Centered Support Plan describing the extensive supports needed and the Rights Modification(s), to include all requirements outlined in Section 8.7001.B.

(ii) The Department shall review the Support Level Review request as outlined in Section 8.7202.5.

(iii) Rights shall be restored as soon as circumstances justify.

When rights are restored prior to the end date of the Support Level Review approval period, the Case Management Agency shall notify the Department of the change in support needs in a manner determined by the Department.
When rights are restored, the Department shall adjust the Support Level override in the Department prescribed Information Management System to the original assessed Algorithm Support Level.
The Case Management Agency shall make any necessary Person-Centered Support Plan and Prior Authorization (PAR) revisions resulting from the Support Level changes within 10 business days of the affected Support Level change.

d) The Case Management Agency shall inform each Member, their Legal Guardian, or their Legally Authorized Representative, if applicable, of their Support Level at the time of the initial or Continued Stay Review (CSR)

Person-Centered Support Plan meeting or when the Support Level changes for any reason.

i) Notification to the Member of a Support Level change shall occur within 20 business days of the date of the Support Level change.

ii) Pursuant to the Department’s rules in Section 8.057.2.A, Section 8.7202.R, and Section 8.7202.S.1(c), the Member shall be notified when a waiver service is changed, reduced, or denied. At any time, the Member may pursue a Medicaid Fair Hearing in accordance with Section 8.057.3.A.

Support Level Assessment Complaint Process a) The Member, their Legal Guardian, or their Legally Authorized Representative, if applicable, may file a complaint regarding the administration of the Support Level Assessment up to 30 calendar days after the Member’s receipt of the Support Level Assessment document.

b) The complaint shall be filed verbally or in writing with the Member's Case Management Agency. Additional information to support the complaint may be submitted at that time. If the complaint has been filed verbally the Case Management Agency shall document in the Member's record on the Department-prescribed Information Management System the time, date and details surrounding the complaint.

c) The Case Management Agency shall make efforts to resolve the complaint and provide the complainant with a written response within 10 business days after receipt of the complaint.

d) When a resolution cannot be reached, the Case Management Agency shall inform the complainant that they may submit the complaint to the Department through the Department’s Complaint Form within 30 calendar days after receipt of the Case Management Agency response.

e) The Department shall provide a written response to the complainant within 15 business days after receipt of the complaint.

Support Level Review Process a) The Case Management Agency shall request a review of the Support Level assigned on behalf of the Member, their Legal Guardian, or their Legally Authorized Representative when they have reason to believe it does not meet the Member's needs.

b) When a Support Level Review is requested, the Case Management Agency shall complete the request with input from the Member Identified Team in a manner determined by the Department on the Department’s prescribed request form.

c) Support Level Review requests must be initiated by the Member, their Legal Guardian, or their Legally Authorized Representative, if applicable, and submitted by the Case Management Agency to the Department for review.

d) Once the request form is completed, the Case Management Agency shall provide an opportunity for the Member, their Legal Guardian, or their Legally Authorized Representative, if applicable, to review the request and provide additional information prior to submission to the Department for review.

e) The Case Management Agency shall submit the Support Level Review request form to the Department within 30 calendar days of the receipt of all necessary information.

f) The Department shall convene a review panel to examine Support Level Review requests monthly or as needed.

i) The review panel shall be comprised of the following:

(1) A minimum of three members designated by the (2) Members shall include staff from the Department with extensive knowledge and experience with the assessments used to determine Support Levels, Case Management, and HCBS waiver services.

ii) The review panel:

(1) Shall examine all of the information submitted by the Case Management Agency and identify any significant factors not included in the Support Level calculation, which may cause the Member to have substantially higher support needs than those in the established Support Level.

(2) In cases where the panel finds that the Member does have substantially higher support needs than those in the established Support Level, the panel may assign the Member to a Support Level that is a closer representation of the Member's overall support needs.

(a) A Member who has been assigned to a higher Support Level shall have this assignment reexamined by the review panel at a frequency determined by the Department.

(i) The Case Management Agency shall submit a Support Level Review request to have the Member’s Support Level re-examined no later than 30 calendar days prior to the end date determined by the Department of the increased Support Level.

(ii) The panel may determine that the Member's condition necessitating a higher Support Level is unlikely to improve and, therefore, does not require a re-examination and, therefore, does not have an end date.

g) The Department shall provide the Case Management Agency with the written decision regarding the requested review of the Member's Support Level within 15 business days after the panel meeting. The written decision notification shall include the date of the Support Level Review request, the Support Level determination, the effective date, and the end date of the increased Support Level and, if denied, the reason for denial of an increased Support Level.

h) The Case Management Agency shall provide the written decision to the Member, their Legal Guardian, or their Legally Authorized Representative, if applicable.

i) The results of the panel review for a Member enrolled in HCBS-DD are conclusive.

ii) If a Member enrolled in HCBS-SLS, their Legal Guardian, or their Legally Authorized Representative, if applicable, disagrees with the decision provided by the panel, the Member, their Legal Guardian, or their Legally Authorized Representative may request a review by the Department’s Executive Director or their designee, within 15 business days after the receipt of the decision.

(1) The Department’s Executive Director, or their designee, shall review the request and provide a written decision within 15 business days of receipt of the requested review.

(2) The decision of the Department’s Executive Director, or their designee, shall constitute the final agency decision and will be subject to judicial review pursuant to Section 24-4-106, i) The Case Management Agency shall make any necessary Person- Centered Support Plan and Prior Authorization Request (PAR) revisions resulting from the Support Level changes within 10 business days of receipt of approval or denial of the Support Level Review request.

j) The Member shall be notified, pursuant to the Department’s rules in

Section 8.057.2.A, Section 8.7202.R, and Section 8.7202.S.1(c) when a waiver service is changed, reduced, or denied. At any time, the Member may pursue a Medicaid Fair Hearing in accordance with Section 8.057.3.A.

Annual Support Level Assessment Overview a) The Case Manager shall provide an overview of the results of the most recent Support Level Assessment during the Continued Stay Review (CSR) Person-Centered Support Plan (PSCP) meeting.

b) For SIS-A, this overview shall include discussion of:

i) The Exceptional Medical and/or Behavioral Support Needs identified in Section 1 of the SIS-A, ii) The areas of priority support needs identified in Section 2 of the SIS-A, iii) The resulting Support Level, and iv) The services necessary to meet these priority areas.

c) For ISLA, the overview shall include discussion of:

i) The Exceptional Medical/Health and/or Psychosocial Support Needs identified in the ISLA, ii) The areas of priority support needs identified in the Activities of Daily Living and Instrumental Activities of Daily Living scale, iii) The resulting Support Level, and iv) The services necessary to meet these priority areas.

d) If upon review of the results of the Support Level Assessment there is a significant change in the Member’s condition or circumstances, the Case Manager should refer to Section 8.7202.AA.5 Support Level Review Process. 8.7202.BB Post Eligibility Treatment of Income (PETI)

Post Eligibility Treatment of Income Application a. When a Member has been determined eligible for Home and Community Based Services (HCBS) according to the 300% income standard (300% eligible Members), according to Section 8.100, the Department may reduce the Medicaid payment for residential services according to the procedures set forth in this section. For purposes of this section, Residential services include:

i. Alternative Care Facility (ACF)

ii. Supportive Living Program (SLP)

iii. Individual Residential Service and Supports (IRSS)

iv. Group Residential Services and Supports (GRSS)} b. Implementation must align with Medicaid Buy-in (WAwD) requirements and protections for earned income under 10 CCR 2505-10.

c. Post Eligibility Treatment of Income Application is required for Medicaid Members enrolled in the HCBS Elderly, Blind, and Disabled (EBD), HCBS- Community Mental Health Supports (CMHS), Developmental Disabilities (DD), and HCBS Brain Injury (BI) waivers who receive residential services.

Case Management Responsibilities a. For 300% eligible Members who are enrolled in the waivers listed in 8.7202.BB.1.b and receive residential services described in 8.7202.BB.1.a, the Case Manager shall complete the State-prescribed form, which calculates the Member payment according to the following procedures:

i. The Member’s Total Gross Monthly Income is determined by adding the Gross Monthly Income to the Gross Monthly Long-Term Care (LTC) Insurance amount if the Long-Term Care Insurance amount is applicable.

ii. Treatment of income placed into or held in a trust shall be determined in accordance with applicable federal and state Medicaid eligibility and post-eligibility requirements. Distributions received by the Member from a trust, including Special Needs Trusts and ABLE accounts, shall be treated as income when required under those provisions.

iii. The Member’s Room and Board amount shall be deducted from the gross income and paid to the Provider Agency. The standard Room and Board amount shall not be deducted when the Member directly pays rent or a mortgage. iv The Member’s Personal Needs Allowance amount is based upon a Member’s gross income, up to the maximum amount set by the v. Members shall be exempt from completion of the PETI worksheet if they are actively enrolled in the Working Adults with Disabilities (WAwD) program, employed as verified by the Case Manager or are participating in supported employment services designated by the Department and approved by the Case Manager.

For purposes of this subsection, employment shall be ongoing and for compensation. Unpaid activities, including volunteer services, shall not qualify as employment for purposes of this exemption.
The Case Manager shall verify employment and maintain documentation, which may include pay stubs, employer verification, tax records, W2’s, 1099’s, and other proof of earned income.

vi. For a Member with financial responsibility only for a spouse, the amount protected under Spousal Protection as defined in Section 8.100.7.K shall be deducted from the Member’s gross income.

vii. If the Member is financially responsible for a spouse plus other dependents, or has financial responsibility for only other dependents, an amount equal to the appropriate Temporary Assistance to Needy Families (TANF) grant level, less any income of the spouse and/or dependents, excluding part-time employment earnings of dependent children (with dependent child as defined at Section 8.100.1) shall be deducted from the Member’s gross income.

viii. Amounts for incurred expenses for medical or remedial care for the Member that are not covered by Medicare, Medicaid, or other third party, shall be deducted from the Member’s gross income as follows:

Health insurance premiums, deductibles, or co-insurance charges if health insurance coverage is documented; and 2) Necessary dental care not to exceed amounts equal to actual expenses incurred; and 3) Vision and auditory care expenses not to exceed amounts equal to actual expenses incurred; and 4) Medications, except for the following:

a) Medications which may be purchased through regular Medicaid prior authorization procedures shall not be deducted from the Member’s gross income.

b) The full cost of brand-name medications shall not be deducted from the Member’s gross income if a generic form is available at a lower price, unless the prescriber has specifically prescribed a name brand medication over the generic formula.

ix. Other necessary medical or remedial care or items shall be deducted from the Member's gross income, with the following limitations:

The need for such care must be documented in writing by the attending physician. The documentation shall list the service, supply, or equipment; state why it is medically necessary; be signed by the physician; and shall be renewed whenever there is a change in the Member’s care needs, or if the ember’s needs do not change, annually.
Any service, supply, or equipment that is available under the Medicaid State Plan, with or without prior authorization, shall not be allowed as a deduction.

x. Deductions for medical and remedial care may be allowed up to the end of the next full month while the physician's prescription is being obtained. If the physician's prescription cannot be obtained by the end of the next full month, the deduction shall be discontinued.

The Member must provide documentation, such as a receipt, for all non-covered medical items to the Case Manager to be attached to the State-prescribed form.

xi. If the Case Manager cannot immediately determine whether a particular medical or remedial service, supply, equipment, or medication is a benefit of Medicaid, the deduction may be allowed up to the end of the next full month while the Case Manager determines whether such deduction is a benefit of the Medicaid program. If it is determined that the service, supply, equipment, or medication is a benefit of Medicaid, the deduction shall be discontinued.

xii. Verifiable Federal and State tax liabilities shall be an allowable deduction up to $300 per month from the Member’s gross income.

xiii. For Members who demonstrate financial responsibility for their housing through a mortgage or legally binding housing obligation in their own name, a household needs allowance shall be deducted from the Member’s gross income for necessary living expenses not covered under the waiver, including utilities, food, and other household costs. Expenses must be for the Member’s residence and paid by the Member. This allowance shall not duplicate Room and Board or Personal Needs Allowance (PNA).

Housing costs may be based on typical monthly expenses, including reasonable averages of recurring costs. Temporary housing expenses may be averaged or allowed for a limited period when expenses are documented.

xiv. An amount equal to the Member’s verified rent or mortgage payment that exceeds the standard room and board amount may be deducted from the Member’s gross monthly income only when the Member is financially responsible for and directly pays the housing expenses. Payments made toward housing costs owned by another individual, including a parent, guardian, or provider-controlled setting, shall not be considered allowable deductions.

Verified rent or mortgage amounts may reflect a consistent monthly estimate when costs vary, based on available documentation, and should be consistent with average housing costs in the local market.

xv. Any remaining income shall be applied to the per-diem cost of the residential service as set forth at section 8.7202.BB.1.a, and shall be paid by the Member directly to the Provider Agency.

xvi. If income remains after the cost of residential services is paid from the Member's income, as set forth in subsection xiii the remaining income shall be retained by the Member and may be used at the Member’s discretion.

b. Case Managers shall inform HCBS Members of their payment obligations in a manner prescribed by the Department at the beginning of each support plan year and no later than ten (10) business days following any significant change to the Member’s payment obligation.

i. Significant change is defined as fifty dollars ($150) or more.

c. The Case Management Agency shall maintain signed copies of Member payment forms in their files. The Case Management Agency shall provide a copy of the form to the Department upon request.

8.7202.CC PRIOR AUTHORIZATION REQUESTS (PAR)

All Home and Community-based Services must be prior authorized by the Department or its agent.

a. The Case Manager shall complete and submit the Department’s approved PAR form within one calendar month of determination of eligibility for a waiver or CFC.

All units of service requested shall be listed on the Person-Centered Support 3. The first date for which services may be authorized is the latest date of the a. The financial eligibility start date, as determined by the financial eligibility site.

b. The assigned start date on the certification page of the Department approved assessment tool.

c. The date, on which the Member’s parent(s) and/or legal guardian signs the Person- Centered Support Plan or Intake form, as prescribed by the Department, agreeing to receive services.

The PAR shall not cover a period of time longer than the certification period assigned on the certification page of the Department approved assessment tool. 5 The Case Manager shall submit a revised PAR if a change in the Person Centered Support Plan results in a change in services.
The revised Person Centered Support Plan shall list the service being changed and state the reason for the change. The services being revised, as indicated in the revised Person Centered Support Plan, plus all services not revised, as shown on the Plan prior to revision, shall be entered on the revised PAR.
Revisions to the Person Centered Support Plan requested by providers after the end date on a PAR shall be disapproved.
If the revisions to the Person Centered Support Plan result in a decrease in services without the Member’s parent’s(s) and/or legal guardian’s agreement, the Case Manager shall notify the Member’s parent(s) and/or legal guardian of the adverse action and appeal rights using the appropriate forms, timelines and process as described in 8.7202.R.
REIMBURSEMENT

a. Providers shall be reimbursed at the lower of:

i. Submitted charges; or ii. The fee schedule amount as determined by the Department.

b. Claims for services are not reimbursable if:

i. Services are not consistent with the Member’s documented medical condition and functional capacity;

ii. Services are not medically necessary or are not reasonable in amount, scope, frequency, and duration;

iii. Services are duplicative of other services included in the Member’s Support Plan;

iv. The Member is receiving non-Medicaid funds to purchase services;

v. Services total more than 24 hours per day of care.

Revisions to the PAR that are requested six months or more after the end date shall be disapproved.
Payment for HCBS waiver and/or CFC services is also conditional upon:

a. The Member’s eligibility for HCBS waiver and/or CFC services;

b. The provider’s certification status, if appropriate; and c. The submission of claims in accordance with proper billing procedures.

Prior authorization of services is not a guarantee of payment. All services must be provided in accordance with regulations and medically necessary.
Services requested on the PAR shall be supported by information on the Person Centered Support Plan and written documentation of the Member’s current monthly income from the income maintenance technician.
The PAR start date shall not precede the start date of HCBS waiver or CFC eligibility.
The PAR end date shall not exceed the end date of the HCBS waiver or CFC eligibility certification period.

8.7202.DD SERVICE PLAN AUTHORIZATION LIMITS (SPAL)

The Service Plan Authorization Limit (SPAL) sets an upper payment limit of total funds available to purchase services to meet a Member’s ongoing service needs within one service plan year.
The following services are not subject to the service plan authorization limit: nonmedical transportation, dental services, vision services, assistive technology, home accessibility adaptations, vehicle modifications, health maintenance activities available under the Consumer Directed Attendant Support Services (CDASS), home delivered meals, life skills training, peer mentorship, transition setup, individual job coaching, individual job development, job placement, workplace assistance, and benefits planning.
The total of all HCBS-SLS services in one service plan shall not exceed the overall authorization limitation as set forth in the federally approved HCBS-SLS 4. Each SPAL is assigned a specific dollar amount determined through an analysis of historical utilization of authorized waiver services, total reimbursement for services, and the spending authority for the HCBS-SLS waiver. Adjustments to the SPAL amount may be determined by the Department and Operating Agency as necessary to manage waiver costs.
Each SPAL is associated with one of the six support levels determined by an algorithm which analyzes the level of support needed by a Member as determined by the SIS assessment, and additional factors, including whether a Member meets the definition of Public Safety Risk-Convicted, Public Safety Risk- Non Convicted, and Extreme Safety Risk to Self.
The SPAL determination shall be implemented in a uniform manner statewide and the SPAL amount is not subject to appeal.

a. If an Adverse Action occurs regarding a Member’s HCBS waiver eligibility and/or services, the Case Manager shall send the Member their appeal rights as required at Sections 8.7202.R and 8.057.2.A.

The Department and/or Utilization Review Contractor (URC) shall implement an Exception Review to allow a Member’s SPAL and/ or HCBS unit limitations to be exceeded in certain situations.

a. To be eligible for the Exception Review Process, the following shall be demonstrated:

i. The Member must be at risk for seeking an emergency Developmental Disability (DD) waiver enrollment because one or more of the following criteria such as listed below are not currently being met through other Long-Term Services and Supports (LTSS) and or State Plan services:

Medically fragile with skilled care needs;
Behavioral and/or Mental Health needs;
Criminal convictions and/or law enforcement involvement;
Homelessness;
Mistreatment, Abuse, Neglect, Exploitation (MANE) reports with potential need to remove from home;
Extreme danger to self/others;
Caregiver capacity or;
1:1 supervision needed.

ii. The Member must demonstrate that less than 10% of current SPAL remains; or iii. The Member must demonstrate that the current rate of utilization of Home and Community-Based Services (HCBS) will exhaust the number of approved units prior to the Member’s regularly scheduled monitoring.

b. When a client is eligible for the Exception Review Process, the Case Manager (CM) shall send the following documentation to the URC for review:

i. “Request for Exception Review Process” form;

ii. Service Plan;

iii. PAR; and, iv. Any documentation from current providers that demonstrate need to exceed service limitation caps for additional planned services.

c. The URC shall review and approve or deny the Exception Review Process requests made.

i. Upon completion of the review, the URC shall notify the CM of the outcome.

The outcome letter shall include the reason for approval or denial, and/ or any information on partial approvals or negotiated outcomes.

ii. The URC shall complete the review in accordance with the timelines as identified in their contract.

d. The Exception Review Process shall not be used in place of a Support Level Review or request for a Support Intensity Scale (SIS) reassessment.

Provider rates shall not be changed based on the outcome of the Exception Review Process.

e. The Exception Review Process shall be implemented in a uniform manner applied to Members statewide, but outcomes shall be based on individual needs and circumstances. The Exception Review Process outcome is not an adverse action subject to appeal. 8.7203 Case Manager Requirements and Responsibilities 8.7203.A Case Manager Requirements 1. The Case Manager(s) hired on or after October 8, 2021 shall meet minimum qualifications for HCBS Case Managers set forth in these regulations and shall be able to demonstrate competency in pertinent Case Management knowledge and skills.

All Home and Community-Based (HCBS) Case Managers must be employed by a contracted Case Management Agency. Case Management Agencies must maintain verification that employed Case Managers meet the minimum qualifications set forth in these regulations.
The minimum qualifications for HCBS Case Managers hired on or after October 8th, 2021 are:

a. A bachelor’s degree; or b. Five (5) years of relevant experience in the field of Long-Term Services and Supports, which includes Developmental Disabilities; or c. Some combination of education and relevant experience appropriate to the requirements of the position.

d. Relevant experience is defined as:

i. Experience in one of the following areas: long-term care services and supports, gerontology, physical rehabilitation, disability services, children with special health care needs, behavioral science, special education, public health or nonprofit administration, or health/medical services, including working directly with persons with physical, intellectual or Developmental Disabilities, mental illness, or other vulnerable populations as appropriate to the position being filled; and, ii. Completed coursework and/or experience related to the type of administrative duties performed by Case Managers may qualify for up to two (2) years of required relevant experience.

Case Managers may not:

a. Be related by blood or marriage to the individual.

b. Be related by blood or marriage to any paid caregiver of the individual.

c. Be financially responsible for the individual.

d. Be the individual’s legal Guardian, Legally Authorized Representative, Long-Term Services and Supports Representative, or Authorized Representative under Sections 8.7515 and 8.7527, or be empowered to make decisions on the individual’s behalf through a power of attorney.

e. Be a provider for the individual, have an interest in, or be employed by a provider for the same individual. Case Managers employed by a Case Management Agency that is operating under an exception approved by the Centers for Medicare and Medicaid Services (CMS) in the approved waiver application are exempt from this requirement.

f. Be related by blood or marriage to the owner or managing employee of a 5. Case Management Agency staff must pass competency-based training requirements as defined and enforced by the Department through contractual agreements.

The Case Management Agency supervisor(s) shall meet all qualifications for Case Managers and have a minimum of two years of experience in the field of HCBS Case Management. 8.7204 Functions of the Case Management Agency Supervisor 8.7204.A Supervision of Case Managers 1. Case Management Agencies shall provide adequate supervisory staff who shall be responsible for:

a. Regular supervisory conferences with Case Managers on a regular basis related to their caseload and Members needs;

b. Approval of indefinite lengths of stay in nursing facilities, determined according to Section 8.402.15;

c. Regular, systematic review and remediation of case records and other Case Management documentation, on at least a sample basis;

d. Communication with the Department when technical assistance is required by Case Managers and the supervisor is unable to provide answers after reviewing the regulations and other departmental publications;

e. Allocation and monitoring of staff to assure that all standards and time frames are met; and f. Assumption of Case Management duties when necessary. 8.7204.B Training of Case Management Agency Staff 1. Case Management Agency staff, including supervisors, shall attend training sessions as directed and/or provided by the Department for Case Management Agencies.

Prior to start-up, the Case Management Agency staff shall receive training provided by the Department or its designee, which shall include, but not be limited to, the following content areas:

a. Background information on the development and implementation of the Case Management Agency system;

b. Mission, goals, and objectives of the Case Management Agency system;

c. Regulatory requirements and changes or modifications in federal and state programs;

d. Contracting guidelines, quality assurance mechanisms, and Certification requirements; and e. Federal and state requirements for the Case Management Agency.

The Case Management Agency is responsible for tracking completion of required Case Management Agency training and staff development of program knowledge. Staff who require retraining or additional training shall receive training through available Department training and the Case Management Agency internal training.
Case Management Agency staff must pass competency-based training requirements as defined by the Department including but not limited to disability/cultural competency, person-centeredness, soft skills, as well as program specific knowledge and skills.
Case Management Agencies are responsible for providing quality oversight of their staff work product. At least quarterly, the Case Management Agency shall audit case records to evaluate Case Management performance. The Case Management Agency shall audit ten percent (10%) of the Case Management Agency average monthly caseload size or ten individual case records, whichever is higher.

a. The Case Management Agency shall utilize the audit form issued by the Department for Case Management Agency quality oversight audits.

b. The Case Management Agency shall audit each Case Manager employed by the Case Management Agency at least once per year.

c. The Case Management Agency shall provide the results of the audit to the Department and shall utilize audit results as part of the Case Management Agency quality assurance efforts. 8.7300 Community Centered Board 1. A Community Centered Board is the Agency, in addition to the Case Management Agency, responsible for leveraging local and regional resources to meet unmet needs for individuals with Intellectual and Developmental Disabilities (IDD) and their families 2. Beginning in 2024, at each Case Management Agency contract period or every ten years, whichever is longer, not for profit entities that have held a previous Community Centered Board designation and are seeking designation as a Community Centered Board, shall submit an application or request for designation to the Department.

Applications shall be submitted in a form and manner specified by the Department which shall be made available to Applicants upon request.
The Department shall notify all Applicants by email to the Community Centered Board (CCB) Executive Director of the designation or non-designation.
The designation shall be valid for up to a ten-year period based on Department approval.
Designation of a Community Centered Board shall be based on the following factor only:

a. Prior Community Centered Board designation.

If no Agency requests the Community Centered Board designation in a defined service area, Community Centered Board (CCB) designation for that area will be discontinued for that defined service area. 8.7400 Home and Community-Based Services Provider Agency 8.7401 Statement of Purpose and Scope A. The purpose of this Section 8.7400 is to outline requirements for Home and Community-Based Services (HCBS) Provider Agencies. These rules apply to all HCBS waivers and Community First Choice. 8.7402 Definitions: Unless otherwise specified, the following definitions apply throughout Sections 8.7000-7500.

A. Case Manager is as defined in Section 8.7100.A.8.

B. Case Management Agency is as defined in Section 8.7100.A.8.

C. Certification means a determination made by the Department, after considering a recommendation from the state survey Agency, that a Provider Agency is compliant with applicable Department statutes, rules, and program requirements for specific Home and Community-Based Services.

D. Contractor is as defined at 8.7001.A.1-B.

E. Department is as defined in Section 8.7200.B.14 F. Direct Care Worker means a non-administrative employee or independent Contractor of a Provider Agency or Consumer Directed Attendant Support Services employer who provides hands-on care, services, and support to older adults and individuals with disabilities across the Long-Term Services and Supports continuum within Home and Community-Based settings.

G. Discrimination is defined at Section 8.7001.A.3.

H. Guardian is as defined at Section 8.7001.A.3-B.

I. Health First Colorado means the state Medicaid program providing public health insurance for qualifying Coloradans.

J. Home and Community-Based Services Waivers are as defined at Section 8.7100.A.35.

K. An Incident means an event or occurrence that may endanger or negatively impact the mental and/or physical well-being of a Member.

L. Intellectual and Developmental Disability is as defined at Section 8.7100.A.40.

M. Legally Authorized Representative is as defined at Section 8.7001.A.7.

N. Member is as defined at Section 8.7001.A.8-B.

O. Medicaid means Health First Colorado, the Colorado state Medicaid program.

P. Organized Health Care Delivery System (OHCDS) means a Case Management Agency that contracts with other qualified providers to furnish services authorized in any of the Home and Community-Based Services waivers. The OHCDS is the Medicaid provider of record for a Member whose services are delivered through the OHCDS.

Q. Prior Authorization Request (PAR) is as defined at 8.7202.B.

R. Protected Health Information (PHI) means individually identifiable health information, including, without limitation any information, whether oral or recorded in any form or medium that relates to the past, present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

Protected Health Information (PHI) includes, but is not limited to, any information defined as Individually Identifiable Health Information pursuant to 42 C.F.R. § 160.103.

S. Provider Agency is as defined at Section 8.7001.A.12-B.

T. Provider Care Plan means the documented approach the Provider Agency plans to take in the provision of services. The purpose of the Provider Care Plan is to outline the service(s) that will/is provided with corresponding functional goals and objectives that describes the need for the service and the anticipated benefit to the Member. The Provider Care Plan determines the focus of the services, while also documenting the scope, duration and frequency to which each service will be provided.

U. Provider Participation Agreement is as defined at Section 8.7001.A.14-B V. Provider Specialty means a service that an HCBS Provider Agency may deliver and be reimbursed for upon meeting the service-specific qualifications and enrolling through the Department’s Fiscal Agent.

W. Telehealth means the provision of health care remotely using telecommunications technologies to provide approved services and supports through HCBS waivers when the Member is in a different location from the 8.7403 Provider Agency Certification, Decertification and Termination A. Certification 1. For services that require HCBS Certification, Provider Agencies shall obtain Certification prior to rendering or billing for services.

A Provider Agency seeking HCBS Certification must submit a request to the Department or its agent.
Upon receipt of the request, the Department or its agent shall forward Certification information and relevant state application forms to the requesting Agency.
Upon receipt of the completed application from the requesting Agency, the Department or its agent shall review the information and complete an initial review of the Agency, based on the state regulations for the service for which Certification has been requested.
Following completion of the initial review, the Department or its agent shall notify the Provider Agency Applicant of its recommendation by forwarding the following information:

a. Results of the initial survey;

b. Recommendation of approval, denial, or provisional approval of Certification; and c. If appropriate, a Corrective Action Plan to satisfy the requirements of a provisional approval.

Determination of Certification approval, provisional approval, or denial shall be made by the Department after the completed application is submitted by the Agency.

B. Change in Information 1. Provider Agencies shall notify the Department of any material or substantial change in information contained in the enrollment application given to the Department by the Provider Agency. This notification shall be made in the Provider Portal within 35 calendar days of the event triggering the reporting obligation. A material or substantial change includes a change in ownership; disclosures; licensure; federal tax identification number, bankruptcy; address, telephone number, or email address; criminal convictions related to involvement in any Medicare, Medicaid or Social Security Act, Title XX Health Services Block Grant program; or change in Geographic Service Area.

Pursuant to Section 8.130.45, Provider Agencies shall notify the Department within 35 calendar days of the loss or termination of Certification and/or licensure that is required for Home and Community- Based Services provider enrollment. The notification shall be submitted through the Provider Portal as a maintenance application to terminate the Provider Agency’s enrollment of a specialty or as a Medicaid provider.

C. Decertification 1. The Department may decertify a Provider Agency if any of the following occur:

a. The Provider Agency fails to comply with any federal or state statute, rules, or guidance.

b. The Provider Agency fails to comply with any lawful requests by the Department or its agents, including providing timely access to records.

c. The Provider Agency is no longer eligible to provide the services for which the provider has received Certification.

d. The Provider Agency poses a threat to the health, safety, or welfare of Medicaid Members.

Decertification may occur without prior notice if the decertification is imperatively necessary for the preservation of the public health, safety or welfare and observance of this notice requirement would be contrary to the public interest. For any decertification action taken without prior notice, the Department shall issue a written notice of decertification within five business days of the action.
If the Provider Agency elects to dispute the decertification, the Department must receive the Provider Agency’s written request to dispute the decertification within thirty (30) calendar days of the date of the decertification notice or the dispute will not be considered.
The Department’s determination on the decertification dispute shall include a statement of the Provider Agency's appeal rights set forth in

Section 8.050.

The effective date of the inactivation may be backdated to the date of the occurrence described above. 8.7404 Change of Ownership A. Certified Provider Agencies and those licensed by Colorado Department of Public Health and Environment (CDPHE) that are undergoing a change of ownership (CHOW) shall complete both the CDPHE CHOW process and the Department's CHOW process concurrently.

B. A CHOW resulting in a change of Federal Employer Identification Number (EIN) terminates the original owner’s Provider Participation Agreement. The new owners shall submit a new enrollment application through the Provider Enrollment Portal that includes the original owner's information, the new owner’s EIN, and a new Provider Participation Agreement. The change of ownership enrollment application cannot be processed for approval until the original owner completes and submits a voluntary disenrollment request through the Provider Web Portal.

The new owner shall meet licensing, Certification, and approval process standards prior to enrollment. 8.7405 Documentation A. In addition to the documentation required by 8.130.2, HCBS Provider Agency documentation shall also include the information below in the following categories:
Incremental units of service a. Location of service provided;

b. Time and date service was provided, including beginning and end time;

c. Name of individual rendering service;

d. Service(s) rendered, and the exact nature of the specific tasks performed that align with the service definition(s) in 8.7500.

e. Documentation of any changes in the Member’s condition or needs and action taken because of the changes; and f. Units of service provided.

Per-diem units of services a. Medication Administration Record if applicable;

b. Daily attendance tracker; and c. Notes, which shall include:

i. Activities Member participated in;

ii. Respite services or overnight stays elsewhere if applicable. 8.7406 Insurance Requirements A. Provider Agencies shall maintain liability insurance in an amount sufficient to cover total bodily injury or property damage liability arising from a single incident.

B. Provider Agencies managing personal needs funds shall comply with all licensing and bonding requirements.

C. Provider Agencies rendering reimbursable Non-Medical Transportation (NMT) services shall maintain liability insurance with the following automobile liability minimum limits:

Bodily injury (BI) $300/$600K per person/per accident; and 2. Property damage $50,000, or 3. $500,000 combined single limit D. Drivers who utilize their personal vehicle on behalf of a Provider Agency to provide reimbursable NMT shall maintain the following minimum automobile insurance coverage, in addition to the insurance maintained by the Provider Agency:
Bodily injury (BI) $25/$50K per person/per accident; and 2. Property damage $15,000. 8.7407 HCBS Provider Agency Billing A. Claims for HCBS services are payable only if submitted in accordance with the following procedures:
Provider Agencies shall verify Member eligibility prior to delivering services;
Provider Agencies shall verify a Prior Authorization Request (PAR) has been approved for the services in question, prior to service provision and claim submission;
Claims shall be submitted to the Fiscal Agent in accordance with Department billing manuals and policies, outlined in Section 8.043;
Claims shall only be submitted for services the Provider Agency is enrolled to provide, including correct HCBS specialties;
Claims shall only be submitted for services provided in accordance with all applicable federal and state statutes, regulations, and other authorities;
Submitted claims shall include all data elements required to complete the National Uniform Claim Committee Form 1500 (CMS 1500).

B. Payment shall not exceed rate shown in the Health First Colorado Fee Schedule in effect on the date services are provided.

C. Pursuant to § 25.5-4-301, C.R.S., Provider Agencies shall not collect copayments or seek reimbursement from eligible Members for covered services. 8.7408 Policies and Procedures A. Provider Agencies shall establish and maintain policies and procedures for each of the items below.

Staffing and employment a. Provider Agencies shall have written policies and procedures for recruiting, selecting, orienting, training, and terminating employees and Contractors. Such policies shall include procedures for conducting criminal background checks, a Colorado Adult Protection Services (CAPS) check, and reference checks prior to employing staff or Contractors providing supports and services, and mitigation procedures to be used if the Provider Agency becomes aware of information that indicates a staff Member or volunteer could pose a risk to the health, safety, and welfare of the Members served.

b. Provider Agencies shall have written policies and procedures to establish qualifications for employees and Contractors. Such policies shall include:

i. Responsibilities assigned to each employee job description.

ii. Procedures for initial and continuing training of staff to ensure all duties and responsibilities are accomplished in a competent manner.

iii. Supervision and management of staff and oversight of contractors.

iv. Restrictions prohibiting staff on-site access if they are under the influence of alcohol or illicit drugs.

Medication Administration a. Provider Agencies shall establish and maintain policies and procedures for the administration of medication including administration by gastrostomy as part of gastrostomy services described at Section 8.7416 b. Provider Agencies shall establish and maintain written policies and procedures for the appropriate procurement, storage, distribution, and disposal of medications.

i. All medications shall be stored under proper conditions of temperature and light, and with regard for safety.

ii. Discontinued and outdated medications, and medication containers with worn, illegible, or missing labels shall be promptly disposed of in a safe manner.

iii. A record shall be maintained of missing, destroyed, or contaminated medications.

c. Medication reminder boxes shall be used in accordance with

Section 25-1.5-303(1), C.R.S.

Protected Health Information (PHI)

a. Provider Agencies shall have written policies governing access to duplication and dissemination of information from the Member’s records in accordance with Section 26-1-114(3), C.R.S. and 42 C.F.R. § 164.502. Within the Agency policies for protection of confidentiality, Provider Agencies shall have written policies and procedures for confidential access to Member information by employees as needed to provide the assigned services.

Mistreatment, Abuse, Neglect, and Exploitation (MANE)

a. Pursuant to Section 25.5-10-221, C.R.S., Provider Agencies shall prohibit MANE of any Member.

b. Provider Agencies shall have written policies and procedures for thoroughly investigating cases of alleged or suspected MANE of any Member.

c. MANE policies and procedures shall be consistent with state law and provide a mechanism for monitoring to detect instances of MANE. Monitoring is to include, at a minimum, the review of:

i. Incident reports;

ii. Verbal and written reports of unusual or dramatic changes in behavior(s) of Members; and, iii. Verbal and written reports from Members, advocates, families, Guardians, and friends of Members.

d. Provider Agencies shall establish and maintain procedures for identifying, reporting, reviewing, and investigating all allegations of MANE. Documentation of all investigations shall be maintained.

Documentation shall include:

i. The Incident report and preliminary results of the investigation;

ii. A summary of the investigative procedures utilized;

iii. The full investigative finding(s); and iv. The actions taken.

e. Provider Agencies shall i. Ensure that appropriate disciplinary actions up to and including termination, and appropriate legal recourse are taken against employees and Contractors who have engaged in MANE.

ii. Ensure that employees and Contractors are made aware of applicable state law and Agency policies and procedures related to MANE.

iii. Require immediate reporting when observed by employees and Contractors according to Agency policy and procedures and to the Agency administrator or his/her designee;

f. Require reporting of allegations within 24 hours to a Legally Authorized Representative and Case Management Agency.

Protection of individual rights a. All Provider Agencies shall have written policies and procedures concerning the exercise and protection of individual rights pursuant to Sections 25.5-10-218 through 231, C.R.S. and

Section 8.7001.

b. Provider Agencies shall supply Members with a Plain Language explanation of their rights.

Non-discrimination policies a. Provider Agencies shall have policies in place that prohibit Discrimination on the basis of race, religious or political affiliation, gender, national origin, age, or disability and outline the Agency's follow up procedures to address any discriminatory acts.
Dispute resolution a. Provider Agencies shall have procedures for resolution of disputes involving Members:

i. Who are found ineligible to receive the service(s) from the Provider Agency;

ii. Whose services or supports are to be terminated; or, iii. Whose services set forth in the Person-Centered Support Plan are to be changed, reduced, or denied.

b. The procedure shall contain an explanation of the process to be used by Members, prospective Members, or Legally Authorized Representatives if they are dissatisfied with the decision or action of the Provider Agency.

c. The dispute resolution procedures of the Provider Agency shall, at a minimum, provide the parties the opportunity to present information and evidence in support of their positions to an impartial decision maker. The impartial decision maker may be the director of the Agency taking the action or their designee. The impartial decision maker shall not have been directly involved in the specific decision at issue.

d. Provider Agencies shall supply Members with a Plain Language explanation of available dispute resolution procedures, along with outside Agency contact information, including phone numbers, for assistance.

e. Provider Agencies must provide Members with 15 days advance notice of any change to or termination of services.

Grievances and Complaints a. Provider Agencies shall have procedures setting forth a process for the timely resolution of Grievances or Complaints of Members, prospective Members, or Legally Authorized Representatives, as appropriate. Use of the Grievance/Complaint procedure shall not prejudice the future provision of appropriate services or supports.

No individual shall be coerced, intimidated, threatened, or retaliated against because the individual has exercised his or her right to file a Grievance/Complaint or participate in the Grievance b. The Grievance/Complaint procedure shall, at a minimum, include:

i. Identification of the staff Member responsible to receive Grievances/Complaints;

ii. A mechanism to receive Grievances/Complaints verbally and/or in writing that requires staff receiving a verbal Grievance/Complaint to record any verbal Grievances and/or Complaints;

iii. Identification of a support person(s) to assist a Member to submit a Grievance/Complaint;

iv. An opportunity for individuals to meet and attempt to reach a mutually acceptable solution;

v. Timelines for the resolution of the Grievance/Complaint;

vi. Consideration by the Agency director or designee if the Grievance/Complaint cannot be resolved at a lower level; and, c. Provider Agencies shall supply Members with a Plain Language explanation of available Grievance/Complaint procedures, along with outside Agency contact information, including phone numbers, for assistance.

d. Provider Agencies shall allow Grievances/Complaints to be submitted anonymously.

Independent Contractors a. Provider Agencies may utilize the services of independent Contractors at their discretion. If an Agency does utilize independent Contractors, it shall conduct the vetting, training, and monitoring of, and take corrective action against Contractors.

b. Nothing in these regulations shall create any contractual relationship between any independent Contractor of the Provider Agency and the Department.

Contingency planning a. Provider Agency shall have a documented contingency plan for providing services if a Member’s caregiver or direct service provider are unavailable due to an emergency or unforeseen 11. Telehealth a. Provider Agencies that provide HCBS Telehealth services shall establish and maintain documented policies on the use of Telehealth services that comply with Section 8.7562.
Written Plans to Address Emergencies a. An emergency can be defined as an unforeseen situation that may endanger the lives of Members and/or staff, as well as disrupt for a short time the normal operations within a setting or Agency.

b. Emergencies can include, but are not limited to:

i. Medical Emergencies ii. Public Health Emergencies iii. Fire iv. Natural Disasters c. Each HCBS Provider Agency shall have written policies and procedures to address emergencies, unless otherwise specified within service regulations.

i. Plans should include how the agency prepares for loss of staff, various emergencies, back up plans, protocols, etc. should any staff be affected.

ii. Day Habilitation services shall have written plans to address emergencies regardless of service location or type of 8.7409 Personnel A. Employee and Contractor records 1. The Provider Agency shall maintain records documenting the qualifications and training of employees and contractors who provide services to Members.

Provider Agencies shall maintain a personnel record for each employee or Contractor. The record shall contain:

a. Documentation of qualifications.

b. Documentation of trainings completed.

c. Documentation of supervision and performance evaluation or contractor management and oversight.

d. Documentation that the employee/Contractor was informed of all policies and procedures required by Section 8.7409.

e. Documentation of the job description or signed contract.

f. Documentation of a criminal background check and a CAPs check.

B. License/Certification 1. The Provider Agency shall meet the enrollment requirements for each service it provides prior to providing services. The agency shall ensure each employee or independent Contractor maintains the necessary and appropriate license and/or Certification to render services. The Provider Agency shall maintain documentation of current and valid individual license(s) and Certification(s) in the personnel record.

C. Medication administration 1. All employees and Contractors, not otherwise authorized by law to administer medication, who assist and/or monitor Members in the administration of medications or the filling of medication reminder boxes shall have passed a “Qualified medication administration person” or “QMAP” competency evaluation offered by an approved training entity, and shall be listed on the Department’s list of persons who have passed the requisite competency evaluation as defined in 6 C.C.R. 1011-1,

Chapter 24. Each facility shall ensure the qualifications of the QMAP employee or Contractor per 6 C.C.R. 1011-1, Chapter 24, Section 3.

D. Trainings 1. Provider Agencies shall have an organized program of orientation and training of sufficient scope for employees and Contractors to carry out their duties and responsibilities efficiently, effectively, and competently. Training shall be provided prior to employees or Contractors having unsupervised contact with Members. The training program shall, at a minimum, provide for and include:

a. Training related to person-centered practices, the role of the Person-Centered Support Plan, and the concept of dignity of risk;

b. Training related to health, safety, and services and supports to be provided related to the specific needs and diagnoses of Members served;

c. Training specific to the individual(s) for whom the employees or Contractors will be providing services and supports which includes medical or behavioral protocols, supervision, dietary and Activities of Daily Living (ADL) needs; and d. Provider Agencies’ internal policies and procedures.

E. Colorado Adult Protective Services (CAPS) and Criminal Background Checks 1. Provider Agencies shall conduct criminal background checks and reference checks and compare the employee’s/independent Contractor’s name against the list of all currently excluded individuals maintained by the Office of Inspector General prior to employing staff or independent Contractors to provide services and supports to Members. All costs related to obtaining a criminal background check shall be borne by the Provider Agency. Background checks shall be completed every five years for each employee and Contractor who provides direct care to Members.

Provider Agencies shall comply with the CAPS check requirements set forth at §26-3.1- 111(6)(a), C.R.S. and 12 C.C.R. 2518-1, § 30.960.G-J.

The Provider Agency shall maintain accurate records and make records available to the Department upon request.

a. HCPF or its designee shall act as the oversight Provider Agency described at 26-3.1-111(6)(a)(III) and shall receive CAPS check results for Provider Agencies requiring Certification, the prospective Agency shall:

i. Submit to the CDPHE a copy of the CAPS check results as

part of their initial application for Certification.

Substantiated findings as outlined in Section 8.7409 E.2.b may result in the denial of the Medicaid enrollment application.

b. Direct Care Workers with any of the following are prohibited from providing direct care to any Member:

i. An allegation of MANE or harmful act, as defined in Section 26-3.1-101, C.R.S., substantiated by Adult Protection Services (APS) within the last 10 years, at a severity level of “Moderate” or “Severe” as defined in 12 C.C.R. 2518-1;

Section 30.100;

ii. Three or more allegations of MANE or harmful act, as defined in Section 26-3.1-101, C.R.S., substantiated by APS within the last five years, at the minor severity level as defined in 12 C.C.R. 2518; Section 30.100; or iii. A criminal conviction of MANE against an at-risk adult defined at 26-3.1- 101, C.R.S.

iv. Only substantiated allegations for which the state level appeal process as defined as 12 C.C.R. 2518-1; Section 30.920 has concluded shall be included in the above exclusions list. 8.7410 Rendering services according to the Person-Centered Support Plan A. Provider Agencies shall provide all Provider Agencies identified in the Person- Centered Support Plan (PCSP) a copy of the PCSP. Provider Agencies shall maintain this plan on file and ensure it is accessible to all staff who need it.

B. Provider Agencies shall utilize the Person-Centered Support Plan as the basis for completing a Provider Care Plan. Any member of the Member Identified Team should be included in the development of the Provider Care Plan.

C. Provider Care Plan 1. All Provider Agencies identified in the Person-Centered Support Plan shall develop a Provider Care Plan for each Member.

The Provider Care Plan should, at a minimum, identify the following:

a. The service and care needs of the Member;

b. Provider Care Plan development date;

c. Goals or Objectives of the service(s);

d. A description of the specific services, supports, methodologies or interventions used to address the identified needs of the Member, written in plain language including;

i. information about the Member’s preferences ii. relevant medical information from medical and therapy providers (PCP, OT, PT, Speech, etc.)

g. Duration: Describes how long the service will be delivered, with the duration of the service corresponding to the abilities of the Member and is reflective of the billing unit identified by service;

h. Frequency: Identifies how often the service or support will be offered to the Member, according to their needs and preferences.

The Provider Care Plan shall assure the protection of the rights of Members as defined by the Department under applicable programs, including but not limited to Section 8.7001, et seq.
Provider Agencies shall follow specific service or care plan regulations for each covered benefit they render to a Member. Provider Care Plans may vary by name depending on the covered benefit, but will describe the information outlined above.
The Provider Care Plan shall be reviewed at least two times a year. as needed, to determine:

a. The results achieved;

b. If the needs of the Member are accurately reflected in the Provider Care Plan;

c. Whether the services and supports identified in the Provider Care Plan are appropriate to meet the Member's needs as assessed in the Person-Centered Support Plan; and d. What actions are necessary for the Provider Care Plan to be successfully implemented.

D. Members receiving services shall be included in developing the Provider Care Plan and have the freedom to choose from willing Provider Agencies.

E. Provider Agencies shall coordinate with other Provider Agencies, when F. A Provider Agency shall not condition a Member’s receipt of any service on the Member’s agreement to receive other services from the provider.

G. A Provider Agency shall not discontinue or refuse to provide agreed upon services to a Member unless documented efforts have been made to resolve the situation that triggers such discontinuation or refusal to provide services. 8.7411 Incident Reporting A. Provider Agencies shall complete the timely reporting, recording, and reviewing of Incidents which shall include, but not be limited to:

Death of Member receiving services;
Hospitalization of Member receiving services;
Medical emergencies, above and beyond first aid;
Allegations of MANE;
Injury to Member or illness of Member;
Damage or theft of Member’s personal property;
Errors in medication administration;
Lost or missing person receiving services;
Criminal activity; and 10. Incidents or reports of actions by Member receiving services that are unusual and require review.

B. A Provider Agency must submit a verbal or written report for all Critical Incidents, as defined at Section 8.7201.L.5, to the HCBS Member’s Case Management Agency Case Manager within 24 hours of discovery of the actual or alleged Incident. All other incidents must be reported to the Case Manager within two business days. The report must include:

Name of person reporting;
Name of Member who was involved in the Incident;
Member’s Medicaid identification number;
Name of persons involved or witnessing the Incident;
Incident type;
Date, time, and duration of Incident;
Location of Incident;
Persons involved;
Description of Incident;
Description of action taken;
Whether the Incident was observed directly or reported to the Provider Agency;
Name of person notified;
Follow-up action taken or where to find documentation of further follow-up;
Name of the person responsible for follow up; and 15. Resolution, if applicable.

C. If any of the above information is not available and reported to the Case Management Agency Case Manager within 24 hours of the Incident, the Provider Agency must submit follow up information as soon as it is obtained.

D. Additional follow up information may also be requested by the Case Manager, or the Department. A Provider Agency is required to submit all follow up information within the timeframe specified by the Case Management Agency.

E. Provider Agencies shall review and analyze information from Incident reports to identify trends and problematic practices which may be occurring in specific services and shall take appropriate corrective action to address problematic practices identified.

F. Provider Agencies shall provide victim support for any allegations of MANE. 8.7412 Environmental Standards for Provider-Owned or -Controlled Settings A. Provider Agencies shall ensure that Provider-Owned or -Controlled Settings defined at Section 8.7001.A.13 and .14 shall comply with all the environmental standards outlined below, in addition to the requirements set forth in Section 8.7001.B 1. The Provider Agency shall conduct fire drills at least quarterly at each physical facility.

All physical facilities shall have working smoke detectors installed and fire extinguishers that have not expired in easily accessible locations that comply with 8 C.C.R. § 1507-101:3.
All physical facilities shall have first aid supplies available.
All Provider Agencies shall comply with the Americans with Disabilities Act (ADA) requirements for accessibility of physical facilities.

B. Physical facilities shall meet all applicable fire, building, licensing, and health 8.7413 Room and Board A. Effective January 1 of each year, the Department shall establish a uniform room and board payment for all Medicaid Members receiving residential HCBS in or through:

Alternative Care Facility 2. Supportive Living Program 3. Transitional Living Program 4. Individual Residential Service and Supports 5. Group Residential Services and Supports 6. Children’s Habilitation Residential Program Out-of-Home residential settings 7. Mental Health Transitional Living Homes B. The standard room and board amount may not exceed an amount equal to the monthly Supplemental Security Income (SSI) benefit , less an amount specified by the Department for personal needs.

C. Provider Agencies shall not charge a Medicaid Member more than the Department’s annually established room and board rate. The room and board rate shall include all food and meals, basic furniture such as a bed, dresser, and nightstand, linens, utilities, and basic toiletries to include toilet paper, soap, tissues, shampoo, toothpaste, and toothbrush. 8.7414 Medication Administration A. Provider Agencies shall provide sufficient support to Members in the use of prescription and non- prescription medications. Members shall be presumed capable of self-administration unless they are determined otherwise. The type and level of medication administration support provided shall be determined by the results of an assessment performed by a qualified person. Medications shall be administered only by persons as authorized by the Colorado Department of Public Health and Environment (CDPHE).

No prescription medication shall be administered without a written order by a licensed medical professional. Medications/prescriptions shall be reviewed by a licensed medical professional annually, or more frequently if recommended by the licensed medical professional or required by law.
The Provider Agency shall ensure that a Member’s refusal to take medication(s) and/or any adverse reaction to a medication are documented in the Member’s medication administration record and reported to the Member’s licensed medical provider.
For Members receiving assistance with medication administration, the licensed medical provider’s order shall be maintained in the Member’s 4. Qualified medication administration personnel shall record all medications administered, including the date, time and amount of each medication administered.

B. For Members who are independent in the administration of medications and who do not require monitoring each time medication is taken, the Provider Agency shall review medications quarterly to determine that medications are taken correctly.

C. CHRP Medication Administration 1. If medications are administered to a Member during the course of HCBS- CHRP service delivery the following shall apply:

a. Medications must be prescribed by a licensed medical professional.

Prescriptions and orders must be kept in the Member’s record.

b. HCBS-CHRP Provider Agencies must complete on-site monitoring of the administration of medications to waiver Members including inspecting medications for labeling, safe storage, completing pill counts, reviewing, and reconciling the medication administration records, and interviews with staff and Members.

c. CHRP Habilitation Provider Agencies providing Foster Care Homes, Kinship Foster Care Homes, Specialized Group Facilities, Residential Child Care Facilities, Licensed Child Care Facilities (less than 24 hours) must ensure compliance with the Colorado Department of Human Services rules regarding medication administration practices.

f. Host Homes Provider Agencies and Contractors must comply with the requirements for the use of medication administration at

Section 8.7414 for Members aged 18 to 20 years receiving Habilitation services.

e. Persons administering medications shall complete a course in medication administration through a training entity approved by the Colorado Department of Public Health and Environment.

D. Administration of Auto-Injectable and Pen Injector Medications (Applicable to Provider Agencies serving Members of the Developmental Disabilities (DD)

Waiver only)

For the purposes of this Section D, the following definitions apply:

a. Auto-Injector / Auto-Injectable Medication means a pre-filled, singleuse injection device designed for rapid self-administration or administration by another trained person. Medication is delivered using a spring-loaded mechanism activated by pressing the device against the skin or depressing a button. Examples include, but are not limited to, glucagon auto-injectors and glucagon-like peptide–1(GLP-1) auto-injectors.

b. Pen Injector means a pre-filled, multi-dose injection device designed for self-administration or administration by another trained person. Pen injectors may deliver fixed or variable doses, may be disposable or reusable, and require manual needle insertion and activation via a button or plunger. Examples include, but are not limited to, insulin pens and GLP-1 auto-injectors.

c. Medication Injection Services means the administration of medication through a pre-filled Auto-Injector or Pen Injector pursuant to a written order from a licensed medical professional.

Residential Services and Supports settings that provide Medication Injection Services shall comply with all applicable federal and state laws and regulations governing medication administration, including but not limited to CDPHE Medication Administration Regulations, Colorado Board of Nursing delegation requirements, and applicable Medicaid Home and Community-Based Services (HCBS) requirements.
Unlicensed individuals employed or contracted with a Provider Agency that serves members of the DD waiver may provide Medication Injection Services only when all of the following requirements are met:

a. A physician or other authorized practitioner has provided a written order specifying the Auto-Injector or Pen Injector medication.

b. The unlicensed individual has completed specialized, devicespecific training in the use, storage, disposal, administration and adverse reactions of the auto-injector or pen injector, provided by a licensed nurse, physician, pharmacist, or other licensed practitioner.

c. Before an unlicensed individual performs Medication Injection Services, a licensed nurse, physician, or other authorized practitioner shall:

i. Provide initial and at least annual training;

ii. Document the dates of training;

iii. Document that the unlicensed individual has demonstrated proficiency in carryingout the individualized protocol;

iv. Document the ongoing oversight and training to be provided to the unlicensed individual to maintain proficiency, and v. Sign and date the training documentation, including professional title.

d. The Provider Agency documents in the Member’s record:

i. The written medication order;

ii. Documentation of All required training; and iii. Documentation of Each administration, including the date, time, amount administered, route of administration, and any problems encountered, and actions taken as directed by the individualized protocol.

e. The Provider Agency maintains written policies and procedures addressing emergency response, frequency of ongoing monitoring, identification of adverse reactions, storage and disposal of devices, and replacement procedures.

Nothing in this Section D shall be construed to prohibit or impede the delegation of nursing tasks, including but not limited to subcutaneous injection of medication or blood glucose monitoring, by a licensed nurse to an unlicensed caregiver when such delegation is conducted within the permissible scope of practice and the agency or facility has written policies and procedures addressing delegation. 3 C.C.R. 716-1.13 (2026) is hereby incorporated by reference. This incorporation by reference excludes later amendments to, or editions of the referenced material. The Department maintains copies of the incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 303 E. 17th Avenue, Suite 1100, Denver, CO80203. Certified copies are available at cost upon 8.7415 Psychotropic Medications A. Psychotropic medication for Members shall be used only for diagnosed psychiatric disorders and:
When prescribed by a licensed medical professional following a psychiatric evaluation; and 2. After informed consent of the Member or Legally Authorized Representative has been obtained.

B. Administration of psychotropic medications to a Member receiving residential services and supports shall:

Be as directed in a time-limited prescription of no more than 90 days written by an authorized medical professional and reviewed at least annually by medically licensed provider;
Be administered per prescriber's orders;
Include regular monitoring of the Member for side effects;
Include documentation of the effects of medications and any changes in medication;
Not be ordered on a PRN or “as needed” basis; and 6. Be reviewed by the Human Rights Committee, if the Member is enrolled in a waiver in which the committee is applicable.

C. The Provider Agency shall ensure all employees and Contractors are aware of and document potential side effects and adverse reactions to psychotropic medications. 8.7416 Gastrostomy Services for Developmental Disabilities (DD) and Supported Living Services (SLS) Waivers A. Gastrostomy services means assistance with the ingestion of food or administration of medication through gastrostomy tubes.

B. Licensed Group Residential Services and Supports (GRSS) settings shall comply with all applicable regulations at 6 C.C.R. 1011-1; Chapter VIII, Section 17 for the administration of gastrostomy services.

C. Gastrostomy services shall not be administered by an unlicensed individual unless that individual is trained and supervised by a licensed physician, nurse, or other practitioner. The licensed nurse, physician or other practitioner overseeing the initial and periodic training shall document in the employee or Contractor record:

The date or dates on which the training occurred;
Documentation confirming that, in the opinion of such licensed nurse, physician, or other practitioner, the unlicensed individual has reached proficiency in performing all aspects of the individualized protocol referred to in section 8.7416.E.1; and, 3. The legible signature and title of such licensed nurse, physician, or other practitioner.

D. A licensed nurse, physician or other authorized health care practitioner shall monitor each unlicensed person performing the gastrostomy services for a Member on a quarterly basis during the first year and semi-annually thereafter, unless more frequent monitoring is required by the individualized protocol.

The supervising nurse, physician or other authorized health care practitioner shall document each instance of monitoring of the Member.

E. The Provider Agency shall ensure that a physician, licensed nurse, or other practitioner has developed a written, individualized gastrostomy service protocol for each Member requiring such service, and that the protocol is updated each time the orders change for that Member’s gastrostomy services.

The Provider Agency shall maintain the individualized protocol in the record of the Member. The protocol shall include, at a minimum:

a. The proper procedures for preparing, storing, and administering gastrostomy services;

b. The proper care and maintenance of the gastrostomy site, needed materials and equipment;

c. The identification of possible problems associated with gastrostomy services; and, d. A list of health professionals to contact in case of problems, including the physician of the individual receiving gastrostomy services and the licensed nurse(s) and/or physician(s) who are responsible for monitoring the unlicensed person(s) performing gastrostomy services pursuant to section 8.7416.

F. The Provider Agency shall ensure that a physician, licensed nurse, or other practitioner provides training to any unlicensed individual who may provide gastrostomy services. Documentation of initial and any subsequent training shall be kept in the Member’s record.

G. The Provider Agency shall ensure that the physician, licensed nurse, or other practitioner observes and documents the unlicensed individual performing gastrostomy services and documents the monitoring in the record of the Member receiving gastrostomy services.

H. For each gastrostomy service received by a Member, the Provider Agency shall ensure the following documentation is included in the Member’s record:

A written record of each nutrient and fluid administered;
The beginning and ending time of nutrient or fluid intake;
The amount of nutrient or fluid intake;
The condition of the skin surrounding the gastrostomy site;
Any problem(s) encountered and action(s) taken; and 6. The date and signature of the person performing the procedure. 8.7417 Telehealth A. Provider Agencies that choose to use HCBS Telehealth shall comply with all regulations at Section 8.7562. 8.7418 Base Wage Requirement for Direct Care Workers A. Base Wage Requirement for Direct Care Workers Definitions 1. Base Wage means the minimum hourly rate of pay of a Direct Care Worker for the provision of Home and Community-Based Services (HCBS) required by the Colorado Department of Health Care Policy and Financing.
Direct Care Worker is as defined in Section 8.7402.F.
Direct Benefit means compensation that is directly bestowed conferred onto Direct Care Workers for their sole benefit and does not include direct benefits to the Provider Agency which may have an indirect benefit to the Direct Care Workers.
Minimum Wage means the rate of pay established in accordance with

Section 15 of Article XVIII of the State Constitution and any other minimum wage established by federal or local laws or regulations. In addition to state wage requirements, federal or local laws or regulations may apply minimum, overtime, or other wage requirements to some or all Colorado employers and employees. If an employee is covered by multiple minimum or overtime wage requirements, the requirement providing a higher wage, or otherwise setting a higher standard, shall apply.

Plan of Correction means a formal, written response from a Provider Agency to the Department on identified areas of non-compliance with requirements listed in Section 8.7418.D.
Participant Directed Program means a service model that provides participants who are eligible for Home and Community-Based Services the ability to manage their own in-home care, or have care managed by a Legally Authorized Representative, provided by a direct care worker.

Participant Directed Program participants, or their Legally Authorized Representative, operate as Employers of Record with an established FEIN.

Per Diem wage means daily rate of pay for Direct Care Workers for the provision of Home and Community-Based Services (HCBS).

B. Qualifying Services for Base Wage Requirement for Direct Care Workers 1. When applicable, the Department will increase reimbursement rates for select services to support the base wage. Provider Agencies must use this increased funding to ensure all Direct Care Workers are paid the wage required by the Department or higher within the timeframe established by the Department. Services requiring Direct Care Workers to be paid at least the base wage include:

a. Adult Day Services b. Alternative Care Facility (ACF)

c. Community Connector d. Consumer Directed Attendant Support Services (CDASS)

e. Foster Care Home (Children’s Habilitation Residential Program)

f. Group Home Habilitation (CHRP)

g. Group Residential Support Services (GRSS)

h. Homemaker i. Homemaker Enhanced j. Host Home (CHRP)

k. In-Home Support Services (IHSS)

l. Individual Residential Support Services (IRSS)

m. Job Coaching n. Job Development o. Mental Health Transitional Living Homes p. Mentorship q. Pediatric Personal Care r. Personal Care s. Prevocational Services t. Respite u. Specialized Habilitation v. Supported Community Connections w. Supported Living Program x. Workplace Assistance 2. In the event that a Direct Care Worker is eligible for a minimum wage that exceeds the base wage requirement based on state or local minimum wage laws, the Provider Agency is required to compensate at the higher wage.

In the event that a Direct Care Worker is eligible for a per diem wage, the Provider Agency is required to increase the Direct Care Worker’s per diem wage by the percent of the Department’s reimbursement rate increase.

C. Base Wage Provider Agency Responsibilities 1. A Provider Agency that renders qualifying service(s) accepts responsibility to ensure qualifying Direct Care Workers currently under their employment are paid, at a minimum, the base wage.

The Provider Agency must ensure that contact information on file with the Department is accurate.
Provider Agencies shall notify Direct Care Workers annually who are affected by the base wage requirement about Direct Care Worker rights, Direct Care Employer and Contractor obligations, and the minimum state and local direct care employment standards.
Provider Agencies shall publish and make readily available the Department’s designated contact for Direct Care Workers to submit questions, concerns, or complaints regarding the base wage requirement.
Provider Agencies shall submit specific information for each Direct Care Worker regarding wage rates, working hours, benefits, work location, employment status, employment type, services provided, independent Contractor agreements, and any other wage related information as requested by the Department. Provider Agencies shall submit the requested information within the Department-specified timeframe.
Provider Agencies shall keep true and accurate records to support and demonstrate that all Direct Care Workers who performed the applicable services received at a minimum the base wage or a per diem wage increase.
Records shall be retained for no less than six (6) years and shall be made available for inspection by the Department upon request. Records may include, but are not limited to:

a. Payroll summaries and details, pay stubs with details b. Timesheets c. Paid time off records d. Cancelled checks (front and back)

e. Direct deposit confirmations f. Independent Contractor documents or agreements g. Per diem wage documents h. Accounting records such as accounts receivable and accounts payable.

D. Base Wage Requirement for Direct Care Workers Reporting & Auditing 1. The Department has ongoing discretion to request information from Provider Agencies to demonstrate that all Direct Care Workers receive the required wage. All records related to the wage requirements for the applicable services shall be made available to the Department upon request, within specified deadlines.

Provider Agencies shall respond to the Department’s request for records to demonstrate compliance within the timelines and format specified by the Department. Incomplete or invalid submissions will be returned to Providers for corrections.
Failure to submit Direct Care Worker information as required or failure to provide adequate documents and timely responses may result in the Provider Agency being required to submit a plan of correction and/or be subject to an overpayment or penalty recovery. The Department may suspend payment of claims until requested information is received and approved by the Department.
If a plan of correction is requested by the Department, the Provider Agency shall submit the plan of correction by the date specified by the Department. The Provider Agency must notify the Department in writing within five (5) business days of receipt of the request if they will not be able to meet the deadline. The Provider Agency must explain the reason for the delay and the Department may or may not grant an extension in writing.
Upon the Department’s receipt of the plan of correction, the Department will accept, request modifications, or reject the proposed plan of correction. Modifications or rejections will be accompanied by a written explanation. If a plan of correction is rejected, the Provider Agency must resubmit a new plan of correction along with any requested documentation to the Department for review within five (5) business days of notification.
IIf the Department determines the Provider Agency is not in compliance with this Section 8.7418, the Department may recoup funds paid to the Provider Agency relating to the base wage increase or impose a penalty. 8.7419 Home and Community-Based Services Weekly Caregiver Limits 1. Definitions a. Caregiver means any individual that is paid to provide Qualifying Services as defined at Section 8.7419.1.s. This term also includes Direct Care Worker (DCW), defined at 8.7402.F, and any other individuals paid to perform such services.

b. Caregiver Compliance Review refers to the Department’s oversight to ensure Caregivers, Provider Agencies, CDASS Employers, and FMS Contractors are complying with State laws and regulations.

c. Caregiver Compliance Workbook refers to the Department-approved workbook that details the days worked, number of hours worked, services provided, and other relevant information that the Provider Agency, Caregiver, CDASS Employer, Department, and/or FMS vendor deem necessary for the Department to complete a compliance review.

d. Case Management Agency as defined in Section 8.7100.A.8 e. Case Manager as defined in Section 8.7200.B.5.

f. Consumer-Directed Attendant Support Services Authorized Representative as defined in Section 8.7515.B.5.

g. Consumer-Directed Attendant Support Services (CDASS) Employer means a Member enrolled in CDASS or their Authorized Representative, who is the legal employer of record for CDASS.

h. Emergency Situation means an unanticipated, short-term event that results in the immediate unavailability of a scheduled Caregiver and creates a risk to the member’s health, safety, or ability to remain in their home if services are not provided. In an Emergency Situation, a Caregiver may temporarily exceed the Weekly Caregiver Limit or the Per Day Hourly Limit per member to prevent a disruption in critical direct care service. The Emergency Situation must:

i. Be unexpected and not routinely foreseeable, ii. Be time-limited in duration to no more than 21 calendar days from the onset of the emergency, iii. Be necessary to address an immediate need, iv. Be used solely to prevent a gap in critical services, and v. Be documented in the Member’s file and maintained by the Provider Agency or FMS.

i. Enforcement means withholding of claim payments and/or recoupment of Medicaid funds for noncompliance with this rule.

j. False Representation means an inaccurate statement made by the Caregiver, Provider Agency, CDASS Member or Authorized Representative, or FMS Contractors that is relevant to a claim for k. Financial Management Services (FMS) Contractors as defined in Section 8.7515.B.15.

l. In-Home Support Services Authorized Representative as defined at

Section 8.7528.B.2.

m. Payment Hold Enforcement refers to the Department withholding claim payments to Provider Agencies or FMS Contractors for noncompliance with this rule.

n. Per Day Hourly Limit means the maximum number of hours a Caregiver may work and be reimbursed for in a single calendar day, from 12:00 a.m. through 11:59 p.m. A Caregiver may not be scheduled for, provide, or receive reimbursement for more than sixteen (16) total hours of care in a calendar day across any combination of the following services, whether provided to one or more Members collectively, unless permitted due to a documented Emergency Situation:

i. Consumer Directed Attendant Support Services as defined at

Section 8.7515, ii. In-Home Support Services as defined at Section 8.7528, iii. Personal Care as defined at Section 8.7538, iv. Homemaker as defined at Section 8.7527, v. Health Maintenance Activities as defined at Section 8.7523, vi. Long-Term Home Health as defined at Section 8.520, and/or vii. Private Duty Nursing as defined at Section 8.540.

o. Provider Agency: For purposes of Section 8.7419, Provider Agencies include HCBS provider agencies as defined at Section 8.7001.A.12-B and Home Health Agencies as defined at Section 8.520.1.L.

p. Provider Agency Caregiver Attestation refers to the annual attestation that Provider Agencies or CDASS Employers are required to sign and maintain. The FMS must retain copies of the signed attestation for each CDASS Employer. This attestation is a signed statement for the Provider Agency or CDASS Employer stating they understand that they are responsible for overseeing each Caregiver and must hold each Caregiver accountable to the Per Day Hourly Limit and Weekly Caregiver Limit, including any limit violations.

q. Qualifying Services include:

i. Consumer Directed Attendant Support Services as defined at

Section 8.7515, ii. In-Home Support Services (IHSS) as defined at Section 8.7528, iii. Personal Care as defined at Section 8.7538.

iv. Homemaker Services as defined at section 8.7527 v. Health Maintenance Activities as defined at Section 8.7523 vi. Long-Term Home Health Nursing Services as defined at Section 8.520.5.A.

vii. Certified Nurse Aide Services as defined at Section 8.520.5.B r. Rural or Frontier means counties or communities classified by the Colorado Rural Health Center in the County Designations system (see Colorado Rural Health Center, “Maps,” available at https://coruralhealth.org/resources/maps-resource).

s. Weekly Caregiver Limit means the maximum number of hours of Qualifying Services a Caregiver can provide to one Member in any week, from 12:00 a.m. Sunday to 11:59 p.m. Saturday. Unless documented by a pending or approved Weekly Caregiver Limit Exception Request, or in a documented Emergency Situation, no individual Caregiver may be scheduled for, or work more than, the following maximum hours:

i. Between July 1, 2026 and December 31, 2026: 84 hours per week;

ii. Between January 1, 2027 and June 30, 2027: 70 hours per week;

iii. From July 1, 2027 and ongoing: 56 hours per week.

t. Weekly Caregiver Limit Exception Request means a formal request submitted by a Provider Agency or CDASS Employer when an individual Caregiver must exceed the Weekly Caregiver Limit because the Member meets one of the criteria described in Section 8.7419.2. The request must include required supporting documentation provided by the Provider Agency or CDASS Employer.

Weekly Caregiver Limit Exception Request a. An exception to the Weekly Caregiver Limit will only be approved if the Member meets one of the following criteria:

i. Extraordinary clinical acuity, which means the Member has a complex diagnosis that results in medical fragility, creates a severe risk of hospitalization or death, and requires extraordinary clinical precautions or limitations on caregiving, such as those related to infection control or safety, that make continuity with a single caregiver clinically necessary and cannot be reasonably mitigated through measures such as personal protective equipment, as supported by clinical documentation.

ii. Demonstrated workforce access barriers, which requires meeting the criteria under Section 8.7419.2.a.ii.1 and 8.7419.2.a.ii.2:

Demonstrated workforce access barrier requires one of the a) The Member lives in a Rural or Frontier area and documented recruitment efforts demonstrate an inability to recruit or retain qualified Caregivers through the local Medicaid workforce; or b) The Member requires documented specialized skills not reasonably available through Medicaid workforce in the Member’s service area and for which a new Caregiver could not reasonably be trained within the timeframe necessary to safely meet the Member’s needs; or c) The Member can only communicate using an uncommon language and requires a Caregiver who speaks the same uncommon language. An uncommon language means a language for which qualified Caregivers are not reasonably available within the Member’s service area, as demonstrated by documented recruitment efforts and limited local provider capacity. Individualized communication preferences or familiarity with a specific Caregiver alone do not constitute sufficient justification for an exception.
All demonstrated workforce access barriers require multiple recruitment attempts that have failed despite documented outreach. Recruitment and retention efforts must demonstrate ongoing attempts to identify and maintain qualified caregivers appropriate to meet the member's assessed needs. At a minimum, documentation must include one or more of the following:

a) At least two (2) documented recruitment attempts conducted over a period of at least 30 calendar days through formal outreach methods such as job postings; or b) Documentation of at least two (2) unsuccessful caregiver retention efforts resulting in service disruption or inability to safely maintain staffing necessary to meet the Member's assessed needs.

iii. Transition or stabilization periods, which includes one or more of 1) Following a hospital discharge within the past 30 days; or 2) During a stabilization period following a Crisis, as defined at

Section 8.7100.A.18; or 3) While a Provider Agency or CDASS Employer recruits and trains additional staff following the loss, long-term illness, resignation, or termination of a Caregiver.

iv. End-of-life circumstances where stability and continuity with a primary Caregiver is clinically appropriate, and requires extraordinary clinical precautions or limitations on caregiving, such as those related to infection control or safety, that make continuity with a single caregiver clinically necessary and cannot be reasonably mitigated through measures such as personal protective equipment, as supported by clinical documentation.

b. In each Weekly Caregiver Limit Exception Request, the submission must include all of the following and be supplied by the Provider Agency or CDASS Employer:

i. Member-specific documentation, including documented diagnoses, functional/medical necessity and/or acuity;

ii. Risks and consequences to the Member if the exception is not granted;

iii. The following, as applicable:

Evidence of the extraordinary clinical acuity criteria met by the Member as described at Section 8.7419.2.a.
Documentation to support the demonstrated workforce access barriers as described at Section 8.7419.2.a.
Discharge summaries or crisis plans, and need for continuity of Caregiver.
End-of-Life diagnosis and need for continuity of care is clinically appropriate and supported by clinical documentation.
Documentation to support the diagnosis of a terminal illness or life-limiting illness and the criteria described at Section 8.7419.2.a.
If applicable, the number of live-in caregivers and family caregivers scheduled to provide services to the Member;

iv. Additional hours requested for the Caregiver beyond the Weekly Caregiver Limit, Provider Agency or CDASS Employer name, and the name/relationship of the Caregiver;

v. A summary of:

The number of Members the Provider Agency or CDASS Employer serves, and 2) The number of Caregivers employed by or contracted with for all Members served by the Provider Agency or CDASS Employer.

vi. How the Provider Agency or CDASS Authorized Representative has ensured informed consent and/or choice, if other Provider Agencies exist in the Member’s geographical area;

vii. How the Provider Agency or CDASS Employer continues to support the recruitment of willing and qualified caregivers in the Member’s geographical area;

viii. Policies in place to ensure Member safety with extended Caregiver hours;

ix. Any additional information requested by the Department that is necessary to substantiate the need for the exception; and x. For Members on Community First Choice or Community First Choice and Long-Term Home Health, the Members Case Management Agency, the Case Manager’s name and contact information.

c. Provider Agency or CDASS Employer Responsibilities Regarding Weekly Caregiver Limit Exception Request i. All Weekly Caregiver Limit Exception Requests must be submitted to the Department as soon as the need for an exception arises, and whenever possible, at least 30 calendar days prior to the service start date. Provider Agencies or CDASS Employers are responsible for following Case Management Agency and Department prescribed timelines.

ii. Provider Agencies or CDASS Employers serving Members on the following programs must submit the request and all relevant documentation to the Department. Prior to submission to the Department, the Provider Agency must inform the Member’s Case Manager.

Community First Choice, and 2) Community First Choice and Long-Term Home Health.

iii. Home Health Provider Agencies who provide services to Members who only receive Long-Term Home Health, and who do not have a Case Management Agency’s involvement, must submit Weekly Caregiver Limit Exception Requests directly to the Department.

iv. Provider Agencies or CDASS Employers are responsible for responding to requests for additional information within 7 calendar days. If additional information is not provided to the Department within 7 calendar days, the Department will issue a decision based on the information that was initially provided.

v. Caregivers for Members with a submitted Weekly Caregiver Limit Exception Request are not required to adhere to the Weekly Caregiver Limit while the Weekly Caregiver Limit Exception Request is pending. If a Weekly Caregiver Limit Exception Request is denied, caregivers must be fully compliant with the weekly caregiver limit within 30 days or as soon as another caregiver has been hired, whichever is sooner.

a. An exception request is considered submitted once it has been completed by the Provider Agency or CDASS Employer and submitted to the Department.

Provider Agencies or FMS Contractors must maintain documentation of the completed submission for their records. FMS Contractors will be provided a copy of the approved or denied Weekly Caregiver Limit Exception request by the Department.

b. Provider Agencies, FMS Contractors, CDASS Employers, and Caregivers must provide documented proof upon request that they have initiated compliance with the Department's determination within 14 calendar days of the Department's decision. Documented proof may include, but is not limited to, evidence that required background checks have been initiated or other actions demonstrating progress toward compliance. Full compliance with the Department's determination must be achieved within 30 calendar days of the Department's decision.

c. Provider Agencies, Caregivers, CDASS Employers, and Case Managers to the extent applicable under Section 8.7202.B.5, must actively work to secure alternative staffing while the Weekly Caregiver Limit Exception Request is under review. The submission of an exception request does not guarantee approval and cannot substitute for ongoing recruitment and staffing efforts.

vi. Caregivers who provide services to more than one Member must comply with the Weekly Caregiver Limit separately for each Member served. A Caregiver may provide up to the Weekly Caregiver Limit for each Member, provided that the Caregiver does not exceed the Per Day Hourly Limit defined at Section 8.7419.1.n across all Members served collectively.

vii. If the Weekly Caregiver Limit Exception Request is denied by the Department, the Provider Agency or CDASS Employer that submitted the request may not submit a new request unless there is (1) a change in circumstance or condition and (2) new documentation that supports the Weekly Caregiver Limit Exception Request Criteria as described at Section 8.7419.2.a.

viii. Provider Agencies or CDASS Employers are responsible for informing Caregivers of Weekly Caregiver Limit Exception Request information and decisions of exception requests.

ix. Weekly Caregiver Limit Exception Requests are applicable to the Caregiver. The Caregiver is responsible for disclosing all hours to each Provider Agency or CDASS Employer through which they provide services. If a Provider Agency or CDASS Employer employs or contracts with a Caregiver who discloses they work with two or more Provider Agencies, the Provider Agency or CDASS Employer must coordinate with all other Provider Agencies or CDASS Employers that employ or contract with the Caregiver when submitting a Weekly Caregiver Limit Exception Request. The CDASS Employer may request assistance with coordination through the Member’s Case Manager.

x. Each approved Weekly Caregiver Limit Exception Request is valid until the Prior Authorization Request (PAR) end date. If a Weekly Caregiver Limit Exception Request is approved within 60 days prior to the PAR end date, the Weekly Caregiver Limit Exception Request will be valid until the following PAR end date.

a. A Weekly Caregiver Limit Exception Request may be submitted at any time.

d. Case Manager Responsibilities for Weekly Caregiver Limit Exception Requests i. Case Managers must review Weekly Caregiver Limit Exception Requests submitted by Provider Agencies or CDASS Employers within seven (7) calendar days. The Case Manager must submit an attestation for the Weekly Caregiver Limit Exception Request using the process prescribed by the Department.

ii. The Department retains final authority regarding approval or denial of Weekly Caregiver Limit Exception Requests.

iii. Case Management Agencies must document all coordination and communication related to the Weekly Caregiver Limit Exception Request in the Care and Case Management (CCM) system.

e. Department Responsibilities for Weekly Caregiver Limit Exception Requests i. The Department will review Weekly Caregiver Limit Exception Requests for:

Thoroughness of documentation, including evaluating documentation to support member-specific needs;
Validation of the risks to the Member if the exception is not granted, which must be clearly identified and substantiated;
Justification that the requested exception to the Weekly Caregiver Limit is necessary to safely and effectively meet the member's already assessed and authorized service needs;
Assessment of workforce availability and documented recruitment efforts, where applicable. The Department will consider the Member’s geographic location, living situation, acuity, communication needs, and other relevant circumstances when evaluating workforce access barriers and recruitment efforts;
Confirmation that the request meets at least one exception category;
The manner in which the Weekly Caregiver Limit Exception Request maintains the Member’s health and safety and promotes sustainable community-based living.

f. The Department will approve Caregiver Limit Exception Requests on a case-by-case basis when a demonstrated need is documented and justified by the Member's Provider Agency or CDASS Employer and sufficiently meets the review criteria outlined at Section 8.7419.2.

g. The Department will provide an initial response to the Provider Agency or CDASS Employer regarding the Weekly Caregiver Limit Exception Request within 14 calendar days. If additional information is needed for the Department to process the Weekly Caregiver Limit Exception Request, a request for additional information will be provided to the submitting Provider Agency or CDASS Employer. If additional information is not provided to the Department within 7 calendar days, the Department will issue a decision based on the information that was initially provided.

h. The Department must issue a determination letter for each Weekly Caregiver Limit Exception Request unless the Weekly Caregiver Limit Exception Request is withdrawn by the Provider Agency CDASS Employer. Each determination letter must include the following and be provided to the Provider Agency or CDASS Employer and FMS Contractor, and the Case Manager:

i. The type of exception that was requested;

ii. The amount requested by the Provider Agency or CDASS Employer;

iii. The Department’s determination, including whether the request was approved or denied;

iv. A summary of the documentation reviewed, including the Person Centered Support Plan (PCSP), as defined at Section 8.7200.B, and supporting justification;

v. The regulatory citation(s) to support the decision; and vi. If approved, the expiration date of the exception.

i. The Weekly Caregiver Limit Exception Request process must be implemented in a uniform manner applied to Members statewide, but decisions must be based on individual assessed needs and 3. Weekly Caregiver Limit Enforcement a. Case Manager Enforcement Responsibilities i. For applicable Weekly Caregiver Limit Qualifying Services, Case Managers must inform Members of this requirement during the PCSP process as defined at Section 8.7200.B.

ii. As appropriate pursuant to Section 8.7202.J.6, Case Managers must assist Members in identifying alternative Provider Agencies or alternative service delivery options when the Member does not have access to adequate Caregivers through their current Provider Agency or service delivery option and must document this assistance in the Member’s record.

iii. Case Managers must assist Members and Authorized Representatives in identifying whether a Weekly Caregiver Limit Exception Request may be necessary to prevent disruption of authorized services, including during the Person-Centered Support Planning process, hospital discharge planning, crisis stabilization, provider transition, or reported caregiver shortage.

b. Provider Agency or CDASS Employer and FMS Contractor Enforcement i. Provider Agencies and FMS Contractors must annually provide the annual caregiver education resource, which is published by the Department, to all Caregivers who provide services to Members that receive Qualifying Services.

ii. The Caregiver Compliance Workbook must be provided to the Department upon request and completed for the requested time period. The Caregiver Compliance Workbook is in addition to, and not a substitution for, any record keeping required by the Caregiver’s professional standards of practice, if applicable.

iii. For the purposes of Members not enrolled in CDASS, the following requirements are applicable to Provider Agencies:

a. The Provider Agency must ensure that individual Caregivers are not scheduled or reimbursed for more than the Per Day Hourly Limit except in a documented Emergency Situation.

b. For all Members cared for by a Provider Agency, the Provider Agency must ensure that individual Caregivers are not scheduled or reimbursed for more than the Weekly Caregiver Limit across Qualifying Services except in a pending or approved Weekly Caregiver Limit Exception Request or in a documented Emergency Situation.

A Caregiver that renders services subject to the Per Day Hourly Limit must ensure the Per Day Hourly Limit is not exceeded. Exceptions to the Per Day Hourly Limit must be supported by a documented explanation of an Emergency Situation.
A Caregiver that renders Qualifying Service(s) must ensure the Weekly Caregiver Limit is not exceeded.

Exceptions to this limit must be supported by a documented pending or approved Weekly Caregiver Limit Exception Request.

iv. For the purposes of CDASS, Weekly Caregiver Limit Provider Agency Responsibilities outlined in 8.7419.3 are the responsibility of the CDASS Employer and the Financial Management Services Contractor and are allocated as follows:

a. CDASS Employer Responsibilities:

Inform Attendants of the Per Day Hourly and Weekly Caregiver Limits;
Ensure Attendants are scheduled in compliance with the Per Day Hourly and Weekly Caregiver Limits, except in a documented Emergency Situation, or with a pending or approved Weekly Caregiver Limit Exception Request;
Approve accurate service hours records in FMS Contractor’s timesheet system for proper payroll processing;
Monitor Attendant hours and work schedules to prevent exceedances;
CDASS Employers must maintain sufficiently qualified Caregivers to ensure compliance with caregiver limits while continuing to meet the Member’s authorized service needs;
Provide necessary and accurate information and documentation to support compliance with the limits, including documentation for Weekly Caregiver Limit Exception Requests and Emergency Situations, when b. Financial Management Services (FMS) Contractor Responsibilities:
Monitor and enforce the Per Day Hourly and Weekly Caregiver Limits through timesheet, payroll and claims processing systems;
Prevent reimbursement for hours that exceed allowable limits, unless supported by a pending or approved exception or documented Emergency Situation;
Process and retain documentation required under this

section; and 4) Provide records and documentation to the Department upon request in accordance with Section 8.7419.4.

Compliance Review Requirements a. Provider Agencies, CDASS Employers, and FMS Contractors are responsible for developing policies and procedures to comply with Section 8.7419.

b. Provider Agencies and CDASS Employers are obligated to compensate Caregivers for all hours worked in accordance with applicable state and federal labor laws, regardless of Medicaid reimbursement limitations or claim payment determinations.

c. Provider Agencies, CDASS Employers, and FMS Contractors must keep true and accurate records to support and demonstrate that the Per Day Hourly Limit and the Weekly Caregiver Limit are not exceeded. Any exceedance must be supported by an approved or pending Weekly Caregiver Limit Exception Request or a documented explanation of an Emergency Situation.

d. The Provider Agency or FMS Contractor must retain records in accordance with sections 8.130.2 and 8.7405 and must make records available for inspection by the Department upon request. In addition to the documentation required by 8.130.2 and 8.7405, Provider Agencies must retain:

i. Provider Agency Caregiver Attestation.

ii. Documentation to support an Emergency Situation that requires an exception to the limit.

iii. Paystubs reflecting, at a minimum, hours worked, pay period, and tax year.

iv. Independent Contractor documents or agreements.

v. Accounting records such as accounts receivable and accounts payable.

vi. Submitted, approved, and denied Weekly Caregiver Limit Exception Requests.

e. The Department may request information regarding Caregiver hours at any time.

i. The Provider Agency or FMS Contractor, must submit specific information regarding each Caregiver’s working hours, work location, services provided, Members served, submitted Weekly Caregiver Limit Exception Requests, Caregiver Compliance Workbook, and documented Emergency Situations to support exceeding the limit if applicable, and any other related information as requested by the Department.

ii. Provider Agencies or FMS Contractors must submit the requested information within 10 business days and in the format requested by the Department. Submitted information must be complete, clear, understandable, readable, and auditable.

f. Failure to submit information as required, failure to provide adequate documentation, False Representation, or failure to provide timely responses may result in the Department suspending payment of claims to the Provider Agency or FMS Contractor until the requested information is received and reviewed by the Department.

g. The Department may perform Caregiver Compliance Reviews regarding compliance with the limits and requirements outlined in 8.7419. Failure to submit information as required or failure to provide adequate documentation within the specified timeframe may result in the Provider Agency or FMS Contractor being required to submit a written response, as defined at Section 8.076.6 and/or be subject to an overpayment or penalty recovery.

i. If a written response is requested by the Department, the Provider Agency or FMS Contractor must submit the response by the date specified by the Department. The Provider Agency must notify the Department in writing within ten (10) business days of receipt of the request if it will not be able to meet the deadline. The Provider Agency or FMS Contractor must explain the reason for the delay.

The Department may or may not grant an extension, and will communicate its decision in writing.

h. Upon the Department’s receipt of the written response, the Department will accept, request modifications, or reject the proposed Plan of Correction. Modifications or rejections will be accompanied by a written explanation. If a Plan of Correction is rejected, the Provider Agency or FMS Contractor must resubmit a new Plan of Correction along with any requested documentation to the Department for review within ten (10) business days of notification. Failure to complete the Plan of Correction as required may result in a Payment Hold Enforcement, an overpayment or penalty recovery, or termination from participation in Colorado Medicaid.

i. If the Department determines the limits were exceeded without a documented Emergency Situation or a pending or approved Weekly Caregiver Limit Exception Request, the Department will issue an adverse action letter to the Provider Agency or FMS Contractor. The Provider Agency or FMS Contractor will have no more than 30 calendar days to respond to the letter with payment or an informal reconsideration request.

The Provider Agency or FMS Contractor will also have appeal rights before any recoupment from the Provider Agency or FMS Contractor by the Department is made.

j. The Department is authorized under C.R.S. Section 25.5-4-301(1) to assess, enforce, and collect penalties for noncompliance with statutes and k. Any payment to a Provider Agency for caregiver hours worked in excess of the Per Day Hourly Limit or the Weekly Caregiver Limit, or for hours that are not adequately documented as being compliant with the limits, is an overpayment subject to recoupment. FMS Contractor claims will be recouped if the FMS fails to meet the requirements of Section 8.7419.3.b.ii.2, resulting in CDASS caregiver hours being processed and paid beyond the allowed limits without adequate documentation demonstrating exception compliance.

l. An overpayment is the result of the Provider Agency or FMS Contractor providing inaccurate statements that are relevant to a claim for reimbursement or failing to accurately maintain and/or process records required by the Department or failing to become familiar with rules, manuals, and bulletins issued by the Department or the Department’s fiscal agent (see C.R.S. 25.5-4-301(2)). Any misleading or false information supplied by a CDASS employer to the FMS Contractor for a Weekly Caregiver Limit Exception Request or for verifying an Emergency Situation occurred may lead to the FMS Contractor being permitted by the Department to seek subsequent recoupment of overpayment from the CDASS employer and/or employer’s employees.

m. Noncompliance issues can result in a claim payment hold, an overpayment recoupment, or termination from participation in Colorado Medicaid. Issues of noncompliance include the following:

i. Failure to meet Department specified deadlines for submitting documentation and/or responses to Department requests for information.

ii. Failure to maintain supporting documentation as required.

iii. Failure to submit supporting documentation that is readable, auditable, complete, or in the requested format.

iv. Failure to create and submit a Plan of Correction if requested by v. Failure to accurately bill Medicaid for rendered services.

vi. Failure to comply with the Daily Caregiver Limit.

vii. Failure to comply with the Weekly Caregiver Limit. 8.7500 HCBS Benefits and Services Requirements 8.7501 Statement of Purpose and Scope A. The purpose of this Section 8.7500, et seq. is to outline the Waiver Benefit and Service and CFC Benefit requirements under the Home and Community-Based Services (HCBS) Waivers and Community First Choice (CFC). 8.7502 Definitions: Unless otherwise specified, the following definitions apply throughout Sections 8.7000-8.7500.

A. Acquisition, Maintenance, and Enhancement of Skills (AME) means functional skills training necessary for the individual to accomplish ADLs and IADLs. AME is a task available through Personal Care and Homemaker.

B. Activities of Daily Living (ADLs) is as defined at Section 8.7100.A.1.

C. Adaptive Equipment means one or more devices used to assist with completing Activities of Daily Living.

D. Case Management Agency is as defined at Section 8.7100.A.8.

E. Case Manager is as defined at Section 8.7200.B.5.

F. Community First Choice (CFC) is as defined at Section 8.7001.A.1-A.

G. CFC Benefit means services defined in the current federally approved CFC State Plan Amendment and does not include other Medicaid State Plan benefits or Waiver Benefits.

H. Congregate Facility is as defined at Section 8.7100.A.12.

I. Department is as defined in Section 8.7200.B.14.

J. Developmental Disability is as defined at Section 8.7100.A.23.

K. Direct Care Services Calculator (DCSC) means the Department’s required service planning assessment tool used by a Case Manager to determine and document the number of hours of Personal Care, Homemaker, and Health Maintenance Activities a Member needs, as informed by Task Standards/Age- Appropriate Task Standards and documented need The DCSC includes task definitions, Age-Appropriate Task Standards for Children, Task Standards for Adults, the CFC HMA Documentation Guide, and embedded ‘exception’ triggers that identify when additional service hours require additional justification and supervisor approval and/or HCPF approval through the CFC Direct Care Services Exception Process. Case Managers must utilize the Task Standards for Adults and the Age-Appropriate Task Standards for Children provided by the Department to establish appropriate service authorization for members. An up-todate version of the DCSC can be found on the Department website.

L. Direct Care Worker is as defined at Section 8.7402.F.

M. Durable Medical Equipment is as defined at Section 8.580.

N. Early And Periodic Screening, Diagnosis and Treatment (EPSDT) is as defined at

Section 8.280.1.

O. Family Member means any person or relative related to the Member by blood, marriage, or adoption, or by common law as determined by a court of law.

P. Financial Eligibility is as defined at Section 8.7100.A.28.

Q. Functional Eligibility is as defined at Section 8.7100.A.29.

R. Home and Community-Based Services (HCBS) waiver is as defined at 8.7100.A.35 S. Intellectual and Developmental Disability is defined at § 25.5-6-403(3.3)(a), C.R.S. and 8.7100.A.40.

T. Instrumental Activities of Daily Living (IADLs) means activities related to independent living, including preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework and communication.

U. Licensed Medical Professional (LMP) means the primary care provider of the Member, who possesses one of the following licenses: Physician (MD/DO), Physician Assistant (PA) and Advanced Practicing Nurse (APN). License Medical Professional practices shall adhere to the Colorado Medical Practice Act or the Colorado Nurse Practice Act, as applicable to the professional licensure category.

V. Legally Authorized Representative is as defined at 8.7001.A.7.

W. Legally Responsible Person means any person who has legal responsibility to care for another person. For children, this includes the parent or legal guardian of a minor child. For adults, this is limited to the Member’s spouse (by marriage or Common Law Marriage as defined at Section 8.100) and does not include the parent or legal guardian of an adult.

X. Long Term Services and Supports Representative is as defined at Section 8.7001.A.8.

Y. Member is as defined at 8.7001.A.8-B.

Z. Person-Centered Support Plan is as defined at 8.7001.A.11.

AA, Prior Authorization Request (PAR) is as defined at 8.7202.B.

BB. Provider Agency is as defined at 8.7001.A.12-B.

CC. Provider Care Plan is as defined at 8.7402.T.

DD. Restraint is as defined at Section 8.7001.A.15.

EE. Universal Precautions means a system of infection control that prevents the transmission of communicable diseases. Precautions include, but are not limited to, disinfecting of instruments, isolation and disinfection of the environment, use of personal protective equipment, hand washing, and proper disposal of contaminated waste.

F F. Waiver Benefit is as defined at section 8.7200.B.31 GG. Waiver Service is as defined at 8.7100.A.68.

HH. Age-Appropriate Task Standards for Children establish expected levels of assistance, participation, or contribution for children from birth through age 18, based on typical developmental abilities within defined age ranges. These standards are used to determine the portion of Homemaker, Personal Care, and Health Maintenance Activities that a child without a disability would reasonably be expected to perform, and therefore the amount of time that may be authorized for a provider to complete tasks the child is unable to perform due to a disability.

The combined total of all task maximums represents the Annual CFC Service Soft Caps, and any amount exceeding the Annual CFC Service Soft Caps requires Department approval. Age-Appropriate Task Standards for Children are parameters designed to facilitate a conversation between Case Managers and Members and are not the exclusive factor in determining a Member’s task and service allocations. Case Managers cannot exceed the maximum allowed time without receiving approval from a Supervisor or Alternative Qualified Professional, as described in Section 8.7607.A.3.

II. Extraordinary Care means a service which exceeds the range of care a Family Member would ordinarily perform in a household on behalf of a person without a disability or chronic illness of the same age, and which is necessary to assure the health and welfare of the Member and avoid institutionalization.

JJ. Task Standards for Adults establish the amount of time associated with the level of assistance, effort, or support an adult is reasonably expected to require or contribute to complete tasks, based on typical functional abilities for adults without impairments. These standards are based on general evidence-based guidelines of typical functional abilities for adults without impairments. These standards are used to determine the portion of Homemaker, Personal Care, and Health Maintenance Activities that an adult without a disability would reasonably be expected to perform, and therefore the amount of time that may be authorized for a provider to complete tasks the adult is unable to perform due to a disability.

The combined total of all task maximums represents the Annual CFC Service Soft Caps, and any amount exceeding the Annual CFC Service Soft Caps requires Department approval. Task Standards are parameters designed to facilitate a conversation between Case Managers and Members and are not the exclusive factor in determining a Member’s task and service allocations. Case Managers cannot exceed the maximum allowed time without receiving approval from a Supervisor or Alternative Qualified Professional, as described in Section 8.7607.A.3.

KK. Parental or Legal Guardian of a Minor Responsibility means the legal rights and duties held by a parent or by a court-appointed legal guardian to provide for the physical, emotional, developmental, and functional well-being of a child under age 18, including the responsibility to assist with or oversee activities of daily living and instrumental activities of daily living necessary for the child’s development. When determining service needs for children, Case Managers must utilize Age-Appropriate Task Standards for Children, if applicable, and distinguish between care that is typical for a child of the same age and care that exceeds age-appropriate expectations. Only supports that rise above normal developmental caregiving, and meet the definition of Extraordinary Care, may be authorized as CFC or waiver services.

LL. Annual CFC Service Soft Caps means annual utilization limits, expressed in hours per Person Centered Support Plan year. Annual CFC Service Soft Caps shall only be exceeded when approved through the CFC Direct Care Services Exception Process as described in Section 8.7607.A. 8.7503 Acupuncture 8.7503.A Acupuncture Eligibility 1. Acupuncture is a covered benefit available to Members enrolled in the HCBS Complementary and Integrative Health Waiver. 8.7503.B Acupuncture Definition 1. Acupuncture means the insertion of needles and/or manual, mechanical, thermal, electrical, and electromagnetic treatment to stimulate specific anatomical tissues for the promotion, maintenance and restoration of health and prevention of disease both physiological and psychological. During an acupuncture treatment, dietary advice and therapeutic exercises may be recommended in support of the treatment. 8.7503.C Acupuncture Inclusions 1. Acupuncture is used for treating conditions or symptoms related to the Member’s qualifying condition and Inability to Independently Ambulate.

Members receiving acupuncture and other complementary and integrative health services shall be asked to participate in an independent evaluation to determine the effectiveness of the services.
Acupuncture shall be provided in the clinic or office of a licensed acupuncturist, an approved outpatient setting, or in the Member’s residence. 8.7503.D Acupuncture Exclusions and Limitations 1. Acupuncture shall be limited to the Member’s assessed need for services as identified and documented in the Person-Centered Support Plan.
A maximum of 408 combined units of Acupuncture, Chiropractic, and Massage Therapy Waiver Services may be covered as a benefit during the support plan year. 8.7503.E Acupuncture Service Provider Agency Requirements 1. Acupuncture providers shall be licensed pursuant to § 12-200-101 et seq (C.R.S) and have at least 1 year of experience practicing Acupuncture at a rate of 520 hours per year; OR 1 year of experience working with individuals with paralysis or other long term physical disabilities.
Acupuncture Provider Agencies shall:

a. Determine the appropriate modality, amount, scope, and duration of acupuncture within the established limits as described at Section 8.7503.D.2.

b. Recommend only services that are necessary and appropriate in a service c. Provide services only in accordance with the Member’s prior authorized 8.7504 Adaptive Therapeutic Recreational Equipment and Fees 8.7504.A Adaptive Therapeutic Recreational Equipment and Fees Eligibility 1. Adaptive Therapeutic Recreational Equipment and Fees is a covered benefit available to Members enrolled in the following HCBS waivers:

a. Children’s Extensive Supports Waiver.

b. Supported Living Services Waiver 8.7504.B Adaptive Therapeutic Recreational Equipment and Fees Definition 1. Adaptive Therapeutic Recreational Equipment and Fees assist a Member in recreating within the Member’s community. These services include recreational equipment that is adapted specific to the Member’s disability and not items that a typical age peer would commonly need as a recreation item. 8.7504.C Adaptive Therapeutic Recreational Equipment and Fees Inclusions 1. Adaptive Therapeutic Recreational Equipment and Fees is authorized for Organized Health Care Delivery System (OHCDS).

Adaptive therapeutic recreational equipment may include an adaptive bicycle, adaptive stroller, adaptive toys, floatation collar for swimming, various types of balls with internal auditory devices and other types of equipment appropriate for the recreational needs of a Member with a Developmental Disability.
A pass for admission to a recreation center for the Member is covered only when the pass is needed to access a professional service or to achieve or maintain a specific therapy goal as recommended and supervised by a doctor or therapist.

Recreation passes shall be purchased by the most cost effective method available 4. Adaptive therapeutic recreation fees include those for water safety training. 8.7504.D Adaptive Therapeutic Recreational Equipment and Fees Exclusions and Limitations 1. The following items are specifically excluded and not eligible for reimbursement:

a. Entrance fees for:

i. Zoos;

ii. Museums;

iii. Movie theaters, performance theaters, concerts, other entertainment venues; and iv. Professional and minor league sporting events.

b. Outdoor play structures; and c. Batteries for recreational items. 8.7504.E Adaptive Therapeutic Recreational Equipment and Fees 1. The maximum annual allowance for adaptive therapeutic recreational equipment and fees is $1,000.00 per support plan year. 8.7505 Adult Day Services 8.7505.A Adult Day Services Eligibility 1. Adult Day Services (ADS) is a covered benefit available to Members enrolled in a. Brain Injury Waiver b. Community Mental Health Services Waiver c. Complementary and Integrative Health Waiver d. Elderly, Blind, and Disabled Waiver 8.7505.B Adult Day Services Descriptions and Definitions 1. Adult Day Services (ADS) Centers are certified centers that provide Basic Adult Day Services and Specialized Adult Day Services to Members.

Adult Day Services (ADS) may be provided out of an Adult Day Services Center or through Non-Center-Based means including Telehealth.
Adult Day Services are provided on a regularly scheduled basis. Services must be delivered as specified in the Member’s Provider Care Plan, and promote social, recreational, physical, and emotional well-being, and shall encompasses the supportive services needed to ensure the optimal wellness of the Member.
Basic Adult Day Services (ADS) Center means a community-based entity that provides basic Adult Day Services.
Center-Based Adult Day Services are services provided in a certified ADS Center.
Licensed Medical Professional for Section 8.7505 Adult Day Services only means the primary care provider of the Member, who possesses one of the following licenses: Physician (MD/DO), Physician Assistant (PA), Advanced Practicing Nurse (APN). Registered Nurse (NR), or Licensed Practical Nurse (LPN).

License Medical Professional practices shall adhere the Colorado Medical Practice Act or the Colorado Nurse Practice Act, as applicable to the professional licensure category.

Non-Center-Based Adult Day Services are services that may be provided outside of the certified ADS Center, where Members may engage in activities and community life, either in-person or through virtual means.
Specialized Adult Day Services (SADS) Center means a community-based entity providing Adult Day Services for Members with a primary diagnosis of dementia related diseases, Multiple Sclerosis, Brain Injury, chronic mental illness, Intellectual and Developmental Disabilities, Huntington’s Disease, Parkinson’s, or post-stroke Members, who require extensive rehabilitative therapies. To be designated as specialized, two-thirds of an ADS Center's population must have one of any of these diagnoses. Each diagnosis must be verified by a Licensed Medical Professional either directly or through Case Management Agency documentation, in accordance with Section 8.7505.E.9.
Telehealth Adult Day Services are services provided through virtual means in a group or on an individual basis. Telehealth ADS allows for Members to engage in activities with their community and connect to staff and other ADS Members virtually or over the phone, only if a Member does not have access or the ability to use video chat technology. Nutrition services are not required to be included in Telehealth Services. 8.7505.C Adult Day Services Inclusions 1. Only Members whose needs may be met by the ADS Provider Agency within its Certification category and populations served may be admitted by the ADS Provider Agency.
A Member can receive either Center-Based ADS, Non-Center-Based ADS, or a combination of Center-Based ADS and Non-Center-Based ADS within the same week.
ADS for all waivers shall include, but are not limited to:

a. Assistance with Activities of Daily Living (ADL), as needed when ADS is provided in-person; monitoring of the Member's health status and personal hygiene; assistance with administering medication and medication management (administration of medication only during the in-person delivery of services); and carrying out physicians' orders as set forth in Member's individual Person-Centered Support Plan.

b. Activities that assist in the development of self-care capabilities, personal hygiene, and social support services.

Nutrition services including therapeutic diets and snacks in accordance with the Member's individual Provider Care Plan and hours of attendance. Nutrition services are not required during the delivery of Non-Center-Based ADS.
Age-appropriate social and recreational supportive services as appropriate for each Member and their needs, as documented in the Member's Provider Care Plan. Activities shall take into consideration individual differences in age, health status, sensory deficits, religious affiliation, interests, abilities, and skills by providing opportunities for a variety of types and levels of involvement.
Members have the right to choose not to participate in social and recreational activities. 8.7505.D Specialized Adult Day Services 1. The Member’s Person-Centered Support Plan and Provider Care Plan must include documentation of their diagnosis(es) and service goals.
A Specialized Adult Day Services (SADS) Provider Agency must verify all Medicaid Member’s diagnosis(es) using the Professional Medical Information Page (PMIP) which shall be supplied by the Case Manager or by documentation from the Member’s Licensed Medical Professional. SADS Provider Agencies must ensure documentation verifying the Member’s diagnosis(es) is obtained at the time of admission and whenever there is a significant change in the Member's condition. The SADS Provider Agency shall record any significant change to the Member’s condition in the Member’s record 3. For Members whose services are reimbursed by a payment source other than Medicaid, diagnosis(es) must be documented in a Person-Centered Support Plan or other admission form and verified by the Member's physician or Licensed Medical Professional. This documentation must be verified at the time of admission, and whenever there is a significant change in the Member's condition.
Adult Day Services Exclusions and Limitations a. The delivery of a meal, workbook, activity packet, or similar materials, does not constitute ADS and is not a covered service unless in-person ADS service is provided in addition to the delivery of food or materials. 8.7505.E Adult Day Services Provider Agency Requirements 1. General a. Adult Day Services Provider Agencies shall be Medicaid certified by the Department in accordance with Section 8.7403.A. Proof of Medicaid Certification consists of an approved Provider Agreement by the Department and the Department’s fiscal agent, and a recommendation for Certification from the Colorado Department of Public Health and Environment (CDPHE).
Environment a. Adult Day Services Centers shall provide recreational areas and activities appropriate to the number and needs of the Members, at the times desired by the Members.

b. Adult Day Services Centers shall provide for a private shower and/or bathing area located on site to address the emergency hygiene needs of Members as needed.

c. To accommodate the activities and program needs of the ADS Center, the center shall provide eating and activity areas that are consistent with the number and needs of the Members being served, at a minimum of 40 square feet per Member.

d. ADS Centers shall maintain a comfortable temperature throughout the center. At no time shall the temperature fall outside the range of 68 degrees to 76 degrees Fahrenheit.

e. ADS Centers shall provide an environment free from Restraints.

f. ADS Centers shall provide a safe environment for all Members, including Members exhibiting behavioral problems, wandering behavior, or limitations in mental/cognitive functioning.

Food Safety Requirements a. ADS providers shall comply with all applicable local food safety regulations. In addition, all ADS Centers shall ensure:

i. Access to a handwashing sink, soap, and disposable paper towels;

ii. Food handlers, cooks, and servers, including Members engaged in food preparation, wash their hands according to food safety handwashing guidelines;

iii. The ADS Centers shall not allow any staff or Members who are not in good health and free of communicable disease to handle, prepare or serve food or handle utensils;

iv. Refrigerated foods opened or prepared and not used within 24 hours are marked with a “use by” or “discard by” date. The “use by” or “discard by” date may not exceed 7 days following opening or preparation, or exceed or surpass the manufacturer’s expiration date for the product or its ingredients;

v. Foods provided as food service are maintained at the proper temperatures at all times. Foods that are stored cold must be held at or below 41 degrees Fahrenheit and foods that are stored hot must be held at or above 135 degrees Fahrenheit in order to control the growth of harmful bacteria;

Kitchen and food preparation equipment shall be maintained in working order and cleanable; and 2) Any equipment or surfaces used in the preparation and service of food shall be washed, rinsed, and sanitized before use or at least every 4 hours of continual use. Dish detergent shall be labeled for its intended purpose. Sanitizer shall be approved for use as a no-rinse food contact sanitizer.

Sanitizers shall be registered with the Environmental Protection Agency (EPA) and used in accordance with labeled instructions.

Medication Administration and Monitoring a. Adult Day Service Provider Agencies shall comply with Medication Administration regulations in Section 8.7414.
Records and Information a. All ADS Provider Agencies shall keep records and information necessary to document the services provided to Members receiving Adult Day Services, as required in Section 8.7405. In addition to the requirements at

Section 8.7405, ADS records must also include:

i. Name, address, and telephone number of primary physician;

ii. Documentation of the supervision and monitoring of services provided;

iii. Documentation that all Members and their Guardian or other Legally Authorized Representative, if authorized/if within the scope of their authority have been oriented to the ADS Center, their policies and procedures, to the services provided by the ADS provider, and delivery methods offered;

iv. A service agreement signed by the Member and/or the Guardian or other Legally Authorized Representative, if authorized/if within the scope of their authority and appropriate Adult Day Services staff;

v. For SADS providers only, a copy of the Professional Medical Information Page, or documentation of diagnosis from the Member’s Licensed Medical Professional; and vi. Documentation specifically stating the types of services and monitoring that are provided when rendered via Telehealth, ensuring the integrity of the service provided and the benefit the service provides the Member.

Service Plan a. The ADS Provider Agency shall document the following information in a care plan, which shall be used to direct the Member’s care.

i. Medical Information:

All medications prescribed for the Member, including those used by the Member while receiving Center-Based or Non- Center-Based ADS, and whether the medication is selfadministered;
Special dietary considerations or instructions;
Services that are administered to the Member while receiving Center-Based and/or Non-Center-Based ADS, which may include nursing or medical interventions, speech therapy, physical therapy, or occupational therapy;

a) Any recommended restrictions on social and/or recreational activities identified by Member’s Licensed Medical Professional; and b) Any other special health or behavioral management services or supports recommended to assist the Member by the Member’s Licensed Medical Professional.

Even if recommended by the Member’s Licensed Medical Professional, staff interventions that interfere with the Member’s choice of food, freedom to determine their own activities, or exercise of any other rights are Rights Modifications for which the ADS Provider Agency must comply with Section 8.7001.B.4.

ii. Provider Care Plan Planning Documentation:

Documentation that the Member and/or Guardian or other Legally Authorized Representative, if authorized/if within the scope of their authority, selected the ADS Provider Agency.
Individual choices, including location and delivery method for ADS, preferences, and needs shall be incorporated into the goals and services outlined in a care plan;
All Member information and the service plan are considered Protected Health Information and shall be kept confidential;
The Member and/or Guardian or other Legally Authorized Representative, must review and sign the care plan and Person-Centered Support Plan.
Any changes to the Person-Centered Support Plan must comply with Section 8.7001.B.4.
Any changes to the care plan must comply with Section 8.7410.
Documentation of whether the Member has executed an advance directive or other declaration regarding medical decisions.

Staff Requirements a. In determining appropriate staffing levels, the Adult Day Services Provider Agency shall adjust staffing ratios based on the individual acuity and needs of the Members being served. At a minimum, staffing must be sufficient in number to provide the services described in the Provider Care Plan, considering the individual needs, level of assistance, and risks of accidents. A staff person may perform multiple functions, if those functions are consistent with the definition of Direct Care Worker, Section 8.7402.F.

Staff counted in the staff-Member ratio are those who are trained and able to provide direct services to Members.

i. Center-Based and in-person, Non-Center-Based ADS shall be staffed at a minimum of 1 staff to 8 Members with continuous supervision of Members during program operation.

ii. Telehealth ADS shall be staffed at a minimum of 1 staff to 15 virtual Members with continuous virtual supervision of Members during Telehealth program operation.

b. Staff shall provide:

i. Immediate response to emergency situations to assure the safety, health, and welfare of Members;

ii. Activities that are planned to support the Person-Centered Support Plans or Provider Care Plan for the Members.

iii. Administrative, recreational, social, and supportive functions and duties.

iv. Nursing services for regular monitoring of the on-going medical needs of Members and the supervision of medications. These services must be available a minimum of two hours daily during Center-Based ADS and as needed for Non-Center-Based Adult Day Services.

v. Nursing services shall be provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN). Certified Nursing Assistants (CNA) may provide nursing services under the direction of a RN or an LPN, in conformance with delegation provisions at in § 12- 38-132, C.R.S. Supervision of CNAs must include documented consultation and oversight on a weekly basis or more frequently according to the Member's needs. If the supervising RN or LPN is an ADS Staff Member with consultation and oversight of CNAs included in the Member’s job description, the supervising nurse’s documented attendance at the ADS center during times when nursing services are provided shall be sufficient to document consultation and oversight.

c. In addition to the above services, Specialized Adult Day Services (SADS)

Centers shall have sufficient staff to provide nursing services during all hours of operation.

Director Qualifications a. All Directors shall meet one of the following qualifications:

i. At least a bachelor’s degree from an accredited college or university and a minimum of two years of social services or health services experience and shall have demonstrated ability to perform all aspects of the position; or ii. An LPN or RN license issued by the state of Colorado and completion of two years of paid or volunteer experience in planning or delivering health or social services including experience in supervision and administration; or iii. A high school diploma or GED equivalent, a minimum of four years of experience in a social services or health services setting, acquired skills in working with aging adults or adults with functional impairment, and skills required to supervise ADS Center staff persons.

Training Requirements a. All staff and volunteers shall be trained in accordance with Section 8.7409.D. and in the use of Universal Precautions and infection control, as defined at Section 8.7502.Y.

b. Direct Care Workers shall complete training prior to providing services.

Dementia Training Requirements a. As of October 1, 2023, each Adult Day Services Provider Agency shall ensure that its Direct Care Workers complete dementia training as required by Section 25.5-6-314, C.R.S.

b. Definitions applicable to Dementia Training Requirements: In addition to those definitions set forth at Section 25.5-6-314, C.R.S., the following definitions apply to regulations in this Section 8.7505.E:

i. “Covered Facility” means a nursing care facility or an assisted living residence licensed by the Department of Public Health and Environment pursuant to Section 25-1.5-103(1)(a).

ii. “Dementia diseases and related disabilities” is a condition in which cognitive ability declines and is severe enough to interfere with an individual’s ability to perform everyday tasks. Dementia diseases and related disabilities include Alzheimer’s disease, mixed dementia, Lewy Body Dementia, vascular dementia, frontotemporal dementia, and other types of dementia.

iii. “Direct Care Worker “ means a Staff Member caring for the physical, emotional, or mental health needs of Members of an Adult Day Services Provider Agency and whose work involves regular contact with Members who are living with Dementia Diseases and related disabilities.

iv. “Equivalent training” means any initial training provided by a Covered Facility that meets the requirements in Section 8.7505.E.10.c. If the Equivalent Training was provided more than 24 months prior to the date of hire as allowed in the exception found in Section 8.7505.E.10.d., the individual must document participation in both the Equivalent Training and all required continuing education subsequent to the initial training.

c. Initial training: Each Adult Day Services Provider Agency is responsible for ensuring that all Direct Care Workers are trained in dementia diseases and related disabilities.

i. Initial training shall be available to Direct Care Workers at no cost to them.

ii. The training shall be competency-based and culturally competent and shall include a minimum of four hours of training in dementia topics including the following content:

Dementia diseases and related disabilities;
Person-centered care;
Care planning;
Activities of Daily Living; and 5) Dementia-related behaviors and communication.

iii. For Direct Care Workers already employed prior to October 1, 2023, the initial training must be completed as soon as practical, but no later than 120 days after October 1, 2023, unless an exception, as described in Section 8.7505.E.10.d.i. applies.

iv. For Direct Care Workers hired or providing care on or after October 1, 2023, the initial training must be completed as soon as practical, but no later than 120 days after the start of employment or the provision of direct-care services, unless an exception, as described in Section 8.7505.E.10.d.ii applies..

d. Exception to initial dementia training requirement i. Any Direct Care Worker who is employed by or providing directcare services prior to the October 1, 2023, may be exempted from the provider’s initial training requirement if all of the following conditions are met:

The Direct Care Worker has completed Equivalent Training program, as defined in these rules, within the 24 months immediately preceding October 1, 2023; and 2) The Direct Care Worker may provide documentation of the satisfactory completion of the Equivalent Training program.

ii. Any Direct Care Worker who is hired or begins providing direct-care services on or after October 1, 2023, may be exempted from the provider’s initial training requirement if the Direct Care Worker:

Has completed an equivalent initial dementia training program, as defined in these rules, either:

a) Within the 24 months immediately preceding October 1, 2023; or b) Within the 24 months immediately preceding the date of hire or the first date the Direct Care Worker provides direct care services; and 2) Provides documentation of the satisfactory completion of the equivalent initial training program; and 3) Provides documentation of all required continuing education subsequent to the initial training.

iii. Such exceptions shall not exempt a Direct Care Worker from the requirement for dementia training continuing education as described in Section 8.7504.E.10.e.

e. Dementia Training: Continuing Education i. After completing the required initial training, all Direct Care Workers shall have completed and documented a minimum of two hours of continuing education on dementia topics every two years.

ii. Continuing education on this topic shall be available to Direct Care Workers at no cost to them.

iii. This continuing education shall be culturally competent, include current information provided by recognized experts, agencies, or academic Institutions, and include best practices in the treatment and care of persons living with dementia diseases and related disabilities.

f. Minimum requirements for individuals conducting dementia training:

i. Specialized training from recognized experts, agencies, or academic Institutions in dementia disease, or ii. Successful completion of other similar training which meets the minimum standards described herein; and iii. Two or more years of experience working with persons living with dementia diseases and related disabilities.

g. Documentation of initial dementia training and continuing education for Direct Care Workers:

i. The Provider Agency shall maintain documentation that each Direct Care Worker has completed initial dementia training and continuing education. Such records shall be made available to the ii. Completion shall be demonstrated by a certificate, attendance roster, or other documentation reliably demonstrating completion of training.

iii. Documentation shall include the number of hours of training, the date on which it was received, and the name of the instructor and/or training entity.

iv. Documentation of the satisfactory completion of an equivalent initial training program shall include the information required in this

Section 8.7505.E.10.g.ii. and iii.

v. After the completion of training and upon request, such documentation shall be provided to the Staff Member. for their use in obtaining employment at another Covered Facility. For the purposes of dementia training documentation, Covered Facilities shall include Assisted Living Residences, and Nursing Care Facilities pursuant to § 25.5-6-314, C.R.S, and Adult Day Care Facilities as defined in § 25.5-6-303(1), C.R.S.

Written Policies a. In addition to the policies and procedures described in Section 8.7408, the ADS provider shall maintain written policies and procedures relevant to the operation of Adult Day Services. Such policies shall include, but not be limited to, statements describing:

i. Admission criteria for Members shall can be appropriately served by the Adult Day Services Provider Agency;

ii. Intake procedures conducted for Members and/or Guardian or other Legally Authorized Representative, if authorized/if within the scope of their authority prior to admission with the ADS provider;

iii. The meals and nourishments, including special diets, that are provided at Center-Based Adult Day Services;

iv. The hours and days that Center-Based Adult Day Services are open and available, and the days and times that Non-Center- Based Adult Day Services are available to Members, including the availability of nursing services;

v. The personal items that the Members may bring with them to the Adult Day Services Center; and vi. The administration of Telehealth Adult Day Services, if provided.

This includes Telehealth options, provision of services, and examples of services offered in a virtual setting.

b. The Adult Day Services Provider Agency shall maintain on file a current, written, signed agreement between the Member and/or Guardian or other Legally Authorized Representative, if authorized/if within the scope of their

authority, and the Adult Day Services Provider Agency outlining the rules and responsibilities of the Adult Day Services Provider Agency and the Member. The Adult Day Services Provider Agency shall provide a copy of the agreement to each party to the agreement. 8.7505.F Adult Day Services Provider Agency Reimbursement Requirements 1. Claims for reimbursement for Adult Day Services provided to Members in the HCBS Elderly, Blind and Disabled (EBD), Community Mental Health Supports (CMHS), and the Complementary and Integrative Health (CIH) waivers shall be submitted in accordance with the current rate schedule:

a. ADS Provider Agencies may submit claims for 15-minute units or for 1-2 units of 3-5 hours depending on the Member’s needs and how the service is delivered.

i. When submitting claims for 15-minute units, which may be delivered either in-person or via Telehealth, the total number of units may not exceed 12 units or three hours per day of Basic Adult Day Services.

ii. A Provider Agency may bill the maximum of 15-minute units for ADS in combination with no more than 1 unit of 3-5 hour ADS on the same day, only if services were rendered consecutively.

For persons in the HCBS waiver for Persons with a Brain Injury (BI), reimbursement for BI- Adult Day Services is to be billed in accordance with the current rate schedule.

a. Adult Day Services Provider Agencies may bill in units of 15 minutes or a unit of 2 or more hours depending on the Member’s needs and how the service is delivered. When billing 15-minute units, which can be delivered either in-person or via Telehealth, the total number of units may not exceed 8 units or two (2) hours per day of services.

b. Units of 2 hours or more delivered only in-person. An Adult Day Services provider may not bill for 15-minute units of ADS if a unit of 2-hour BI ADS was provided to the same Member on the same day.

Adult Day Services (ADS) Centers are permitted to utilize funding from other Federal sources, such as the Child and Adult Care Food Program (CACFP), in addition to the Medicaid per diem. If such funding is utilized, a Center must acknowledge the use of multiple funding sources and demonstrate that the services funded by a federal source do not duplicate Medicaid-funded services.
Only providers certified as a Specialized Adult Day Services (SADS) Center are permitted to receive the SADS reimbursement rate. The SADS reimbursement rate applies to every Member at a SADS Center, even if the Member does not have a specialized diagnosis.
Certified SADS providers may provide Non-Center-Based Adult Day Services, including Telehealth ADS Non-Centered-Based Adult Day Services, shall be billed only as Basic Adult Day Services using the 15-minute unit, up to 3 hours per day. The SADS provider may bill the maximum of 15-minute units for Basic Adult Day Services in combination with no more than 1 unit of 3-5 hour SADS on the same day, as long as services were rendered at separate times.
Adult Day Services are not covered when provided on the same date as HCBS residential services, unless the following criteria have been met:

a. Adult Day Services and residential services have been authorized by the Department and are included in an approved Prior Authorization Request PAR;

b. Documentation from the Member’s physician demonstrates the required specialized services in the Adult Day Services Center are necessary because of the Member’s diagnosis(es), are essential to the care of the Member, and are not included in the residential per diem;

c. Documentation that the extensive rehabilitative therapies and therapeutic needs of the Member are not being met by the residential program and are not included in the residential per diem; and d. Documentation from the Member’s physician recommends Adult Day Services and describes how it will meet the Member’s needs as described in subsection b, above. 8.7506 Alternative Care Facility 8.7506.A Alternative Care Facility Eligibility 1. Alternative Care Facility is a service available to Members enrolled in one of the a. Community Mental Health Services Waiver b. Elderly, Blind, and Disabled Waiver 8.7506.B Alternative Care Facility Definitions 1. Alternative Care Facility defined at C.R.S. § 25.5-6-303(3), means an Assisted Living Residence , which has been licensed by the Colorado Department of Public Health and Environment (CDPHE) as an Assisted Living Residence and certified by the Department to provide Alternative Care Services to Medicaid a. Alternative Care Services as defined at C.R.S. § 25.5-6-303(4), means a package of personal care and homemaker services provided in a state licensed and certified alternative care facility including, but not limited to: assistance with bathing, skin, hair, nail and mouth care, shaving, dressing, feeding, ambulation, transfers, positioning, bladder & bowel care, medication reminding and monitoring, accompanying, routine house cleaning, meal preparation, bed making, laundry, shopping, medication Administration, and Protective Oversight.

Protective Oversight means monitoring and guidance of a Member to assure their health, safety, and well-being. Protective Oversight also includes but is not limited to: monitoring the Member while on the premises of service setting, monitoring the Members' needs, and ensuring that the Member receives the services and care necessary to protect their health and welfare. Protective Oversight shall be no more intrusive than necessary to protect the health and welfare of the Member and others. If Protective Oversight for a Member entails Intensive Supervision as defined at Section 8.7001.A.6 or otherwise limits a Member’s privacy, autonomy, access to the community, or other rights, then the Alternative Care Facility shall follow the Rights Modification process at Section 8.7001.B.4. 8.7506.C Alternative Care Facility Inclusions 1. Member Eligibility a. Members enrolled in the HCBS Elderly, Blind and Disabled (EBD) and the HCBS Community Mental Health Supports (CMHS) Waivers to are eligible to receive services in an Alternative Care Facility.

i. Potential Members shall be assessed, at a minimum, by a team that includes the Member and/or Guardian or other Legally Authorized Representative, the Alternative Care Facility administrator or appointed representative, and Case Management Agency Case Manager to determined that the Alternative Care Facility is an appropriate community setting that will meet the Member’s choice and need for independence and community integration. If one of the parties listed above is not available, input or information must be obtained from each party prior to making an admission determination. The team may also include Family Members, Accountable Care Collaborative or Mental Health Center Case Managers, and any other interested parties as approved by the Member.

An assessment shall be conducted prior to admission, annually, whenever there is a significant change in physical, cognitive, or behavioral needs, or as requested by the Member. The annual assessment must be completed by the team described in Section 8.7506.C.1.a.i.
The assessment shall document that the setting will support the Member and their needs. The assessment shall also document the Member’s physical, behavioral and social needs, so that supports can be identified to enable them to lead as independent a life as possible. The assessment shall be used to develop the Member’s care plan. 8.7506.D Alternative Care Facility Member Benefits 1. Alternative Care Services described at Section 8.7506.B.1.a are benefits to Members residing in an Alternative Care Facility .

a. When Medication Administration is provided as an Alternative Care Service reimbursement for Medication Administration is included in the reimbursement rate for Alternative Care Services and shall not be billed separately from Alternative Care Facility services.

Alternative Care Facility Provider Agencies shall not provide additional services which are available as a State Plan benefit or other HCBS-Community Mental Health Supports (CMHS) or HCBS-Elderly, Blind, and Disabled (EBD) waiver 3. Alternative Care Facility Provider Agencies shall provide Member engagement opportunities described in 6 C.C.R. 1011-1, Chapter VII, Part 13.1(C). 8.7506.E Alternative Care Facility Member Rights 1. Alternative Care Facility Provider Agencies shall inform Members of their rights, as set forth at 6 C.C.R. 1011-1, Chapter VII, Part 13 and Section 8.7001. Any modification of those rights shall be in accordance with Section 8.7001.B.

Pursuant to 6 C.C.R. 1011-1, Chapter VII, Part 13.1, the policy on resident rights shall be in a visible location so that they are always available to Members and visitors.

Even if recommended by the Member’s physician, staff interventions that interfere with the Member’s choice of food, freedom to determine their own activities, or exercise of any other rights are Rights Modifications that may only be implemented following compliance with Section 8.7001.B.4.
Alternative Care Facility Provider Agencies shall inform Members of all Alternative Care Facility policies upon admission to the setting, and when changes to policies are made Rules and/or policies shall apply consistently to the administrator, staff, volunteers, and Members residing in the facility and their Family or friends who visit. Alternative Care Facility Provider Agencies shall document Member acknowledgement of rules and policies in a Provider Care Plan or a resident agreement.
If requested by the Member, the Alternative Care Facility shall provide bedroom furnishings, including but not limited to a bed, bed and bath linens, a lamp, a chair and a dresser and a way to secure personal possessions.
Alternative Care Facility Provider Agencies shall not discontinue services to a Member unless documented efforts have been ineffective to resolve the conflict leading to the discontinuance of services in accordance with 6 C.C.R. 1011-1, Ch. VII Section 11.
Alternative Care Facility Provider Agencies shall inform Members of the setting’s policies and procedures for implementation of an individual’s advance directives.
Alternative Care Facility Provider Agencies shall not require Medicaid Members to take part in performing household cleaning or maintenance tasks. 8.7506.F Alternative Care Facility Provider Agency Requirements 1. Alternative Care Facility Provider Agencies shall be licensed by the Colorado Department of Public Health and Environment as an Assisted Living Residence facility and obtain an Alternative Care Facility Certification prior to enrollment with 2. Member Engagement a. In consultation with Members served, Alternative Care Facility Provider Agencies shall provide social and recreational engagement opportunities both within and outside the setting.

i. Opportunities for social and recreational engagement shall take into consideration the individual interests and wishes of the Members.

ii. In determining the types of opportunities and activities offered, the Provider Agencies shall consider the physical, social, and mental stimulation needs of the Members.

Member Leave a. Alternative Care Facility Provider Agencies shall notify the Member’s Case Manager of any Member planned or unplanned non-medical and/or programmatic leave of a duration greater than 24 hours.

b. The therapeutic and/or rehabilitative purpose of leave shall be documented in the Member’s Provider Care Plan.

Provider Care Plan a. The following information must be documented in the Member’s Provider Care Plan:

i. Medical Information:

Medications the Member takes and how they are administered, with reference to the Medication Administration Record (MAR);
Special dietary needs, if any; and 3) Physician orders.

ii. Social and recreational engagement:

The Member’s preferences and current relationships; and 2) Any recommended restrictions on social and/or recreational activities identified by a physician.

iii. Any other special health or behavioral management needs that support the Member’s individual needs.

b. Additional Provider Care Plan Documentation:

i. Documentation from the admission process which demonstrates that the setting was selected by the Member;

ii. Identification of the Member’s goals, choices, preferences, and needs and incorporation of these elements into the supports and services described in the Person-Centered Support Plan;

iii. Any modifications to the Member's rights, with the required supporting documentation; and iv. Evidence the Member and/or their Guardian, or other Legally Authorized Representative has had the opportunity to participate in the development of the Provider Care Plan, as evidenced by the Member or other Legally Authorized Representatives’ signature on the plan.

Environmental Standards a. The Alternative Care Facility shall be an environment that supports individual comfort, independence, and preference, maintains a home-like quality and feel for Members at all times, and provides Members with unrestricted access to the Alternative Care Facility in accordance with the residency agreement or modifications as agreed to and documented in the Member’s Provider Care Plan.

b. Alternative Care Facilities shall provide an outdoor area accessible to Members without staff assistance that is well maintained, facilitates community gatherings, and is appropriately equipped for the population served.

c. Alternative Care Facilities shall maintain a comfortable temperature throughout the Alternative Care Facility and Member rooms, sufficient to accommodate the use and needs of the Members, never to fall outside the range of 68 degrees to 76 degrees Fahrenheit.

d. The Alternative Care Facility shall develop and follow written policies and procedures to ensure the continuation of necessary care to all Members for at least 72 hours immediately following any emergency including, but not limited to, a long-term power failure.

e. The Alternative Care Facility Provider Agency shall display the monthly schedule of daily recreational and social engagement opportunities in a visible location so that it is always available to Members and visitors, and developed in accordance with 6 C.C.R. 1011-1, Chapter VII, Section 12.26, pertaining to Member Engagement.

i. Staff shall be responsible for ensuring that the daily schedule of recreational and social engagement opportunities is implemented and offered to all Members.

f. The Alternative Care Facility Provider Agency shall provide reading material in the common areas at all times, reflecting the interests, hobbies, and requests of the Members.

g. The Alternative Care Facility Provider Agency shall provide nutritious food and beverages that Members have access to at all times. Access to food and cooking of food shall be in accordance with 6 C.C.R. 1011-1, Chapter VII, Section 17.1-3. The access to food shall be provided in at least one of the following ways:

i. Access to the Alternative Care Facility kitchen.

ii. Access to an area separate from the Alternative Care Facility kitchen stocked with nutritious food and beverages.

iii. A kitchenette with a refrigerator, sink, and stove or microwave, separate from the Member’s bedroom.

iv. A safe, sanitary way to store food in the Member’s room.

h. The Alternative Care Facility Provider Agency shall assess each Member’s cooking capacity shall be assessed as part of the pre-admission process and updated in the Provider Care Plan as necessary.

Staffing Requirements a. In determining appropriate staffing levels, the Alternative Care Facility Provider Agency shall adjust staffing ratios based on the individual acuity and needs of the Members in the Alternative Care Facility. At a minimum, staffing must be sufficient in number to provide the services described in the Provider Care Plan, considering the Member’s needs, level of assistance, and risks of accidents. A staff person may have multiple functions, as long as they meet the definition of Direct Care Worker at

Section 8.7402.F Staff counted in the staff-to-Member ratio are those who are trained and able to provide direct services to Members.

b. The Alternative Care Facility Provider Agency shall ensure that all staff and volunteer training be completed within the first 30 days of employment. Training shall include, but is not limited to, the training topics described in 6 C.C.R. 1011-1, Chapter VII, Section 7.9.

c. The Provider Agency shall ensure the Administrator and all staff meet the qualifications and employment standards set forth in 6 C.C.R. 1011-1,

Chapter VII, Section 7.4. 8.7506.G Alternative Care Facility Standards for Secured Environment 1. Alternative Care Facility Provider Agencies providing a secured environment may be licensed for a maximum of 30 secured beds.

a. A waiver may be granted by the Department when adequate documentation of the need for additional beds has been proven and the number of beds would not jeopardize the health, safety and quality of care of Members.

The Alternative Care Facility shall establish an environment that promotes independence and minimizes agitation and unsafe wandering through the use of visual cues and signs.
Provide a secured outdoor area accessible without staff assistance, which shall be level, well maintained, and appropriately equipped for the population served. 8.7506.H Appropriateness of Medicaid Participant Placement 1. Alternative Care Facilities must comply with 6 C.C.R. 1011-1 Chapter 7, Part 11 when admitting a Member or providing a 30 days’ notice of discharge. 8.7506.I Alternate Care Facility Provider Agency Reimbursement 1. Room and board shall not be a benefit of Alternative Care Facility services.
Alternative Care Facility services shall be reimbursed according to a per diem rate, using a methodology determined by the Department.

a. Alternative Care Facility services are subject to Post Eligibility Treatment of Income (PETI), as outlined in Section 8.7202.BB.

Non-Medical/Programmatic Leave Reimbursement a. The Alternative Care Facility may receive reimbursement for a maximum of 42 days in a calendar year for Non-Medical/Programmatic Leave Days combined.

b. The Alternative Care Facility shall not be reimbursed for services during Leave Days if the Member is receiving Medicaid services over 24 hours in another approved Medicaid Facility, such as a nursing facility or hospital. 8.7507 Assistive Technology 8.7507.A Assistive Technology Eligibility 1. Assistive Technology is a covered service available to Members enrolled in one a. Brain Injury Waiver b. Children’s Extensive Supports Waiver c. Supported Living Services Waiver 8.7507.B Assistive Technology Definitions 1. Assistive Technology Device means an item, piece of equipment, or product system, including tablets, software, and phone applications, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of Members.

Assistive Technology Service means a service that directly assists a Member in the selection, acquisition, or use of an assistive technology device. 8.7507.C Assistive Technology Inclusions 1. Assistive Technology is authorized for Organized Health Care Delivery System 2. HCBS Supported Living Services (SLS) Waiver, Children’s Extensive (CES)

a. The evaluation of the assistive technology needs of a Member, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the Member in the customary environment of the Member.

b. Assistive technology recommendations shall be based on an Assessment provided by a qualified provider within the provider’s scope of practice.

c. Training and technical assistance shall be time limited, goal specific and outcome focused.

d. Services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices.

e. Training or technical assistance for the Member, or where appropriate, the Family Members, Guardians, caregivers, advocates, or Legally Authorized Representatives of the Member.

f. Warranties, repairs, or maintenance on assistive technology devices purchased through the waiver.

g. Adaptations to computers, or computer software related to the Member’s identified needs in their Person-Centered Support Plan.

HCBS Brain Injury (BI) Waiver a. For Members enrolled in the HCBS-BI Waiver, the following are covered Assistive Technology benefits:

i. Specialized medical equipment and supplies including devices controls, or appliances specified in the plan of care, which enable recipients to increase their abilities to perform Activities of Daily Living, or to perceive, control, or communicate with the environment in which they live.

ii. Assistive devices that augment an individual's ability to function at a higher level of independence.

iii. Assistive devices that enable the individual to secure help in the event of an emergency or are used to provide reminders to the individual of medical appointments, treatments, or medication schedules.

iv. Assistive devices to augment cognitive processes, “cognitiveorthotics” or memory prostheses. Examples of cognitive orthotic devices include informational databases, spell checkers, text outlining programs, timing devices, security systems, car finders, sounding devices, cueing watches, electronic medication monitors, and memory communication devices.

v. Training or technical assistance for the Member, or where appropriate, the Family Members, Guardians, caregivers, advocates, or Legally Authorized Representatives of the Member.

vi. Warranties, repairs, or maintenance on assistive technology devices purchased through the waiver.

b. All items shall meet applicable standards of manufacture, design, and installation. 8.7507.D Assistive Technology Exclusions and Limitations 1. Assistive technology devices and services are only available to meet needs identified through the Person-Centered Support Plan. They shall be the most cost effective and efficient means to meet the identified need and cannot be available through the Medicaid state plan, other HCBS Waiver Services, or thirdparty resources.

Items which are not of direct medical or remedial benefit to the Member are excluded 3. HCBS Supported Living Services (SLS) Waiver, Children’s Extensive (CES)

a. When the expected cost exceeds $2,500 per device, the Case Manager shall obtain and maintain three estimates in the case record and the most cost-effective option shall be selected. When it is not possible to obtain three estimates, documentation shall be maintained in the case record the reason for less than three estimates.

b. The following devices and services are specifically excluded under HCBS waivers and not eligible for reimbursement:

i. Purchase, training, or maintenance of service animals, ii. Computers or cell phones unless prior authorized according to procedure.

iii. Training or adaptation directly related to a school or home educational goal or curriculum for members under 21 years of age.

iv. Internet or broadband access.

v. In-home installed video monitoring equipment.

vi. Medication reminders.

vii. Items considered as typical toys for children.

viii. Items or devices that are experimental.

ix. Items or devices that are used for typical daily activities and are not used to increase, maintain, or improve the functional capabilities of Members. 8.7507.E Assistive Technology Reimbursement Requirements 1. HCBS Supported Living Services (SLS) Waiver, Children’s Extensive (CES)

a. The total cost of home accessibility adaptations, vehicle modifications, and assistive technology shall not exceed $10,000 over the five-year life of the waiver without an exception granted by the Department.

b. Costs that exceed this limitation may be approved by the Department for devices to ensure the health and safety of the Member or that enable the Member to function with greater independence in the home or if it decreases the need for paid assistance in another waiver service on a long-term basis.

c. Requests for an exception shall be prior authorized within 30 days of the request in accordance with the Department’s procedures.

HCBS Brain Injury (BI) Waiver:

a. Reimbursement for assistive devices will be on a per unit basis. If assistive devices are to be used primarily in a vocational application, devices should be funded through the Division of Vocational Rehabilitation with secondary funding from Medicaid 8.7508 Behavioral Programming/Behavioral Management and Education 8.7508.A Behavioral Programming/Behavioral Management and Education Eligibility 1. Behavioral Programming/Behavioral Management and Education is a covered benefit available to Members enrolled in the HCBS Brain Injury Waiver. 8.7508.B Behavioral Programming/Behavioral Management and Education Definition 1. Behavioral programming and education means individually developed interventions designed to decrease/control the Member's severe maladaptive behaviors which, if not modified or prevented, will interfere with the Member's ability to remain integrated in the community. 8.7508.C Behavioral Programming/Behavioral Management and Education Inclusions 1. Programs should consist of a comprehensive Assessment of behaviors, development of a structured behavioral intervention plan, and ongoing training of Family and caregivers for feedback about plan effectiveness and revision.

Consultation with other providers may be necessary to ensure comprehensive application of the program in all facets of the Member's environment.

Behavioral programs may be provided in the community, or in the Member's residence unless the residence is a Transitional Living Program which provides behavioral intervention as a treatment component.
All behavioral programming must be documented in the Member’s Provider Care Plan and may not exceed 30 units of service. The Department may authorize additional units based on needs identified in the Member’s Person-Centered Support Plan or Provider Care Plan. 8.7508.D Behavioral Programming/Behavioral Management and Education Provider Agency Requirements 1. The program should have as its director a Licensed Psychologist who has one year of experience in providing neurobehavioral services or services to persons with brain injury or a healthcare professional such as a Licensed Clinical Social Worker, Registered Occupational Therapist, Registered Physical Therapist, Speech Language Pathologist, Registered Nurse or Master’s level Psychologist with three years of experience in caring for persons with neurobehavioral difficulties. Behavioral specialists who directly implement the program shall have two years of related experience in the implementation of behavioral management concepts.
Behavioral specialists will complete a 24-hour training program dealing with unique aspects of caring for and working with individuals with Brain Injury if their work experience does not include at least one year of the same. 8.7508.E Behavioral Programming/Behavioral Management and Education 1. The Case Manager must document the behavioral programming service on the Member's Person-Centered Support Plan and include the number of service units on the Member’s Prior Authorization Request (PAR).
Behavioral programming services will be reimbursed on an hourly basis as established by the Department. 8.7509 Behavioral Therapies 8.7509.A Behavioral Therapies Eligibility 1. Behavioral Therapies are a covered benefit available to Members enrolled in one a. Developmental Disabilities Waiver b. Supported Living Services Waiver c. Brain Injury Waiver 8.7509.B Behavioral Therapies Definition 1. Behavioral Therapies mean services related to the Member’s intellectual or Developmental Disability that assist a Member to acquire or maintain appropriate interactions with others. 8.7509.C Behavioral Therapies Inclusions 1. Behavioral Therapies shall address specific challenging behaviors of the Member and identify specific criteria for remediation of the behaviors.
A Member with a co-occurring diagnosis of an intellectual or Developmental Disability and mental health diagnosis covered in the Medicaid state plan shall have identified needs met by each of the applicable systems without duplication but with coordination by the behavioral services professional to obtain the best outcome for the Member.
Behavioral Therapies include:

a. Behavioral consultations and recommendations for behavioral interventions and development of behavioral support care plans that are related to the Member’s Developmental Disability and are necessary for the Member to acquire or maintain appropriate adaptive behaviors, interactions with others and behavioral self-management.

b. Intervention strategies related to an identified challenging behavioral need of the Member. Specific goals and procedures for the behavioral service shall be established.

c. Behavioral plan assessment services include observations, interviews of direct care staff, functional behavioral analysis and assessment, evaluations, and completion of a written assessment document.

d. Individual or group counseling services include psychotherapeutic or psychoeducational intervention that:

i. Is related to the Developmental Disability in order for the Member to acquire or maintain appropriate adaptive behaviors, interactions with others and behavioral self-management, and ii. Positively impacts the Member’s behavior or functioning, and iii. May include cognitive behavior therapy, systematic desensitization, anger management, biofeedback, and relaxation therapy.

e. Behavioral line services include direct one on one (1:1) implementation of the behavioral support care plan and are:

i. Delivered under the supervision and oversight of a behavioral consultant.

ii. Inclusive of acute, short-term interventions at the time of enrollment from an institutional setting, or 1) To address an identified challenging behavior of a Member at risk of institutional placement, and that places the Member’s health and safety or the safety of others at risk. 8.7509.D Behavioral Therapies Exclusions and Limitations 1. Services covered as Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) or a covered mental health diagnosis in the Medicaid State Plan, covered by a third-party source or available from a natural support are excluded and shall not be reimbursed.

Behavioral consultation services are limited to 80 units per support plan year.

One unit is equal to 15 minutes of service.

Behavioral plan Assessment services are limited to 40 units and one assessment per support plan year. One unit is equal to 15 minutes of service.
Behavioral line services are limited to 960 units per support plan year. One unit is equal to 15 minutes of service.
Counseling services are limited to 208 units per support plan year. One unit is equal to 15 minutes of service.
Services for the sole purpose of training basic life skills, such as Activities of Daily Living, social skills and adaptive responding are excluded and not reimbursed under behavioral services. 8.7509.E Behavioral Therapies Provider Agency Requirements 1. Behavioral Therapies consultants shall meet one of the following minimum a. Shall have a Master's degree or higher in behavioral, social, or health sciences or education and be nationally certified as a “Board Certified Behavior Analyst” (BCBA), or certified by a similar, nationally-recognized organization. Shall have at least 2 years of directly-supervised experience developing and implementing behavioral support plans utilizing established approaches including Behavioral Analysis or Positive Behavioral Supports that are consistent with best practices for and research on effectiveness for people with intellectual and developmental b. Shall have a Baccalaureate degree or higher in behavioral, social, or health sciences or education and i. Be certified as a “Board Certified Assistant Behavior Analyst”

(BCABA) or ii. Be enrolled in a BCABA or BCBA certification program or have completed a Positive Behavior Supports training program and be working under the supervision of a certified or licensed Behavioral Services Provider. 2.. Counselors shall meet one of the following minimum requirements:

a. Shall hold the appropriate license or certification for the provider's discipline according to state or federal law as a Licensed Clinical Social Worker, Certified Rehabilitation Counselor, Licensed Professional Counselor, Licensed Clinical Psychologist, or BCBA, and must demonstrate or document a minimum of two years’ experience in providing counseling to individuals with intellectual and developmental disabilities; or b. Have a Baccalaureate degree or higher in behavioral, social, or health science or education and work under the supervision of a licensed or certified professional as set forth in Section 8.7509.E.1.

Behavioral Plan Assessor shall meet one of the following minimum qualifications:

a. Shall have a Master's degree or higher in behavioral, social, or health science or education and be nationally certified as a BCBA or certified by a similar, nationally-recognized organization. Shall have at least 2 years of directly-supervised experience developing and implementing behavioral support plans utilizing established approaches including Behavioral Analysis or Positive Behavioral Supports that are consistent with best practices for and research on effectiveness for people with intellectual and developmental disabilities; or b. Shall have a Baccalaureate degree or higher in behavioral, social, or health science or education and be i. certified as a “Board Certified Associate Behavior Analyst”

(BCABA), or ii. be enrolled in a BCABA or BCBA certification program or completed a Positive Behavior Supports training program and working under the supervision of a certified or licensed Behavioral Services 4. Behavioral Line Staff shall meet the following minimum requirements:

a. Must be at least 18 years of age, have graduated from high school or earned a high school equivalency degree, and have a minimum of 24 hours training inclusive of practical experience in the implementation of positive behavioral supports and/or applied behavioral analysis and that is consistent with best practices for and research on effectiveness for people with intellectual and developmental disabilities.

b. Must work under the direction of a Behavioral Consultant. 8.7510 Benefits Planning Service 8.7510.A Benefits Planning Service Eligibility 1. Benefits Planning Service is available to Members enrolled in one of the following a. Developmental Disabilities Waiver b. Supported Living Services Waiver 8.7510.B Benefits Planning Service Definition 1. Benefits Planning means analysis and guidance provided to a Member and their family/support network to improve their understanding of the potential impact of employment-related income on the Member’s public benefits. Public benefits include, but are not limited to Social Security, Medicaid, Medicare, food/nutrition programs, housing assistance, and other federal, state, and local benefits.

Benefits Planning gives the Member an opportunity to make an informed choice regarding employment opportunities or career advancement. 8.7510.C Benefits Planning Service Inclusion 1. Benefits Planning is available regardless of employment history or lack thereof and may be accessed throughout the phases of a Member’s career such as: when considering employment, changing jobs, or for career advancement/exploration.

Certified Benefits Planners support Members by providing any of these core activities:

a. Intensive individualized benefits counseling;

b. Benefits verification;

c. Benefit summary & analysis;

d. Identifying applicable work incentives, and if needed, developing a work incentive plan for the Member and team;

In addition to the core activities, Benefits Planning may also be utilized to:

a. Conduct an informational meeting with the Member, alone or with their support network.

b. Assist with evaluating job offers, promotional opportunities (increase in hours/wage), or other job changes that the Member is considering which change income levels; and outlining the impact that change may have on public benefits.

c. Provide information on Waiver Benefits (including Buy-In options), federal/state/local programs, and other resources that may support the Member in maintaining benefits while pursuing employment.

d. Assist with referrals and connecting the Member with identified resources, as needed, and coordinating with the Member, Case Manager, family, and other team Members to promote accessing services/resources that will advance the Member’s desired employment goals.

e. Navigate complicated benefit scenarios and offer problem-solving strategies, so the Member may begin or continue working while maintaining eligibility for needed services.

f. Offer suggestions to the Member and their family/support network regarding how to create and maintain a recordkeeping structure and reporting strategy related to benefit eligibility and requirements.

If the Member needs assistance with the collection and submission of income statements and/or documentation related to the Social Security Administration (SSA), or other benefits managing organizations, and the Member does not have other supports to do so, the Benefits Planner may assist on a temporary basis.

g. Assist in accessing federal/state/local resources, evaluating the potential impact on benefits due to changes in income, and if there is a negative impact identified, explore alternatives to meet existing needs, all in collaboration with the Member’s Case Manager and support team. 8.75010.D Benefits Planning Service Exclusions and Limitations 1. Benefits Planning shall not take the place of, nor shall it duplicate services received through the Division of Vocational Rehabilitation.

Benefits Planning services are limited to 40 units per support plan year. One unit is equal to 15 minutes of service. 8.75010.E Benefits Planning Service Provider Agency Requirements 1. Benefits Planning may be provided only by Certified Benefits Planners. A Certified Benefits Planner holds at least one of the following credentials:

a. Community Work Incentives Coordinator (CWIC);

b. Community Partner Work Incentives Counselor (CPWIC);

c. Credentialed Work Incentives Practitioner (WIP-CTM).

Documentation of the Benefits Planner’s Certification and additional trainings shall be maintained and provided upon request by a surveyor or the Department.
Certified Benefits Planners must obtain and sustain a working knowledge of Colorado’s Medicaid Waiver system as well as federal, state, and local benefits.
The Benefits Planning provider must maintain records which reflect the Benefits Planning activities that were completed for the Member, including copies of any reports provided to the Member.
If the Certified Benefits Planner encounters a benefit situation that is beyond their expertise, consultation with technical assistance liaisons is expected. 8.7511 Bereavement Counseling 8.7511.A Bereavement Counseling Eligibility 1. Bereavement Counseling is a covered benefit available to Members and/or Family Members enrolled in the HCBS Children with Complex Health Needs (CwCHN) Waiver.. 8.7511.B Bereavement Counseling Definition 1. Bereavement Counseling means counseling provided to the Member and/or Family Members to guide and help them cope with the Member’s illness and the related stress that accompanies the continuous, daily care required by a child with a complex or life-threatening condition. 8.7511.C Bereavement Counseling Exclusions and Limitations 1. Bereavement Counseling shall be a benefit only if it is not available under Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) coverage, Medicaid State Plan benefits, third party liability coverage or from other sources. 8.7511.D Bereavement Counseling Provider Agency Requirements 1. Bereavement Counseling shall be provided only by individuals licensed or certified in at least one of the following:

a. Licensed Clinical Social Worker (LCSW)

b. Licensed Professional Counselor (LPC)

c. Licensed Social Worker (LSW)

d. Licensed Independent Social Worker (LISW)

e. Licensed Psychologist; or f. Non-denominational spiritual counselor, if employed by a qualified Medicaid home health or hospice agency.

Providers shall be licensed and in good standing with their specific specialty practice act or with current state licensure statutes and regulations.
Each individual providing Bereavement Counseling shall enroll as a Medicaid provider or be employed by an enrolled Medicaid home health or hospice provider agency. 8.7511.E Bereavement Counseling Reimbursement 1. Bereavement Counseling may be initiated and reimbursed while the Member is on the CwCHN waiver but may continue for one year following the death of the 8.7512 Child and Youth Mentorship 8.7512.A Child and Youth Mentorship Eligibility 1. Child and Youth Mentorship is a covered benefit available to Members enrolled in the HCBS Children's Habilitation Residential Program Waiver. 8.7512.B Child and Youth Mentorship Definition 1. Child and Youth Mentorship means the implementation of therapeutic and/or behavioral service and support plans, building life skills, providing guidance to the child or youth with self-care, learning self-advocacy, and Protective Oversight as defined at Section 8.7506.B.2. 8.7512.C Child and Youth Mentorship Inclusions 1. This service may be utilized in maintaining stabilization, preventing Crisis situations, and/or de-escalation of a Crisis.
Service may be provided in the Member’s home or community as determined by the Wraparound Plan.
Child and Youth Mentorship may be provided individually, or in conjunction with the Wraparound Service, defined at Section 8.7557. 8.7512D Child and Youth Mentorship Provider Agency Requirements 1. Individuals providing Child and Youth Mentorship must meet the following criteria:

a. Complete at least 40 hours of training in Crisis Prevention, De-escalation, and Intervention that must encompass all of the following:

i. Trauma informed care.

ii. Youth mental health first aid.

iii. Positive Behavior Supports, behavior intervention, and deescalation techniques.

iv. Cultural competency.

v. Family systems and Family engagement.

vi. Child and adolescent development.

vii. Mental health topics and services.

viii. Substance abuse topics and services.

ix. Psychotropic medications.

x. Prevention, detection, and reporting of mistreatment. abuse, neglect, and exploitation.

xi. Intellectual and Developmental Disabilities.

xii. Child/youth specific training.

b. Complete annual refresher courses on the above training topics. 8.7513 Chiropractic 8.7513.A Chiropractic Eligibility 1. Chiropractic is a covered benefit available to Members enrolled in the HCBS Complementary and Integrative Health Waiver. 8.7513.B Chiropractic Definition 1. Chiropractic means the use of manual adjustments (manipulation or mobilization) of the spine or other parts of the body with the goal of correcting and/or improving alignment, neurological function, and other musculoskeletal problems.

During a chiropractic treatment, nutrition, exercise, and rehabilitative therapies may be recommended in support of the adjustment. 8.7513.C Chiropractic Inclusions 1. Chiropractic may be utilized to treat conditions or symptoms related to the Member’s qualifying condition and Inability to Independently Ambulate.

Members receiving Chiropractic services, or other complementary and integrative health services shall be asked to participate in an independent evaluation to determine the effectiveness of the services.
Chiropractic shall be provided in the office or clinic of a licensed chiropractor, an approved outpatient setting, or in the Member’s residence. 8.7513.D Chiropractic Exclusions and Limitations 1. Chiropractic shall be limited to the Member’s assessed need for services as identified and documented in the Person-Centered Support Plan.
A maximum of 408 combined units of Acupuncture, Chiropractic, and Massage Therapy Waiver Services may be covered as a benefit during the support plan year. 8.7513.E Chiropractic Service Provider Agency Requirements 1. Chiropractors shall be licensed by the State Board of Chiropractic pursuant to § 12-215-101 et seq (C.R.S.) and have at least one year experience practicing Chiropractic at a rate of 520 hours per year; OR one year of experience working with individuals with paralysis or other long term physical disabilities.
Chiropractic Provider Agencies shall:

a. Determine the appropriate modality, amount, scope, and duration of chiropractic service within the established limits described at Section 8.7513.D.2.

b. Recommend only services that are necessary and appropriate in a care c. Provide only services in accordance with the Member’s prior authorized 8.7514 Community Connector Services 8.7514.A Community Connector Services Eligibility 1. Community Connector Services is a covered benefit available to Members a. Children’s Extensive Support Waiver b. Children's Habilitation Residential Program Waiver 8.7514.B Community Connector Services Definition 1. Community Connector services shall be delivered on a one-to-one basis exclusively to children with an assessed exceptional or extraordinary need whose need for community engagement support substantially exceeds age-typical Parental or Legal Guardian of a Minor Responsibilities, as defined by Section 8.7502.KK, and cannot be met solely through the age-typical actions or involvement of the parent or legal guardian.

Community Connector services shall support the Member’s active and consistent engagement, meaningful participation, and contribution to community life by facilitating interaction with community members who are not paid supports, family, or known providers/caregivers, promoting integration into community settings available to the general public, and supporting the use of natural community resources. Community Connector services shall not supplant, replace, or duplicate supports that are Parental or Legal Guardian of a Minor Responsibilities, as defined by Section 8.7502.KK. This benefit shall not be available to children without an assessed age-appropriate extraordinary need, using the assessment in Section 8.400-499, Appendix A, as community engagement, activities, and skill development that fall within typical Parental or Legal Guardian of a Minor Responsibility are not covered under this service. 8.7514.C Community Connector Services Inclusions 1. Community Connector services shall be authorized only for Members who demonstrate an assessed age-appropriate extraordinary need, using the assessment in Section 8.400-499, Appendix A, that substantially exceeds ageappropriate and ordinarily expected Parental or Legal Guardian of a Minor Responsibilities, as defined in Section 8.7502.KK, and cannot be solely met through the age-typical actions or involvement of the Legally Responsible Person. Authorization shall be limited to circumstances in which the service is necessary to enable the Member to access and engage in community life with the general public.
Community Connector services shall support the development and maintenance of relationships with community members through inclusive, public, communitybased activities. Activities shall be used as learning environments to build natural supports and community connections with individuals who are not paid supports, Family Members, providers or caregivers and to support the Member’s increasing independence navigating and participating in broader community settings.
Community Connector services shall focus on developing and strengthening skills that promote the Member’s increased independence in community settings, including the ability to actively and consistently participate for the majority of the activity duration in activities that require meaningful engagement and are reasonably expected to develop or strengthen skills related to community engagement and independence. Skill development shall be directly related to the Member’s assessed extraordinary need and documented goals.
Community Connector services shall be delivered exclusively on a one-to-one

basis and are limited to supports necessary to enable the Member to access and engage in community life beyond age-typical. Parental or Legal Guardian of a Minor Responsibility.

Community Connector services shall be delivered in accordance with a Person- Centered Support Plan that identifies targeted skills and behaviors, includes measurable and time-limited goals, and clearly outlines the strategies, supports, and methods to address the Member’s extraordinary community engagement 6. Community Connector services shall be delivered in coordination with all other appropriate waiver and non-waiver services, as applicable, to ensure a comprehensive and non-duplicative approach to meeting the Member’s Extraordinary Care needs. 8.7514.D Community Connector Services Exclusions and Limitations 1. Community Connector services are limited to 1,040 units per Person-Centered Support Plan (PCSP) year. This unit limit applies to Community Connector services provided by a Legally Responsible Person(s), another service provider, or any combination thereof.

a. Community Connector Service Limit Exception Request i. Community Connector Service Limit Exception Request means the required process for requesting and authorizing service units above 1,040 units per PCSP year. Case Managers must follow the guidelines outlined at Section 8.7514.D.1.a.ii. and all additional operational guidance from the Department. The Department must follow the requirements outlined at Section 8.7514.D.1.a.iii.

ii. Community Connector Service Limit Exception Request Case Manager Responsibilities 1) Case Managers are responsible for submitting a Community Connector Service Limit Exception Request to the Department at least 30 calendar days prior to the service start date only if an assessed, age-appropriate exceptional need is present, all proposed activities meet applicable requirements, and the time reasonably necessary to complete those activities exceeds the 1,040-unit limit. The Case Manager makes the final determination on submitting a Community Connector Service Limit Exception Request.

In each Community Connector Service Limit Exception Request, the Case Manager must include Member-specific documentation, including assessment findings and service plan details outlining other authorized services, that demonstrate service appropriateness and compliance with applicable policy.
In each Community Connector Service Limit Exception Request, the Case Manager must clearly describe the Member’s needs, the reason the annual 1,040 unit limit is insufficient, and how the requested exception supports the Member’s health, safety, and community-based living.
Case Managers are responsible for responding to requests for additional information within 7 calendar days. If additional information is not provided to the Department, the Department will issue an outcome based on the information that was initially provided.
Case Managers shall ensure compliance with all Member noticing requirements and issue a Notice of Action for any adverse action, as described in Section 8.7202.R., taken as a result of the Community Connector unit limit or the Community Connector Service Limit Exception Request.
Case Managers must involve Members in the Community Connector Service Limit Exception Request by reviewing materials with the Member prior to submitting a Community Connector Service Limit Exception Request and providing copies of submitted information, requests for additional information, and Community Connector Service Limit Exception Request outcomes at the Member’s request.

iii. Community Connector Service Limit Exception Request Department Responsibilities 1) The Department will provide an initial response to the Case Manager regarding the Community Connector Service Limit Exception Request within 14 calendar days.

a) If additional information is needed for the Department to process the Community Connector Service Limit Exception Request, a request for additional information will be provided to the submitting Case Manager. If additional information is not provided to the Department, the Department will issue an outcome based on the information that was initially provided.

The Department will review Community Connector Service Limit Exception Requests for:

a) Whether the service units requested are duplicative and/or meet the definition of Extraordinary Care;

b) The reason the annual 1,040 units are insufficient based on the Members assessed need and the previously approved units;

c) How the Community Connector Service Limit Exception Request maintains the Member’s health and safety and promotes sustainable communitybased living; and d) Age-appropriateness and for duplication of Parental or Legal Guardian of a Minor Responsibilities.

The Department shall approve additional hours on a caseby-case basis when a demonstrated need is documented and justified by the Member's Case Manager and sufficiently meets the review criteria outlined at Section 8.7514.D.1.iii.
The Department shall issue a determination letter for each Community Connector Service Limit Exception Request unless the Community Connector Service Limit Exception Request is withdrawn by the Case Manager. Each determination letter shall include:

a) The type of exception that was requested;

b) The amount of units requested by the Case Manager;

c) The approved, partially approved, or denied service units;

d) A summary of the documentation reviewed, including the PCSP and supporting justification; and e) The regulatory citation(s) to support the decision.

The Community Connector Service Limit Exception Request process shall be implemented in a uniform manner applied equally to Members statewide, but outcomes shall be based on individual assessed needs and circumstances.

Units shall be authorized only for activities directly related to the Member’s assessed age-appropriate extraordinary need, using the assessment in Section 8.400-499, Appendix A, community engagement needs, and shall reflect the reasonable amount of time necessary to support those activities on a weekly

basis.

Telehealth Community Connector services shall not be provided by the Member’s Legally Responsible Person(s).
The following activities are excluded from Community Connector services:

a. Activities that involve only brief, incidental, or minimal interaction with community members who are not paid supports or Family Member(s), or that do not otherwise involve meaningful engagement with others in community settings the majority of the activity.

b. Activities that fall within age-appropriate and ordinarily expected Parental or Legal Guardian of a Minor Responsibilities, as defined in Section 8.7502.KK, or that would otherwise duplicate, replace, or supplant such responsibilities.

c. Specialized or segregated activities that only take place in the community but do not promote inclusive participation or integration into the broader d. Admission, registration, or membership fees, and food or beverage costs, which are not reimbursable under this service.

e. Services or supports provided through, or otherwise available through, the educational system, including school-based or home school-based services, or that would otherwise duplicate, replace, or supplant such 5. The paid support providing Community Connector services shall not be responsible for the supervision, care, or support of any other child(ren) or individual during any time for which Community Connector services are billed. 8.7515 Consumer Directed Attendant Support Services (CDASS) 8.7515.A CDASS Eligibility 1. CDASS is a covered benefit available to Members enrolled in CFC. 8.7515.B CDASS Definitions 1. Adaptive Equipment is as defined at 8.7502.

Allocation means the funds determined by the Case Manager in collaboration with the Member and made available by the Department through the Financial Management Service (FMS) Contractor for Attendant support services available in the Consumer Directed Attendant Support Services (CDASS) delivery option.
Attendant means the individual who meets qualifications in 8.7515.I who provides CDASS as described in Section 8.7515.D and is hired by the Member or Authorized Representative through the FMS Contractor.
Attendant Support Management Plan (ASMP) means the documented plan described in Section 8.7515.F, detailing management of Attendant support needs through CDASS.
Authorized Representative (AR) means an individual designated by the Member or the Member’s legal Guardian, if applicable, who has the judgment and ability to direct CDASS on a Member’s behalf and meets the qualifications contained in Sections 8.7515.G and 8.7515.H.
Consumer-Directed Attendant Support Services (CDASS) means the service delivery option that empowers Members to direct their care and services to assist them in accomplishing Activities of Daily Living when included as a CFC Benefit.

CDASS benefits may include assistance with health maintenance, personal care, and homemaker activities.

CDASS Person-Centered Support Plan Year Allocation means the funds determined by the Case Manager to be required to cover the cost of Attendant services, made available by the Department for the period the Member is approved to receive CDASS within the annual support plan year.
CDASS Coaching means technical support provided to Members/Authorized Representatives by the Training and Support Contractor for skills related to allocation and budget management, planning and organizing attendant services, managing employer of record responsibilities, communication skills, assessing resources, care quality, and working with the Financial Management Services vendor. The Department may mandate CDASS coaching as outlined in section 8.7515.N.2.
CDASS Orientation means the required orientation for CDASS members and Authorized Representatives that includes, but is not limited to: an overview of the program, member/and or authorized rights and responsibilities, planning and organizing attendant services, managing personnel issues, communication skills, recognizing and recruiting quality attendant support, managing health, allocation budgeting, accessing resources, safety, and prevention strategies, managing emergencies, and working with the Financial Management Services vendor.
CDASS Training is voluntary and supplemental to CDASS Orientation and CDASS Coaching. Including additional support surrounding the topics covered in Orientation and Coaching, CDASS Training topics may include, but are not limited to, Electronic Visit Verification compliance, employer of record requirements, and self-advocacy techniques for additional self-directed services 11. Electronic Visit Verification (EVV) means the use of technology, including mobile device technology, telephony, or Manual Visit Entry, to verify the required data elements related to the delivery of a service mandated to be provided using EVV by the “21st Century Cures Act,” P.L. No. 114-255, or Section 8.001.
Intentionally omitted 13. Family Member means any person related to the Member by blood, marriage, adoption, or common law as determined by a court of law.
Financial Eligibility means the Health First Colorado Financial Eligibility criteria based on Member income and resources.
Financial Management Services (FMS) Contractor means an entity contracted with the Department and chosen by the Member or Authorized Representative to complete employment-related functions for CDASS Attendants and to track and report on individual Member CDASS Allocations.
Fiscal/Employer Agent (F/EA) provides FMS by performing payroll and administrative functions for Members receiving CDASS benefits. The F/EA pays Attendants for CDASS services and maintains workers’ compensation policies on the Member-employer’s behalf. The F/EA withholds, calculates, deposits and files withheld federal income tax and both Member-employer and Attendant-employee Social Security and Medicare taxes.
Inappropriate Behavior means offensive behavior toward Attendants, Case Managers, the Training and Support Contractor or the FMS Contractor, and which includes documented verbal, sexual and/or physical abuse. Verbal abuse may include threats, insults or offensive language.
Notification means a communication from the Department or its designee concerning information about CDASS. Notification methods include but are not limited to announcements via the Department’s CDASS website, Member account statements, Case Manager contact, or FMS Contractor contact.
Stable Health means a medically predictable progression or variation of disability or illness.
Training and Support Contractor means the organization contracted by the Department to provide orientation, coaching, training, and customer service for self-directed service delivery options to Members, Authorized Representatives, and Case Managers. 8.7515.C CDASS Member Eligibility 1. To be eligible for the CDASS delivery option, the Member shall meet the following eligibility criteria:

a. Choose the CDASS delivery option.

b. Be enrolled in CFC.

c. Demonstrate a current need for covered Attendant support services.

d. Provide a statement, at enrollment and following any change in condition, from the Member’s primary care physician, physician assistant, or advanced practice nurse, attesting to the Member’s ability to direct their care with sound judgment or the ability of a required AR to direct the care on the Member’s behalf.

e. Members under the age of 18 are not required to provide a statement from their primary care physician as outlined in 8.7515.C.1.d and are required to have an AR.

f. Complete all aspects of the Attendant Support Management Plan (ASMP) and orientation and demonstrate the ability to direct care or have care directed by an Authorized Representative (AR).

i. Member orientation obligations 1) Members and ARs who have completed orientation through the Training and Support Contractor in the past two years or utilized CDASS in the previous six months may receive a modified orientation to begin or resume CDASS. A Member who was terminated from CDASS due to a Medicaid Financial Eligibility denial that has been resolved may resume CDASS without attending orientation if they received CDASS in the previous six months. 8.7515.D CDASS Inclusions and Covered Services 1. Covered services shall be for the benefit of the Member only and not for the benefit of other persons.

Services include:

a. Homemaker services as described at Section 8.7527.

b. Personal Care services as described at Section 8.7538.

c. Health Maintenance Activities services as described at Section 8.7523. 8.7515.E CDASS Exclusions and Limitations 1. CDASS Attendants shall not perform services and shall not receive reimbursement for services performed:

a. While Member is admitted to a nursing facility, hospital, a long-term care facility or is incarcerated; or b. Following the death of the Member.

The Attendant shall not be reimbursed for performing tasks when the Member is concurrently receiving a waiver service or CFC service for which a provider is required to perform the same task as part of a billed service.
Companionship is not a covered CDASS service.
Billing for travel time to and from the Member’s home at the beginning and end of the visit is prohibited. Accompaniment of a Member by a Direct Care Worker in the community is reimbursable. Employers must follow all Department of Labor and Employment guidelines on time worked.
All CDASS tasks must meet Age-Appropriate Task Standards for Children for Members under 18 or Task Standards for Adults for Members age 18 and older. If in Section 8.7607.A.
Authorization of CDASS tasks must be limited to services that exceed those considered part of Parental or Legal Guardian of a Minor Responsibility as defined at Section 8.7502.KK.
This service is subject to the following Annual CFC Service Soft Caps: Members shall not be authorized for more than 4,750 hours per PCSP of Health Maintenance Activities, 2,500 hours per PCSP of Personal Care, and/or 1,125 hours per PCSP of Homemaker services. Case Managers may request additional hours through the Department prescribed exception process outlined in Section 8.7607.A.
Members may receive up to 364 hours of Homemaker services annually from a Legally Responsible Person. Additional hours may be authorized when services are provided by a non-Legally Responsible Person.
Attendants must adhere to the Weekly Caregiver Limit and Per Day Hourly Limit 8.7515.F CDASS Attendant Support Management Plan 1. The Member/Authorized Representative (AR) shall develop a written Attendant Support Management Plan (ASMP) after completion of orientation but prior to the start date of services, which shall be reviewed by the Training and Support Contractor and approved by the Case Manager. CDASS shall not begin until the Case Manager approves the plan and provides a start date to the Financial Management Services (FMS) Contractor. The Attendant Support Management Plan shall be completed following initial orientation and mandatory coaching and shall be modified when there is a change in the Member’s needs. The plan shall describe the Member’s:

a. Attendant support needs;

b. Plans for locating and hiring Attendants;

c. Plans for handling emergencies;

d. Assurances and plans regarding direction of CDASS Services, as described at Sections 8.7515.G; 8.7523.C; 8.7528.C; and 8.7538.C as applicable;

e. Plans for budget management within the Member’s Allocation;

f. Designation of an AR, if applicable; and g. Designation of regular and back-up employees proposed or approved for hire.

If the ASMP is disapproved by the Case Manager, the Member or AR has the right to Case Management Agency review of the disapproval. The Member or AR shall submit a written request to the Case Management Agency stating the reason for the review and justification of the proposed ASMP. The Member’s most recently approved ASMP shall remain in effect while the review is in 8.7515.G CDASS Member/AR Responsibilities 1. Member/AR shall complete the following responsibilities for CDASS management:

a. Complete orientation provided by the Training and Support Contractor.

Members who cannot complete orientation shall designate an AR.

b. Complete and submit an ASMP at initial enrollment when a Member’s Allocation changes by 25% or more and whenever required based on the Member’s needs.

c. Determine wages for each Attendant not to exceed the rate established by d. Determine the required qualifications for Attendants.

e. Recruit, hire and manage Attendants.

f. Complete employment reference checks on Attendants.

g. Train Attendants to meet the Member’s needs. When necessary to meet the goals of the ASMP, the Member/AR shall verify that each Attendant has been or will be trained in all necessary health maintenance activities before the Attendant provides direct care to the Member.

h. Terminate Attendants when necessary, including when an Attendant is not meeting the Member’s needs.

i. Operates as the Attendant’s legal employer of record.

j. Complete necessary employment-related functions through the Financial Management Services (FMS) Contractor, including hiring and termination of Attendants and employer-related paperwork necessary to obtain an employer tax ID.

k. Ensure all Attendant employment documents have been completed and accepted by the FMS Contractor prior to beginning Attendant services.

l. Follow all relevant laws and regulations applicable to the supervision of Attendants.

m. Explain the role of the FMS Contractor to the Attendant.

n. Budget for Attendant care within the established monthly and CDASS Certification Period Allocation. Services that exceed the Member’s monthly CDASS Allocation by 30% or higher are not allowed and cannot be authorized by the Member or AR for reimbursement through the FMS Contractor unless prior approval is obtained from the Department or its designee.

o. Authorize Attendant to perform services allowed through CDASS.

p. Ensure all Attendants required to utilize Electronic Visit Verification (EVV) are trained and complete EVV for services rendered. Timesheets shall reflect time worked and capture all required data points to maintain compliance with Section 8.001, et seq.

q. Review all Attendant timesheets and statements for accuracy of time worked, completeness, and Member/AR and Attendant signatures.

Timesheets shall reflect actual time spent providing CDASS.

r. Review and submit approved Attendant timesheets to the FMS by the established timelines for submission of timesheets for Attendant s. Authorize the FMS Contractor to make any changes in the Attendant wages.

t. Understand that misrepresentations or false statements may result in administrative penalties, criminal prosecution, and/or termination from CDASS. Member/AR is responsible for assuring timesheets submitted are not altered in any way and that any misrepresentations are immediately reported to the FMS Contractor.

u. Complete and manage all paperwork and maintain employment records.

v. Select an FMS Contractor upon enrollment into CDASS.

Member/AR responsibilities for Verification:

a. Sign and return a responsibilities acknowledgement form for activities listed in Section 8.7515.G to the Case Manager.

Members utilizing CDASS have the following rights:

a. To receive training on managing CDASS.

b. To receive program materials in accessible format.

c. To receive advance Notification of changes to CDASS.

d. To participate in Department-sponsored opportunities for input.

e. To transition to alternative service delivery options at any time. The Case Manager shall coordinate the transition and Referral process.

f. To request a Reassessment if the Member’s level of service needs have changed.

g. To revise the ASMP at any time with Case Manager approval. 8.7515.H CDASS Authorized Representatives (AR)

A person who has been designated as an AR shall submit an AR designation affidavit attesting that he or she:

a. Is at least eighteen years of age;

b. Has known the eligible person for at least two years;

c. Has not been convicted of any crime involving exploitation, abuse, or assault on another person; and d. Does not have a mental, emotional, or physical condition that could result in harm to the Member.

CDASS Members who require an AR may not serve as an AR for another CDASS Member.
An AR shall not receive reimbursement for CDASS AR services and shall not be reimbursed as an Attendant for the Member they represent.
An AR must comply with all requirements contained in Section 8.7515.G.
An AR who has failed to meet the responsibilities of an AR as outlined in 8.7515.N .for a member will be removed as the AR and cannot become or continue to be an AR for another member. 8.7515.I CDASS Attendants 1. Attendants shall be at least 16 years of age and demonstrate competency in caring for the Member to the satisfaction of the Member/Authorized Representative (AR).

a. Minor attendants ages 16 to 17 will not be permitted to operate floorbased vertical powered patient/resident lift devices, ceiling-mounted vertical powered patient/resident lift devices, and powered sit-to-stand patient/resident lift devices (lifting devices).

b. Attendants may not be reimbursed for more than sixteen (16) hours of care per day for one or more members collectively.

An AR shall not be employed as an Attendant for the same Member for whom they are an AR.
Attendants must be able to perform the tasks on the Attendant Support Management Plan (ASMP) they are being reimbursed for and the Member must have adequate Attendants to assure compliance with all tasks on the ASMP.
Attendant timesheets submitted for approval must be accurate and reflect time worked.
Attendants shall not misrepresent themselves to the public as a licensed nurse, a certified nurse’s aide, a licensed practical or professional nurse, a registered nurse or a registered professional nurse.
Attendants shall not have had their license as a nurse or certification as a nurse aide suspended or revoked or their application for such license or certification denied.
Attendants shall receive an hourly wage based on the rate negotiated between the Attendant and the Member/AR not to exceed the amount established by the Department. The Financial Management Services (FMS) Contractor shall make all payments from the Member’s Allocation under the direction of the Member/AR within the limits established by the Department.
Attendants are not eligible for hire if their background check identifies a conviction of a crime that the Department has identified as a high-risk crime that can create a health and safety risk to the Member. A list of high-risk crimes is available through the Department, Training and Support Contractor and FMS Contractor.
Attendants may not participate in Member orientation or coaching provided by the Training and Support Contractor. Members may request to have their Attendant, or a person of their choice, present to assist them during the session based on their personal assistance needs. Attendants may not be present during the budgeting portion of the orientation or coaching.
Attendants must adhere to the Weekly Caregiver Limit and Per Day Hourly Limit 8.7515.J CDASS Financial Management Services (FMS)
FMS Contractor shall be responsible for the following tasks:

a. Collect and process timesheets submitted by attendants within agreedupon timeframes as identified in FMS Contractor materials and websites.

b. Conduct payroll functions, including withholding employment-related taxes such as workers’ compensation insurance, unemployment benefits, withholding of all federal and state taxes, and compliance with federal and state laws regarding overtime pay and minimum wage.

c. Distribute paychecks in accordance with agreements made with Member/Authorized Representative (AR) and timelines established by the Colorado Department of Labor and Employment.

d. Submit authorized claims for CDASS provided to an eligible Member.

e. Verify Attendants’ citizenship status and maintain copies of I-9 documents.

f. Track and report utilization of Member Allocations.

g. Comply with Department regulations and the FMS Contractor contract with h. Maintain compliance with Electronic Visit Verification (EVV) requirements as defined under Section 8.001 et seq. and 8.7515 et seq., including the provision of an EVV system for Members and their attendants to collect and maintain data that verifies when CDASS services have occurred.

i. Enforce Weekly Caregiver Limit and Per Day Hourly Caregiver Limit as outlined in Section 8.7419, and accurately process and retain documentation that supports any pending or approved exceptions to those limits.

In addition to the requirements set forth at Section 8.7515.J.1, the FMS Contractor operating under the Fiscal/Employer Agent (F/EA) model shall be responsible for obtaining designation as a Fiscal/Employer Agent in accordance with Section 3504 of the Internal Revenue Code, 26 U.S.C § 2504 (2024). 8.7515.K CDASS Selection of Financial Management Services (FMS)

Contractor 1. The Member/Authorized Representative (AR) shall select an FMS from the list of FMS contracted with the Department at the time of enrollment.

The Member/AR may select a new FMS during the designated open enrollment periods. The Member/AR shall remain with their selected FMS until the transition to the new FMS Contractor is completed. 8.7515.L CDASS Start of Services 1. The CDASS start date shall not occur until all of the requirements contained in Sections 8.7515.C, 8.7515.F, 8.7515.G, 8.7515.H have been met.
The Case Manager shall approve the Attendant Support Management Plan (ASMP), establish a service period, submit a Prior Authorization Request (PAR) and receive a Prior Authorization Request (PAR) approval before a Member is given a start date and may begin CDASS.
The FMS Contractor shall process the Attendant’s employment packet within the Department’s prescribed timeframe and ensure the Member has a minimum of two approved Attendants prior to starting CDASS. The Member must maintain employment relationships with two Attendants while participating in CDASS.
The FMS Contractor will not reimburse Attendants for services provided prior to the CDASS start date. Attendants are not approved until the FMS Contractor provides the Member/Authorized Representative (AR) with employee numbers and confirms Attendants’ employment status.
If a Member is transitioning from a hospital, nursing facility, or HCBS Agency services, the Case Manager shall coordinate with the discharge coordinator to ensure that the Member’s discharge date and CDASS start date correspond. 8.7515.M CDASS Service Substitution 1. Once a start date has been established for CDASS, the Case Manager shall establish an end date and discontinue the Member from any other Medicaidfunded Attendant support including In-Home Support Services, homemaker services, and personal care services effective as of the start date of CDASS.
Case Managers shall not authorize Prior Authorization Requests (PARs) with concurrent payments for CDASS and other CFC service delivery options for Personal Care services, Homemaker services, and Health Maintenance Activities for the same Member.
Members may receive up to 60 days of Medicaid Acute Home Health services directly following acute episodes as defined by 8.520.4.C.1.c. Members are permitted to utilize Long Term Home Health and Private Duty Nursing in conjunction with CDASS so long as the services are not utilized concurrently and are not duplicative of the services received through CDASS. CDASS service plans shall be modified to ensure no duplication of services.
Members may receive Hospice services in conjunction with CDASS services.

CDASS service plans shall be reviewed and may be modified to ensure no duplication of services. 8.7515.N CDASS Failure to Meet Member/Authorized Representative (AR)

If a Member/AR fails to meet their CDASS responsibilities, the Member may be terminated from CDASS. Prior to a Member being terminated from CDASS the following steps shall be taken:

a. Mandatory coaching conducted by the contracted Training and Support Contractor.

b. Required designation of an AR if one is not in place, or mandatory redesignation of an AR if one has already been assigned.

Actions requiring mandatory coaching, or appointment or change of an AR include any of the following:

a. The Member/AR does not comply with CDASS program requirements including service exclusions.

b. The Member/AR demonstrates an inability to manage Attendant support.

c. The Member no longer meets program eligibility criteria due to deterioration in physical or cognitive health as determined by the Member's physician, physician assistant, or advance practice nurse.

d. The Member/AR spends the monthly Allocation in a manner causing premature depletion of funds without authorization from the Case Manager or reserved funds. The Case Manager will follow the service utilization protocol.

e. The Member/AR exhibits Inappropriate Behavior as defined at Section 8.7515.B toward Attendants, Case Managers, the Training and Support Contractor, or the Financial Management Services (FMS) Contractor.

f. The Member/AR authorizes the Attendant to perform services while the Member is in a nursing facility, hospital, a long-term care facility or while incarcerated. 8.7515.O CDASS Immediate Involuntary Termination 1. Members may be involuntarily terminated immediately from CDASS for the following reasons:

a. A Member no longer meets program criteria due to deterioration in physical or cognitive health AND the Member refuses to designate an Authorized Representative (AR) to direct services.

b. The Member/AR demonstrates a consistent pattern of overspending their monthly Allocation leading to the premature depletion of funds AND the Case Manager has determined that attempts using the service utilization protocol to assist the Member/AR to resolve the overspending have failed.

c. The Member/AR exhibits Inappropriate Behavior as defined at Section 8.7515.B toward Attendants, Case Managers, the Training and Support Contractor or the Financial Management Services (FMS) Contractor, and the Department has determined that the Training and Support Contractor has made attempts to assist the Member/AR to resolve the Inappropriate Behavior or assign a new AR, and those attempts have failed.

d. Member/AR authorized the Attendant to perform services for a person other than the Member, authorized services not available in CDASS, or allowed services to be performed while the Member is in a hospital, nursing facility, a long-term care facility or while incarcerated and the Department has determined the Training and Support Contractor has made adequate attempts to assist the Member/AR in managing appropriate services through mandatory coaching.

e. Intentional submission of fraudulent CDASS documents or information to Case Managers, the Training and Support Contractor, the Department, or the FMS Contractor.

f. Instances of proven fraud, abuse, and/or theft in connection with the Colorado Medical Assistance program.

g. Member/AR fails to complete mandatory coaching, appoint an AR, or remediate CDASS management per Section 8.7515.N.1.

h. Member/AR demonstrates a consistent pattern of non-compliance with Electronic Visit Verification (EVV) requirements determined by the EVV CDASS protocol.

i. Members experiencing FMS EVV systems issues must notify the FMS Contractor and/or Department of the issue within five (5) business days. In the event of a confirmed FMS EVV system outage or failure impacting EVV submissions, the Department will not impose strikes or pursue termination, as appropriate, as outlined in the EVV Compliance protocol. 8.7515.P Ending the CDASS Delivery Option 1. If a Member chooses to use an alternate care option or is terminated involuntarily, the Member will be terminated from CDASS when the Case Manager has secured an adequate alternative to CDASS in the community.

In the event of discontinuation of or termination from CDASS, the Case Manager shall:

a. Complete the Long Term Care Notice of Action (LTC-803) and provide the Member or Authorized Representative (AR) with the reasons for termination, information about the Member’s rights to fair hearing, and appeal procedures. Once notice has been given for termination, the Member or AR may contact the Case Manager for assistance in obtaining other home care services or additional benefits, if needed.

b. The Case Manager has thirty (30) calendar days prior to the date of termination to discontinue CDASS and begin alternate care services.

Exceptions may be made to increase or decrease the thirty (30) day advance notice requirement when the Department has documented that there is danger to the Member. The Case Manager shall notify the FMS Contractor of the date on which the Member is being terminated from CDASS.

Members who are involuntarily terminated pursuant to Sections 8.7515.O.1.b, 8.7515.O.1.d, 8.7515.O.1.e, 8.7515.O.1.f, and 8.7515.O.1.g may not be reenrolled in CDASS as a service delivery option.
Members who are involuntary terminated pursuant to Section 8.7515.O.1.a are eligible for enrollment in CDASS with the appointment of an AR or eligibility documentation as defined at 8.7515.C.1.e. The Member or AR must have successfully completed CDASS orientation prior to enrollment in CDASS.
Members who are involuntary terminated pursuant to 8.7515.O.1.c are eligible for enrollment in CDASS with the appointment of an AR. The Member must meet all CDASS eligibility requirements with the AR completing CDASS orientation prior to enrollment in CDASS.
Members who are involuntarily terminated pursuant to 8.7515.O.1.h are eligible for enrollment in CDASS 365 days from the date of termination. The Member must meet all eligibility requirements and complete CDASS orientation prior to enrollment in CDASS. 8.7515.Q CDASS Case Management Functions 1. The Case Manager shall review and approve the Attendant Support Management Plan (ASMP) completed by the Member/Authorized Representative (AR). The Case Manager shall notify the Member/AR of ASMP approval and establish a service period and Allocation.
If the Case Manager determines that the ASMP is inadequate to meet the Member’s CDASS needs, the Case Manager shall work with the Member/AR to complete a fully developed ASMP.
The Case Manager shall calculate the Allocation for each Member who chooses CDASS as follows:

a. Calculate the number of personal care, homemaker, and health maintenance activities hours needed on a monthly basis using the Department’s prescribed method. The needs determined for the Allocation should reflect the needs in the Department-approved Assessment tool and the service plan. The Case Manager shall use the Department’s established rate for personal care, homemaker, and health maintenance activities to determine the Member’s Allocation.

b. The Allocation should be determined using the Department’s prescribed method at the Member’s initial CDASS enrollment and at Reassessment.

Service authorization will align with the Member’s need for services and adhere to all service authorization requirements and limitations established by the Member’s waiver program.

c. The Case Manager shall follow the Department’s assessment process and receive prior authorization before authorizing a CDASS start date for Attendant services for Person-Centered Support Plan that;

i. Contain Health Maintenance Activities; or ii. Exceed the cost of care received in an institutional setting.

Prior to orientation or when an Allocation changes, the Case Manager shall provide written Notification of the Allocation to the Member and the AR, if 5. A Member or AR who believes the Member needs a change in Attendant support, may request the Case Manager to perform a review of the Direct Care Services Calculator and CDASS Allocation for services. Review should be completed within five (5) business days.

a. If the review indicates that a change in Attendant support is justified, the following actions will be taken:

i. The Case Manager shall provide notice of the Allocation change to the Member/AR utilizing a long-term care notice of action form within ten (10) business days regarding their appeal rights in accordance with Section 8.057, et seq.

ii. The Case Manager shall complete a Prior Authorization Request (PAR) revision indicating the increase in CDASS Allocation using the Department’s Medicaid Management Information System and FMS Contractor system. Prior Authorization Request (PAR) revisions shall be completed within five (5) business days of the Allocation determination.

iii. The Member/AR shall amend the ASMP and submit it to the Case Manager.

b. The Training and Support Contractor is available to facilitate a review of services and provide mediation when there is a disagreement in the services authorized on the Direct Care Services Calculator.

c. The Case Manager will notify the Member of CDASS Allocation approval or disapproval by providing a long-term care notice of action form to Members within ten (10) business days regarding their appeal rights in accordance with Section 8.057, et seq.

In approving an increase in the Member’s Allocation, the Case Manager shall consider the following:

a. Any deterioration in the Member’s functioning or change in availability of natural supports, meaning assistance provided to the Member without the requirement or expectation of compensation;

b. The appropriateness of Attendant wages as determined by Department’s established rate for equivalent services; and c. The appropriate use and application of funds for CDASS services.

In reducing a Member’s Allocation, the Case Manager shall consider:

a. Improvement of functional condition or changes in the available natural b. Inaccuracies or misrepresentation in the Member’s previously reported condition or need for service; and c. The appropriate use and application of funds for CDASS services.

Case Managers shall cease payments for all existing Medicaid-funded personal care, homemaker, and/or health maintenance activities as of the Member’s CDASS start date.
For effective coordination, monitoring and evaluation of Members receiving CDASS, the Case Manager shall:

a. Contact the CDASS Member/AR once a month during the first three months to assess their CDASS management, their satisfaction with Attendants, and the quality of services received. Case Managers may refer Members/ARs to the FMS Contractor for assistance with payroll and to the Training and Support Contractor for training needs, budgeting, and support.

b. Contact the Member/AR quarterly after the first three months to assess their implementation of Attendant services, CDASS management issues, quality of care, Allocation expenditures, and general satisfaction.

c. Contact the Member/AR when a change in AR occurs and contact the Member/AR once a month for three months after the change takes place.

d. Review monthly FMS Contractor reports to monitor Allocation spending patterns and service utilization to ensure appropriate budgeting and follow up with the Member/AR when discrepancies occur.

e. Utilize Department overspending protocol when needed to assist CDASS Member/AR.

f. Follow protocols established by the Department for Case Management Activities.

Reassessment: The Case Manager will follow in-person and phone contact requirements based on the Member’s waiver program or CFC requirements.

Contacts shall include a review of care needs, the ASMP, and documentation from the physician, physician assistant, or advance practice nurse stating the Member’s ability to direct care.

Case Managers shall participate in training and consulting opportunities with the Department’s contracted Training and Support Contractor.
Case Managers must review all documentation and observations and use the Age-Appropriate Task Standards for Children for Members under the age of 18 and Task Standards for adults for Members age 18 years or older when determining appropriate authorization for tasks. If additional hours are needed beyond the Age-Appropriate Task Standards for Children for Members under 18 or Task Standards for Adults, Case Managers shall follow the CFC Direct Care Services Exception Request process described in 8.7607.A.
Case Managers must review all exception requests to exceed Weekly Caregiver Limit as outlined in Section 8.7419. 8.7515.R CDASS Attendant Reimbursement 1. Attendants shall receive an hourly wage not to exceed the rate established by the Department and negotiated between the Attendant and the Member/Authorized Representative (AR) hiring the Attendant. Wages shall be established in accordance with Colorado Department of Labor and Employment standards including, but not limited to, minimum wage and overtime requirements.

Attendant wages may not be below the local, state, and federal requirements for the location where the service is provided. The Financial Management Services (FMS) Contractor shall make all payments from the Member’s Allocation under the direction of the Member/AR. Attendant wages shall be commensurate with the level of skill required for the task and wages shall be justified in the Attendant Support Management Plan (ASMP).

Attendant timesheets that exceed the Member’s monthly CDASS Allocation by 30% or more are not allowed and cannot be authorized by the Member or AR for reimbursement through the FMS Contractor unless prior approval is obtained from the Department or its designee.
Once the Member’s yearly Allocation is used, further payment will not be made by the FMS Contractor, even if timesheets are submitted. Reimbursement to Attendants for services provided when a Member is no longer eligible for CDASS or when the Member’s Allocation has been depleted are the responsibility of the Member/AR. 8.7515.S CDASS Reimbursement to Family Members 1. Family Members/Legal Guardians may be employed by the Member/Authorized Representative (AR) to provide CDASS, subject to the conditions below.

a. The Family Member or Legal Guardian shall be employed by the Member/AR and be supervised by the Member/AR.

b. The Family Member and/or Legal Guardian being reimbursed as a Personal Care, Homemaker, and/or Health Maintenance Activities attendant shall be reimbursed at an hourly rate with the following restrictions:

i. Family Member wages shall be commensurate with the level of skill required for the task and should not deviate from that of a non- Family Member Attendant unless there is evidence that the Family Member has a higher level of skill.

ii. A member of the Member’s household may only be paid to furnish Extraordinary Care as defined at Section 8.7502.II, as determined by the Case Manager. Extraordinary Care shall be documented on the service plan.

c. Reimbursement for Homemaker services provided by one or more Legally Responsible Persons is limited to a maximum of 364 total hours per year, per member.

d. A Member/AR who chooses a Family Member as a care provider, shall document the choice on the Attendant Support Management Plan (ASMP). 8.7516 Counseling Services 8.7516.A Counseling Services Eligibility 1. Counseling Services is a service available to Members enrolled in the HCBS Brain Injury Waiver. 8.7516.B Counseling Services Definition 1. Counseling services mean individualized services designed to assist Members and their support systems to more effectively manage stress related situations due to a Brain Injury diagnosis. 8.7516.C Counseling Services Inclusions 1. Counseling is available to the Member’s Family and support network in conjunction with the Member if they: a) have a significant role in supporting the Member or b) live with or provide care to the Member. “Family” and “support network” includes a Parent, spouse, child, relative, foster family, in-laws, or other person who may have significant ongoing interaction with the Member.

Services may be provided in the Member’s residence, in community settings, or in the provider's office.
Intervention may be provided in either a group or individual setting: however, charges for group and individual therapy shall reflect differences.
The need for all Counseling Services must be documented in the Person- 5. All Counseling Services must be provided by enrolled HCBS Provider Agencies.
Family training/counseling must be carried out for the direct benefit of the Members of the HCBS-Brain Injury program.
Family training is considered an integral part of the continuity of care in transition to home and community environments. Services are directed towards instruction about treatment regimens and use of equipment specified in the service plan and shall include updates as may be necessary to safely maintain the Member at 7. The service is limited to thirty 30 visits of individual, group, family, or a combination of counseling services. The Department may authorize additional units based on needs identified in the Person-Centered Support Plan or Provider Care Plan. 8.7516.D Counseling Services Exclusions and Limitations 1. Family training is not available to individuals who are employed to care for the 8.7516.E Counseling Services Provider Agency Requirements 1. Professionals providing Counseling Services must hold the appropriate license or certification for their discipline according to state law or federal regulations and represent one of the following professional categories: Licensed Clinical Social Worker, Certified Rehabilitation Counselor, Licensed Professional Counselor, or Licensed Clinical Psychologist. Master's or doctoral level counselors who meet experiential and educational requirements but lack the certification or credentialing as described above, may submit their professional qualifications via curriculum vitae or resume for consideration.
All professionals applying as Provider Agencies of Counseling Services must demonstrate or document a minimum of two years of experience in providing counseling to Members with a Brain Injury and their families. 8.7516.F Counseling Services Reimbursement 1. Reimbursement will be on an hourly basis per type of counseling service as established by the Department. Three distinct counseling services are allowable for Members enrolled in the HCBS-Brain Injury Waiver: Counseling Services including Family Counseling, Individual Counseling, and Group Counseling. 8.7517 Day Habilitation 8.7517.A Day Habilitation Eligibility 1. Day Habilitation is a covered benefit for Members enrolled in one of the following a. Developmental Disabilities Waiver b. Supported Living Services Waiver 8.7517.B Day Habilitation Inclusions 1. Day Habilitation shall foster the acquisition of skills, appropriate behavior, greater independence, and personal choice. Services and supports include assistance with the acquisition, retention or improvement of self-help, socialization and adaptive skills that take place in a non-residential setting, separate from the Member’s private residence or other residential living arrangement.
Day Habilitation services and supports encompass three (3) types of habilitative services; Specialized Habilitation Services, Supported Community Connections, and Prevocational Services.

a. Specialized Habilitation (SH) services are community-integrated services provided out of a non-residential setting, provided to enable the Member to attain the maximum functional level or to be supported in such a manner that allows the Member to gain an increased level of selfsufficiency. Specialized Habilitation services:

i. Include the opportunity for Members to select from Age-Appropriate Activities and Materials, as defined in Section 8.7001.A.1 both within and outside of the setting;

ii. Include assistance with self-feeding, toileting, self-care, sensory stimulation and integration, self-sufficiency, and maintenance skills; and iii. May reinforce skills or lessons taught in school, therapy or other settings and are coordinated with any physical, occupational or speech therapies listed in the Person-Centered Support Plan.

b. Supported Community Connections (SCC) services are provided to support the abilities and skills necessary to enable the Member to access typical activities and functions of community life, such as those chosen by the general population, including community education or training, retirement, and volunteer activities. SCC services:

i. Provide a wide variety of opportunities to facilitate and build relationships and natural supports in the community while utilizing the community as a learning environment to provide services and supports as identified in a Member’s care plan or Person- Centered Support Plan;

ii. Are conducted in a variety of settings in which the Member interacts with persons without disabilities other than those individuals who are providing services to the Member. These types of services may include socialization, adaptive skills and personnel to accompany and support the Member in community settings;

iii. Provide resources necessary for participation in activities and supplies related to skill acquisition, retention or improvement and are provided by the Provider Agency as part of the established reimbursement rate; and iv. May be provided in a group setting or on a one-to-one (1:1) basis as identified in the Person-Centered Support Plan.

v. Activities provided exclusively for recreational purposes are not a benefit and shall not be reimbursed.

c. Prevocational services must comply with Supported Employment regulations at Section 8.7549.

d. Telehealth Day Habilitation services i. Telehealth Specialized Habilitation services includes providerhosted virtual meetings, groups, and activities where Members virtually engage and interact with Provider Agency staff, volunteers, and other Members.

ii. Telehealth Supported Community Connections services includes virtual meetings, groups and activities, that are hosted by nonprovider entities where Members virtually engage and interact with persons without disabilities other than those individuals who are providing services to the Member. 8.7517.C Day Habilitation Exclusions and Limitations 1. Day Habilitation Services and Supports are to be provided outside of the person's living environment, unless otherwise indicated by the person's needs. If services cannot be provided outside of the living environment due to a person's medical or safety needs, this shall be documented.

Day Habilitation services may not be delivered virtually 100% of the time.

a. Specialized Habilitation Provider Agencies must maintain a physical location where in-person services are offered.

b. There will always be an option for in-person Day Habilitation services 8.7517.D Day Habilitation Provider Agency Requirements 1. Provider Agencies shall maintain documentation that includes the date and start/end times of activities completed, what activities were completed, and what Person-Centered Support Plan goals of the Member are being achieved through the activity(ies).

Integrated employment should be considered as the primary option for all persons receiving Day Habilitation Services and Supports.
If the Provider Agency provides services in the community to persons who may visit the offices of the Provider Agency (or another service operated facility), but the persons receive services at such location(s) for less than one hour per visit, requirements of Sections 8.7412.A.1-4 do not apply. The Provider Agency shall, however, ensure that the facility complies with the ADA and contains no hazards which could jeopardize the health or safety of persons visiting the site.
For physical facilities used as community integrated sites over which the Provider Agency exercises little or no control, the Provider Agency shall:

a. Conduct an on-site visit to ensure that there is no recognizable safety or health hazards which could jeopardize the health or safety of individuals;

b. Address any safety or health hazards which could jeopardize the health or safety of individuals with the owner/operator of the physical facility.

Specialized Habilitation Services Provider Setting a. Specialized Habilitation settings must meet the criteria outlined in Section 8.7001.B.

b. The Specialized Habilitation location shall provide a clean and sanitary environment that is physically accessible to the Members, including those Members with supportive devices for ambulation or who are in wheelchairs.

c. The Specialized Habilitation location shall provide age-appropriate activities appropriate to the number and needs of the Members, at the times desired by the Members. 8.7517.E Day Habilitation Provider Agency Reimbursement Requirements 1. Supported Living Services Waiver:

a. Day habilitation services, in combination with prevocational services and supported employment, are limited to seven thousand one hundred and twelve (7,112) units per support plan year. One (1) unit is equal to fifteen (15) minutes of service.

Developmental Disabilities Waiver:

a. Day Habilitation services, in combination with Prevocational services, are limited to four thousand eight hundred (4,800) units. When used in combination with supported employment services, the total number of units available for day habilitation services in combination with prevocational services will remain at four thousand eight hundred (4,800) units and b. The cumulative total, including supported employment services, may not exceed seven thousand one hundred and twelve (7,112) units. One (1) unit is equal to fifteen (15) minutes of service.

DD & SLS: Day Habilitation services have 3 tiers for service provision:

a. Tier 1 - Specialized Habilitation and Supported Community Connections services are provided virtually via Telehealth. Tier 1 services should be billed at the Tier 2 rate, according to the Member’s Support Level.

b. Tier 2 - Traditional Specialized Habilitation and Supported Community Connections services provided in a group setting, apart from the Member’s residence, and billed for at the Tier 2 rate, according to the Member’s Support Level. Tier 2 Supported Community Connections services may also be provided to a single Member, utilizing the community as the learning environment. Tier 2 services are delivered in-person.

c. Tier 3 - Supported Community Connections services.

i. SCC services are provided 1:1, to a single Member, and billed for at the Tier 3 Supported Community Connections rate. Members who receive Supported Community Connections services under Tier 3 are also required to stay within the Member’s individual annual dollar limit for the combination of group and 1:1 Day Habilitation services. Tier 3 services must be delivered in-person.

One-on-one Supported Community Connections services may be billed for at the individualized rate and when this occurs the combination of group and 1:1 Day Habilitation services are required to stay within the Member’s individual annual dollar limit, as well as the unit limit. Members who have an exceptional need to exceed one’s individualized annual dollar limit may request additional funding through the Department’s exception process. 8.7518 Day Treatment 8.7518.A Day Treatment Eligibility 1. Day Treatment is a covered benefit available to Members enrolled in the HCBS Brain Injury Waiver. 8.7518.B Day Treatment Definition 1. Day Treatment means intensive therapeutic services scheduled on a regular

basis for two or more hours per day, one or more days per week directed at the ongoing development of community living skills. Services take place in a nonresidential setting separate from the home in which the Member lives. 8.7518.C Day Treatment Inclusions 1. Day Treatment includes the following components:

a. Social skills training, sensory motor development, reduction/elimination of maladaptive behavior and services aimed at preparing the individual for community reintegration (reaching concepts such as compliance, attending, task completion, problem solving, safety, money management).

b. Professional services including occupational therapy, physical therapy, speech therapy, vocational counseling, nursing, social work, recreational therapy, Case Management and neuropsychology should be directly available from the provider or available as contracted services when deemed medically necessary by the treatment plan.

Certified occupational therapy aides, physical therapy aides, and communication aides may be used in lieu of direct therapy with fully licensed therapists to the extent allowed in existing state statute.
The provider shall coordinate with other community-based resources and providers.

a. Counseling and Referrals to appropriate professionals when Crisis situations occur with the Member and Family or staff.

b. Behavioral programming which contains specific guidelines on treatment parameters and methods.

Transportation between therapeutic tasks in the community shall be included in the rate for day treatment. 8.7518.D Day Treatment Provider Agency Requirements 1. Directors of day treatment programs shall have professional licensure in a healthrelated program in combination with at least 2 years of experience in head trauma rehabilitation programming.
Providers are required to have regular contact and meetings with the Members and their families to discuss care plan progress and revision. 8.7518.E Day Treatment Provider Reimbursement Requirements 1. Day treatment services will be paid on a per diem basis at a rate to be determined by the Department. In order for a Provider Agency to be paid for a day of treatment, a Member must have attended and received day treatment services for a minimum of 2 hours per day. 8.7519 Dental 8.7519A Dental Eligibility 1. Dental is available to Members enrolled in one of the following HCBS waivers:

a. Developmental Disabilities Waiver b. Supported Living Services Waiver 8.7519.B Dental Definition 1. Dental care means services administered for diagnostic and preventative care to abate tooth decay, and medically appropriate treatments to restore dental health. 8.7519.C Dental Inclusions 1. Preventative services include:

a. Dental insurance premiums, copayments/and coinsurance;

b. Periodic examination and diagnosis;

c. Radiographs when indicated;

d. Non-intravenous sedation;

e. Basic and deep cleanings;

f. Mouth guards;

g. Topical fluoride treatment; and h. Retention or recovery of space between teeth when indicated 2. Basic services include:

a. Fillings;

b. Root canals;

c. Denture realigning or repairs;

d. Repairs/re-cementing crowns and bridges;

e. Non-emergency extractions including simple, surgical, full and partial;

f. Treatment of injuries; or g. Restoration or recovery of decayed or fractured teeth.

Major services include:

a. Implants when necessary to support a dental bridge for the replacement of multiple missing teeth or are necessary to increase the stability of crowns of, crowns, bridges, and dentures. The cost of implants is only reimbursable with prior approval in accordance with The Department procedures.

b. Crowns.

c. Bridges.

d. Dentures. 8.7519.D Dental Exclusions and Limitations 1. Dental services are provided only when the services are not available through the Medicaid State Plan due to not meeting the need for medical necessity as defined at Section 8.076.1.8, or available through a third party. General limitations to dental services including frequency will follow the Department’s guidelines using industry standards and are limited to the most cost effective and efficient means to alleviate or rectify the dental issue associated with the 2. Implants are a benefit only when the procedure is necessary to support a dental bridge for the replacement of multiple missing teeth or is necessary to increase the stability of dentures. The cost of implants is reimbursable only with prior authorization by the Administrative Service Organization.

Implants shall not be a benefit for Members who use tobacco daily due to the substantiated increased rate of implant failures for chronic tobacco users.
Subsequent implants are not a covered service. Exceptions would be exclusive to situations involving failure of the implant. In these instances, a formal grievance must be filed in order to determine if a full review is necessary to assess the cause of the implant failure.
Full mouth implants or crowns are not covered.
Dental services do not include cosmetic dentistry, procedures predominated by specialized prosthodontic, maxillo-facial surgery, craniofacial surgery or orthodontia, which includes, but is not limited to:

a. Elimination of fractures of the jaw or face, b. Elimination or treatment of major handicapping malocclusion, or c. Congenital disfiguring oral deformities.

Cosmetic dentistry is defined as aesthetic treatment designed to improve the appearance of the teeth or smile, including teeth whitening, veneers, contouring and implants or crowns solely for the purpose of enhancing appearance.
Preventative and basic services are limited to $2,000 per support plan year.

Major services are limited to $10,000 for the five year renewal period of the 8.7520 Electronic Monitoring 8.7520.A Electronic Monitoring Eligibility 1. Electronic Monitoring is a covered benefit available to Members enrolled in CFC. 8.7520.B Electronic Monitoring Definitions 1. Electronic Monitoring services means electronic equipment, or adaptations, that are related to an eligible person's disability and/or that enable the Member to remain at home, and includes the installation, purchase, or rental of electronic monitoring devices which:

a. Enable the Member to secure help in the event of an emergency;

b. May be used to provide reminders to the Member of medical appointments, treatments, or medication schedules;

c. Are required because of the Member's illness, impairment or disability as identified and documented in the Person-Centered Support Plan or service plan; and d. Are essential to prevent institutionalization of the Member.

Electronic Monitoring Provider means a Provider Agency as defined in Section 8.7400 and Section 25.5-6-303. C.R.S., that has met the Provider Agency requirements for electronic monitoring services specified in Section 8.7520.E.
Medication Reminders means devices, controls, or appliances that remind or signal the participant to take actions related to medications 4. Personal Emergency Response System (PERS) means ongoing remote monitoring through a device designed to signal trained alarm monitoring personnel in an emergency situation. 8.7520.C Electronic Monitoring Inclusions 1. Electronic monitoring services shall include personal emergency response systems, medication reminder systems, or other devices which comply with the definition above and are not included in the non-benefit items below at Section 8.7520.D. 8.7520.D Electronic Monitoring Exclusions and Limitations 1. Electronic Monitoring services shall be authorized for Members who live alone or who are alone for significant parts of the day, or whose only companion for significant parts of the day is too impaired to assist in an emergency, and who would otherwise require extensive supervision.
Electronic Monitoring services shall be authorized for Members who have the physical and mental capacity to utilize the particular system requested for that 3. Electronic Monitoring services shall not be authorized as a CFC benefit if the service or device is available elsewhere as a state plan Medicaid benefit.
The following are not benefits of electronic monitoring services:

a. Augmentative communication devices and communication boards;

b. Hearing aids and accessories;

c. Phonic ears;

d. Environmental control units, unless required for the medical safety of a Member living alone unattended; or as part of Remote Supports;

e. Computers and computer software unrelated to the provision of Remote Supports;

f. Wheelchair lifts for automobiles or vans g. Exercise equipment, such as exercise cycles; or h. Hot tubs, Jacuzzis, or similar items. 8.7520.E Electronic Monitoring Provider Agency Requirements 1. Electronic Monitoring Provider Agencies shall conform to the following standards for electronic monitoring services:

a. All equipment, materials or appliances used as part of the electronic monitoring service shall carry a UL (Underwriter's Laboratory) number or an equivalent standard. All telecommunications equipment shall be Federal Communications Commission (FCC) registered.

b. All equipment, materials or appliances shall be installed by properly trained individuals, and the installer and/or Provider Agency of Electronic Monitoring shall train the Member in the use of the device as requested by c. All equipment, materials or appliances shall be tested for proper functioning at the time of installation, and at periodic intervals thereafter, and be maintained based on the manufacturer’s recommendations. Any malfunction shall be promptly repaired, and equipment shall be replaced when necessary, including buttons and batteries.

d. All telephone calls generated by monitoring equipment shall be toll-free, and all Members shall be allowed to run unrestricted tests on their equipment.

e. Electronic Monitoring Provider Agencies shall send written information to each Member's Case Manager about the system, how it works, and how it will be maintained. 8.7520.F Electronic Monitoring Reimbursement 1. Payment for Electronic Monitoring services shall be the lower of the billed charges or the prior authorized amount.

For Electronic Monitoring the unit of reimbursement shall be one unit per service for non-recurring services, or one unit per month for services recurring monthly.
No reimbursement is available for Electronic Monitoring in Provider-owned, - Controlled, or Congregate Facilities. 8.7521 Expressive Therapy- Art, Music, Play Therapy 8.7521.A Expressive Therapy Eligibility 1. Expressive Therapy is a covered benefit available to Members enrolled in the HCBS Children with Complex Health Needs Waiver. 8.7521.B Expressive Therapy Definition 1. Expressive Therapy means creative art, music or play therapy which provides Members the ability to express their medical situation creatively and kinesthetically for the purpose of allowing the Member to express feelings of isolation, to improve communication skills, to decrease emotional suffering due to health status, and to develop coping skills. 8.7521.C Expressive Therapy Inclusions 1. Expressive Therapy may be provided in an individual or group setting. 8.7521.D Expressive Therapy Exclusions and Limitations 1. Expressive Therapy is limited to the Member’s assessed need up to a maximum of 39 hours per annual support plan year. 8.7521.E Expressive Therapy Provider Agency Requirements 1. Individuals providing Expressive Therapy shall enroll with the fiscal agent or be employed by a Medicaid enrolled home health or hospice Agency.

a. Individuals providing Expressive Therapy delivering art or play therapy services shall meet the requirements for individuals providing Therapeutic Life Limiting Illness Support services and shall have at least one year of experience in the provision of art or play therapy to pediatric/adolescent b. Individuals providing Expressive Therapy delivering music therapy services shall hold a Bachelor’s, Master’s or Doctorate in Music Therapy, maintain certification from the Certification Board for Music Therapists, and have at least one year of experience in the provision of music therapy to pediatric/adolescent Members. 8.7522.01 Extraordinary Cleaning 8.7522.01.A Extraordinary Cleaning Eligibility 1. Extraordinary Cleaning Services is a covered benefit available to Members a. Children’s Extensive Support Waiver b. Supported Living Services Waiver 8.7522.01.B Extraordinary Cleaning Definitions 1. Extraordinary Cleaning means specialized cleaning, disinfection, and sanitization services necessary to ensure a safe, hygienic living environment and prevent the spread of infectious diseases or pathogens. Extraordinary cleaning includes the use of commercial-grade products, infection control protocols, handling and disposal of biohazard materials, and specialized materials or equipment.

Personal Protective Equipment (PPE) is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses. Personal protective equipment may include items such as gloves, safety glasses and shoes, wellfitting masks or NIOSH-approved respirators, gowns, shoe covers, etc.
Commercial-Grade Product means a cleaning substance or mixture of substances registered with the Environmental Protection Agency (EPA) that destroys or irreversibly inactivates bacteria, fungi, and viruses. The product must be clearly labeled and registered with the EPA and must be stored in a location sufficiently secure to deny access to children, pets, or at-risk adults.
Standard Precautions means an infection-control principle that treats all blood, bodily fluids and other potentially infectious materials as infectious. 8.7522.01.C Extraordinary Cleaning Inclusions 1. Service shall be for the benefit of the Member and not for the benefit of other persons living in the home. Extraordinary Cleaning services must be completed within spaces a Member frequents such as their home or vehicle.
Extraordinary Cleaning tasks are beyond routine homemaking tasks and are necessary to ensure a safe and hygienic living environment due to or as a result of a Member’s disability.
Services include professional and specialized cleaning, disinfection, and/or sanitization. Tasks require specialized knowledge, training, and use of Commercial-Grade Products and equipment. Providers must use standard precautions and personal protective equipment in the provision of services, when 4. Extraordinary Cleaning services may be authorized due to a member’s disabilities/behaviors causing an unsafe and unsanitary living environment for the Member which requires extraordinary cleaning to mitigate. The Member’s needs must be documented in the Person-Centered Support plan and then outlined in the Provider Care Plan or included in sub-contractor documentation, along with details on how the service frequency and scope is appropriate to address concerns.
Extraordinary Cleaning tasks may include:

a. Cleaning floors and other household surfaces including wood, laminate, engineered flooring materials, vinyl, tile, carpets or rugs, counters, and/or walls using Commercial-Grade Products and equipment.

i. Cleaning, sanitization and disinfection of mattresses, surfaces, furniture, upholstery, and other household items requiring use of Commercial-Grade Products and equipment.

b. Laundering and disinfecting a member’s clothing, towels, bedding or linens soiled with blood or other bodily fluids. Laundry services or commercial/professional laundering may be appropriate to manage the laundering needs.

c. Air duct cleaning that is essential for the health and safety of the member that mitigates disability-related health complications. 8.7522.01.D8.7522.D Extraordinary Cleaning Exclusions and Limitations 1. Extraordinary Cleaning service may NOT include:

a. Personal care services.

b. Homemaker services.

c. Services the member can perform independently.

d. Adaptations or improvements to the home that are considered to be ongoing home maintenance and are not of direct medical or remedial benefit to the Member.

e. Services that are not essential to the health and safety of the Member.

f. Services that do not meet the task definition for Extraordinary Cleaning may not be approved.

g. Services that are deemed typical parental responsibility may not be approved.

h. Services that do not follow Age- Appropriate Guidelines may not be approved.

i. Extraordinary cleaning services provided in Uncertified Congregate Facilities may not be approved.

j. In the case a Member resides in a rental property, the responsibility of the landlord, pursuant to the lease agreement, must be examined prior to the authorization of service. 8.7522.01.E Extraordinary Cleaning Case Management Agency Responsibilities:

Detailed, task-related goals shall be documented by the case manager in the Person-Centered Support Plan, including documentation and goals of extraordinary cleaning projects as it relates to improving the health and safety of 2. Requests for costs that exceed an amount equal to 700 15-minute units over the course of a Support Plan year may be approved by the Department, as prescribed by the Department, if it:

a. Ensures the health and safety of the Member in the home;

b. Decreases the need for paid assistance in another HCBS waiver service or CFC on a long-term basis.

Case Management Agency approval for a higher amount shall include a thorough review of the current request to ensure cost effectiveness and no unnecessary duplication. 8.7522.01.F Extraordinary Cleaning Provider Agency Requirements 1. A provider enrolled with Colorado Medicaid or contracting with a Case Management Agency to provide the Extraordinary Cleaning service must be a legally constituted domestic or foreign business entity registered with the Colorado Secretary of State Colorado and hold a Certificate of Good Standing to do business in Colorado. 8.7522.01.G Extraordinary Cleaning Provider Services Reimbursement 1. HCBS Supported Living Services (SLS) Waiver; Children’s Extensive Support (CES) Waiver:

a. Payment does not include travel time to or from the Member’s residence.

b. Reimbursement shall not exceed an amount equal to 700 15-minute units and may be billed as a 15-minute unit and/or project total for services rendered.

c. Work that was completed prior to authorization by the Department or Case Management Agency is not eligible for reimbursement.

d. Extraordinary Cleaning is authorized for Organized Health Care Delivery System (OHCDS).

Family Members/Legally Responsible Persons may provide Extraordinary Cleaning and are subject to the conditions below:

a. The Family Member/Legally Responsible Person must be employed with a Medicaid enrolled provider who is eligible to provide the Extraordinary Cleaning service.

b. The Family Member/Legally Responsible Person shall be reimbursed at an hourly rate and may only provide services that meet the definition of Extraordinary Care as defined in 8.7502.II.

c. Extraordinary Cleaning services furnished by a Family Member/Legally Responsible Person shall:

i. Exceed typical household cleaning or Parental Responsibility as defined at 8.7502.KK;

ii. Be necessary to ensure the health and safety of the Member due to the Member’s disability; and iii. Require specialized cleaning, infection control protocols, or commercial-grade products or equipment consistent with Section 8.7522.01.B and 8.7522.01.C.

d. Payment to a Family Member/Legally Responsible Person must be prior authorized by a Case Management Agency. Any Extraordinary Cleaning provided without a prior authorization is not reimbursable. 8.7522 CHRP Habilitation 8.7522.A CHRP Habilitation Eligibility 1. CHRP Habilitation is a covered benefit available to Members enrolled in the HCBS Children's Habilitation Residential Program Waiver 8.7522.B CHRP Habilitation Inclusions 1. CHRP Habilitation is a 24-hour service that includes assisting a Member in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in Home and Community-Based settings.

Service components include the following:

a. Independent living training, which may include personal care, household services, infant and childcare when the Member has a child, and communication skills.

b. Self-advocacy training and support which may include assistance and teaching of appropriate and effective ways to make individual choices, accessing needed services, asking for help, recognizing Abuse, Neglect, Mistreatment, and/or Exploitation of self, responsibility for one’s own actions, and participation in meetings.

Cognitive services which include assistance with additional concepts and materials to enhance communication. Cognitive Services are intended to help the Member better understand cause and effect and the connection between behaviors and consequences. Services may also include training in repetitive directions, staying on task, levels of receptive language capabilities, and retention of information.
Emergency assistance which includes safety planning, fire and disaster drills, and Crisis intervention.
Community Access Supports includes assistance developing the abilities and skills necessary to enable the Member to access typical activities and functions of community life such as education, training, and volunteer activities.

Community access supports includes providing a wide variety of opportunities to develop socially appropriate behaviors, facilitate and build relationships and natural supports in the community while utilizing the community as a learning environment to provide services and supports as identified in Member’s Person- Centered Support Plan or Provider Care Plan. These activities are conducted in a variety of settings in which the Member interacts with non-disabled individuals (other than those individuals who are providing services to the Member). These services may include socialization, adaptive skills, and personnel to accompany and support the Member in community settings, resources necessary for participation in activities and supplies related to skill acquisition, retention, or improvement and are based on the interest of the Member.

Transportation services are encompassed within Habilitation and are not duplicative of the non-emergent medical transportation that is authorized in the Medicaid State Plan. Transportation services facilitate Member access to activities and functions of community life.
Follow-up counseling, behavioral, or other therapeutic interventions, and physical, occupational or speech therapies delivered under the direction of a licensed or certified professional in that discipline.
Medical and health care services that are integral to meeting the daily needs of the Member and include such tasks as routine administration of medications or providing support when the Member is ill. 8.7522.C CHRP Habilitation Service Requirements 1. Services may be provided to Members who require additional care for the Member to remain safely in Home and Community-Based settings. The Member must demonstrate the need for such services above and beyond those of a typical child of the same age.
Habilitation services under the CHRP waiver differ in scope, nature, supervision, and/or Provider Agency type (including provider training requirements and qualifications) from any other services in the Medicaid State Plan.
Habilitation may be provided in a Foster Care Home or Kinship Foster Care Home certified by a licensed Child Placement Agency or County Department of Human Services, Specialized Group Facility licensed by the Colorado Department of Human Services, or Residential Child Care Facility licensed by the Colorado Department of Human Services.
Habilitation may be provided for Members aged eighteen (18) to twenty (20) in a Host Home. The Host Home must meet all requirements as defined in Sections 8.7541 Residential Habilitation Services and Supports (RHSS) and 8.7542 Individual Residential Service and Supports (IRSS).
Provider Agencies and child placement agencies must comply with the habilitation capacity limits at 12 C.C.R. 2509-5; Section 7.406.2.M. 8.7522.D CHRP Habilitation Provider Agency Requirements 1. The Provider Agency or child placement Agency shall ensure choice is provided to all Members in their living arrangement.
The Foster Care Home or Kinship Foster Care Home provider must ensure a safe environment and safely meet the needs of all Members living in the home.
The Provider Agency shall provide the Case Management Agency a copy of the Foster Care Home or Kinship Foster Care Home certification before any child or youth may be placed in that home. If emergency placement is needed outside of business hours, the Provider Agency or child placement Agency shall provide the Case Management Agency a copy of the Foster Care Home or Kinship Foster Care Home certification the next business day.
Provider Agencies for habilitation services and services provided outside the Family home shall meet all of the certification, licensing, waiver, and quality assurance regulations related to their provider type.
Service in a foster care home may be provided by a provider that is licensed by the State Department of Human Services or certified by the county or Child Placement Agency. For youth aged 18-20, service may be provided in a host 8.7522.E CHRP Habilitation Reimbursement 1. A Support Need Level Assessment must be completed upon determination of eligibility. The Support Need Level Assessment is used to determine the level of reimbursement for Habilitation services.
Reimbursement for Habilitation service does not include the cost of normal facility maintenance, upkeep, and improvement. This exclusion does not include costs for modifications or adaptations required to assure the health and safety of the Member or to meet the requirements of the applicable life safety code.
Room and board shall not be a benefit of habilitation services. Members shall be responsible for room and board, per Section 8.7413. 8.7523 Health Maintenance Activities Self-Directed 8.7523.A Health Maintenance Activities Eligibility 1. Health Maintenance is available to Members eligible for Consumer Directed Attendant Support Services (CDASS) or In-Home Support Services (IHSS) within CFC. 8.7523.B Health Maintenance Activities Definition 1. Health Maintenance means routine and repetitive health-related tasks furnished to a Member in the community or in the Member's home that is necessary for the health and normal bodily functioning that a person with a disability is physically unable to carry out. "Health Maintenance Activities" include skilled tasks typically performed by a certified nursing assistant or a licensed nurse that does not require the clinical assessment and judgment of a licensed nurse.

a. Member’s record must include clinical documentation to substantiate any Health Maintenance Activities on the Care Plan. This includes all applicable documentation associated with the Direct Care Services Calculator, as defined at Section 8.7502.K.

Home Exercise Plan is an exercise plan that is developed by a Licensed Medical Professional, an occupational therapist, a speech language pathologist, a Registered Nurse, or physical therapist that instructs the Member what exercises must be completed in the home or in the community. The exercises identified in the Home Exercise Plan must not replace the services that are traditionally received through Occupational Therapy, Physical Therapy, and/or Speech Therapy services. 8.7523.C Health Maintenance Activities Inclusions 1. Services may include:

a. Skin care, when the skin is broken, or a chronic skin condition is active and could potentially cause infection and the Member is unable to apply creams, lotions, sprays, or medications independently due to illness, injury, or disability. Skin care may include wound care, dressing changes, application of prescription medicine, and foot care for people with diabetes when directed by a Licensed Medical Professional (LMP).

b. Hair care includes shampooing, conditioning, drying, and combing when performed in conjunction with health maintenance level bathing, dressing, or skin care. Hair care may be performed when:

i. The Member is unable to complete task independently;

ii. Application of a prescribed shampoo/conditioner which has been dispensed by a pharmacy; or iii. The Member has open wound(s) or neck stoma(s).

c. Nail care in the presence of medical conditions that may involve peripheral circulatory problems or loss of sensation; includes soaking, filing, and trimming.

d. Mouth care performed when health maintenance level skin care is required in conjunction with the task, or:

i. There is injury or disease of the face, mouth, head, or neck;

ii. In the presence of communicable disease;

iii. When the Member is unable to participate in the task;

iv. Oral suctioning is required;

v. There is decreased oral sensitivity or hypersensitivity;

vi. The Member is at risk for choking and aspiration.

e. Shaving performed when health maintenance level skin care is required in conjunction with the shaving, or:

i. The Member has a medical condition involving peripheral circulatory problems;

ii. The Member has a medical condition involving loss of sensation;

iii. The Member has an illness or takes medications that are associated with a high risk for bleeding;

iv. The Member has broken skin at/near shaving site or a chronic active skin condition.

f. Dressing performed when health maintenance-level skin care or transfers are required in conjunction with the dressing, or:

i. Assistance with the application of prescribed anti-embolic or pressure stockings is required;

ii. Assistance with the application of prescribed orthopedic devices such as splints, braces, or artificial limbs is required.

g. Feeding is considered a health maintenance task when the Member requires health maintenance-level skin care or dressing in conjunction with the task, or:

i. Oral suctioning is needed on a stand-by or intermittent basis;

ii. The Member is on a prescribed modified texture diet;

iii. The Member has a physiological or neurogenic chewing or swallowing problem;

iv. Syringe feeding or feeding using adaptive utensils is required;

v. Oral feeding when the Member is unable to communicate verbally, non-verbally or through other means.

h. Exercise including passive range of motion. Exercises must be specific to the Member’s documented medical condition and require hands-on assistance to complete. A Home Exercise Plan must be developed by a Licensed Medical Professional, Occupational Therapist, a speech language pathologist, a Registered Nurse, or Physical Therapist.

i. Registered nurses who are affiliated with the Home Care Agency in which the member receives services are not permitted to develop the home exercise plan for the member in which they are serving.

i. Transferring a Member when they are not able to perform transfers independently due to illness, injury, or disability, or:

i. The Member lacks the strength and stability to stand, maintain balance or bear weight reliably;

ii. The Member has not been deemed independent with Adaptive Equipment or assistive devices by a Licensed Medical Professional;

iii. The use of a mechanical lift is needed.

j. Bowel care performed when health maintenance-level skin care or transfers are required in conjunction with the bowel care, or:

i. The Member is unable to assist or direct care;

ii. Administration of a bowel program including but not limited to digital stimulation, enemas, or suppositories;

iii. Care of a colostomy or ileostomy that includes emptying and changing the ostomy bag and application of prescribed skin care products at the site of the ostomy.

k. Bladder care performed when health maintenance-level skin care or transfers are required in conjunction with bladder care, or;

i. The Member is unable to assist or direct care;

ii. Care of external, indwelling, and suprapubic catheters;

iii. Changing from a leg to a bed bag and cleaning of tubing and bags as well as perineal care.

l. Medical management as directed by a Licensed Medical Professional to routinely monitor a documented health condition, including but not limited to: blood pressures, pulses, respiratory rate, blood sugars, oxygen saturations, intravenous or intramuscular injections.

m. Respiratory care:

i. Postural drainage;

ii. Cupping;

iii. Adjusting oxygen flow within established parameters;

iv. Suctioning mouth and/or nose;

v. Nebulizers;

vi. Ventilator and tracheostomy care;

vii. Assistance with set-up and use of respiratory equipment.

n. Bathing assistance is considered a health maintenance task when the Member requires health maintenance-level skin care, transfers or dressing in conjunction with bathing.

o. Medication assistance, which may include setup, handling and administering medications.

i. For In-Home Support Services (IHSS) only, The IHSS Agencies Licensed Health Care Professional must validate Attendant skills for medication administration and ensure that the completion of task does not require clinical judgment or Assessment skills.

p. Accompanying includes going with the Member, as necessary according to the care plan, to medical appointments, and errands such as banking and household shopping. Accompanying the Member may also include providing one or more health maintenance tasks as needed during the trip.

Attendants must assist with communication, documentation, verbal prompting and/or hands on assistance when the task may not be completed without the support of the Attendant.

q. Mobility assistance is considered a health maintenance task when health maintenance-level transfers are required in conjunction with the mobility assistance, or:

i. The Member is unable to assist or direct care;

ii. When hands-on assistance is required for safe ambulation and the Member is unable to maintain balance or to bear weight reliably due to illness, injury, or disability; and/or iii. The Member has not been deemed independent with Adaptive Equipment or assistive devices ordered by a Licensed Medical Professional r. Positioning includes moving the Member from the starting position to a new position while maintaining proper body alignment, support to a Member’s extremities and avoiding skin breakdown. May be performed when health maintenance level skin care is required in conjunction with positioning, or;

i. The Member is unable to assist or direct care, or ii. The Member is unable to complete task independently 2. Additional HMA inclusion criteria for children are available within the Health Maintenance Activities Documentation Guide. 8.7523.D Health Maintenance Activities Exclusions and Limitations 1. This service is subject to the following Annual CFC Service Soft Caps: Members shall not be authorized for more than 4,750 hours of Health Maintenance Activities per Person-Centered Support Plan year. Case Managers may request additional hours through the Department prescribed exception process as defined at Section 8.7607.A.

Attendants must adhere to the Weekly Caregiver Limit and Per Day Hourly Limit 8.7524 [Reserved] 8.7525 Home Accessibility Modifications and Adaptations 8.7525.A Home Accessibility Modifications and Adaptations Eligibility 1. Home Accessibility Modifications and Adaptations is a covered benefit available to Members enrolled in one of the following HCBS waivers:

a. Brain Injury Waiver b. Children’s Extensive Support Waiver c. Community Mental Health Supports Waiver d. Complementary and Integrative Health Waiver e. Elderly, Blind, and Disabled Waiver f. Supported Living Services Waiver 8.7525.B Home Accessibility Modifications and Adaptations Definitions 1. The Division of Housing (DOH) is a State entity within the Department of Local Affairs that is responsible for approving Home Modification requests oversight on the quality of Home Modification projects, and inspecting Home Modification projects, as described in 2. Eligible Member means a Member who is enrolled in the following Home and Community-Based Services waivers: Brain Injury, Complementary and Integrative Health, Community Mental Health Supports, or Elderly, Blind and Disabled, Supported Living Services (SLS) and Children’s Extensive Supports (CES).

Home Modification means specific modifications, adaptations or improvements in an eligible Member’s existing home setting which, based on the Member’s medical condition:

a. Are necessary to ensure the health, welfare and safety of the Member and b. Enable the Member to function with greater independence in the home, c. Are required because of the Member’s illness, impairment or disability, as documented on the Assessment and Person-Centered Support Plan; and d. Prevents institutionalization or supports the deinstitutionalization of the 8.7525.C Home Accessibility Modifications and Adaptations Inclusions 1. Home Modifications, adaptations, or improvements may include but are not limited to the following:

a. Installing or building ramps.

b. Installing grab-bars and installing other Durable Medical Equipment (DME) items if such installation shall not be performed by a DME supplier.

c. Widening doorways.

d. Modifying a bathroom facility for the purposes of accessibility, health and safety, and independence in Activities of Daily Living.

e. Modifying kitchen facilities.

f. Installing specialized electric and plumbing systems that are necessary to accommodate medically necessary equipment and supplies.

g. Installing stair lifts or vertical platform lifts.

h. Modifying an existing second exit or egress window for emergency purposes.

i. The modification of a second exit or egress window must be approved by the Department, or its agent as recommended by an occupational or physical therapist (OT/PT) for the health, safety, and welfare of the Member.

Previously completed home modifications, regardless of original funding source, shall be eligible for maintenance or repair within the remaining balance of the Member’s available cap for home modifications while remaining subject to

Section 8.7525.C. The cap will be noted in the Home Modification page of the Department’s website.

Home Modification Funding Limits a. HCBS Supported Living Services (SLS) and Children’s Extensive Services (CES) Waivers:

ii. The combined cost of Home Accessibility Adaptations, Vehicle Modifications, and Assistive Technology shall not exceed the cap determined by the Department per member.

ii. Costs that exceed this cap may be approved by the Department or DOH to ensure the health, and safety of the member, or enable the member to function with greater independence in the home, if:

The adaptation decreases the need for paid assistance in another waiver service on a long-term basis, and 2) Either:

i) There is an immediate risk to the member’s health or safety, or ii) There has been a significant change in the member’s needs since a previous Home Accessibility Adaptation.

i. The cost of the home modification shall not exceed the cap determined by the Department per member. The current cap will be posted on the Home Modification page of the Department’s website and will reset when each waiver resets, every 5 years.

ii. The Department may authorize funds in excess of the member’s cap if there is:

An immediate risk of the member being institutionalized; or ii) A significant change in the member’s needs since a previous home modification. 8.7525.D Home Accessibility Modifications and Adaptations Exclusions and 1. Home Modifications must be a direct benefit to the Member and not for the benefit or convenience of caregivers or other residents of the home.

Duplicate adaptations, improvements, or modifications are not a benefit. This includes, but is not limited to, multiple bathrooms within the same home.
Adaptations, improvements, or modifications as a part of new construction costs are not a benefit.

a. Finishing unfinished areas in a home to add to or complete habitable square footage is prohibited.

b. Adaptations that add to the total square footage of the home are excluded from this benefit except when necessary to complete an adaptation to:

i. improve entrance or egress to a residence; or, ii. configure a bathroom to accommodate a wheelchair.

c. Any request to add square footage to the home must be approved by the Department or DOH and shall be prior authorized in accordance with Department procedures.

The purchase of items available through Durable Medical Equipment (DME) is not a benefit.
The following items are specifically excluded from Home Accessibility Adaptations and shall not be reimbursed:

a. Roof repair, b. Central air conditioning, c. Air duct cleaning, d. Whole house humidifiers, e. Whole house air purifiers, f. Installation and repair of driveways and sidewalks, unless the most costeffective means of meeting the identified need, g. Monthly or ongoing home security monitoring fees, h. Home furnishings of any type, i. HOA fees, j. Walk-In Tubs.

k. Adaptations or improvements to the home that are considered to be ongoing home repair or maintenance and are not related to the Member's ability and needs are prohibited.

l. Upgrades beyond what is the most cost-effective means of meeting the Member’s identified need, including, but not limited to, items or finishes required by a Homeowner Association’s (HOA), items for caregiver convenience, or any items and finishes beyond the basic required to meet the need, are prohibited.

The Department may deny requests for Home Modification projects that exceed usual and customary charges or do not meet local building requirements, the Long-Term Services and Supports Home Modification Benefit Construction Specifications developed by the Division of Housing (DOH), or industry standards.
Home Modification projects are prohibited in any Provider -Owned or -Controlled setting.
Volunteer work on a Home Modification project approved by the Department shall be completed under the supervision of the Home Modification Provider Agency as stated on the bid.

a. Volunteer work performed by Department-approved organizations must be described according to Department prescribed processes and procedures.

A list of these organizations may be found on the Department website.

b. Work performed by an unaffiliated party, such as, but not limited to, volunteer work performed by a friend or Family Member, or work performed by a private contractor hired by the Member or family, must be described and agreed upon, in writing, by the Provider Agency responsible for completing the home modification, according to Department prescribed processes and procedures and must be approved by the Department.

If a Member lives in a property where adaptations, improvements, or modifications as a reasonable accommodation through federally funded assisted housing are required by the Fair Housing Act, the Member’s Home Modification funds may not be used unless reasonable accommodations have been denied. 8.7525.E Home Accessibility Modifications and Adaptations Case Management Agency Responsibilities 1. The Case Manager shall consider alternative funding sources to complete the Home Modification. These alternatives and the reason they are not available shall be documented in the case record.

a. The Case Manager must confirm that the Member is unable to receive the proposed adaptations, improvements, or modifications as a reasonable accommodation through federally funded assisted housing as required by the Fair Housing Act.

The Case Manager may approve Home Modification projects estimated at less than $2,500 without Department approval, contingent on Member authorization and confirmation of Home Modification fund availability.
The Case Manager shall obtain prior approval by submitting a prior request to the Department for Home Modification projects estimated to cost over $2500.

a. The Case Manager must submit the request and all supporting documentation according to Department prescribed processes and procedures. Home Modification requests submitted with improper documentation cannot be authorized.

b. The Case Manager and Case Management Agency are responsible for retaining and tracking all documentation related to a Member’s previous home modification benefit lifetime use and communicating that information to the Member and Provider Agencies. The Case Manager may request confirmation of a Member’s home modification use from the Department, its fiscal agent, or Division of Housing.

Home Modifications estimated to cost $2,500 or more shall be evaluated according to the following procedures:

a. An occupational or physical therapist (OT/PT) shall assess the Member’s needs and the therapeutic value of the requested Home Modification.

When an OT/PT with experience in Home Modification is not available, a Department-approved qualified individual may be substituted. An evaluation specifying how the Home Modification would contribute to a Member’s ability to remain in or return to their home, and how the Home Modification would increase the individual's independence and decrease the need for other services, shall be completed before bids are solicited.

This evaluation shall be submitted with the Home Modification request..

b. The evaluation services may be provided by a home health Agency or other qualified and approved OT/PT through the Medicaid Home Health benefit consistently with Home Health rules set forth in Section 8.520, including physician orders and plans of care.

i. A Case Manager may initiate the OT/PT evaluation process before the Member has been approved for Waiver Services, as long as the Member is Medicaid Eligible.

ii. A Case Manager may initiate the OT/PT evaluation process before the Member physically resides in the home to be modified, as long as the current property owner agrees to the evaluation.

c. The Case Manager and the OT/PT shall consider less expensive alternative methods of addressing the Member’s needs.

The Case Manager shall solicit bids according to the following procedures:

a. The Case Manager shall solicit bids from at least two Home Modification Provider Agencies.

i. The Case Manager must verify that the provider is an enrolled Home Modification Provider Agency.

ii. The bids must be submitted according to Department prescribed processes and procedures.

b. The bids shall include a breakdown of the costs of the project including:

i. Description of the work to be completed.

ii. Description and estimate of the materials and labor needed to complete the project. Material costs should include price per square foot for materials purchased by the square foot. Labor costs should include price per hour.

iii. Estimate for building permits, if needed.

iv. Estimated timeline for completing the project.

v. Name, address, and telephone number of the Home Modification Provider Agency.

vi. Signature, including option for digital signature, of the Home Modification Provider Agency.

vii. Signature, including option for digital signature, of the Member or Guardian or other indication of approval.

viii. Signature, including option for digital signature, of the homeowner or property manager if applicable.

c. Home Modification Provider Agencies have a maximum of 30 days to submit a bid for the Home Modification project after the Case Manager has solicited the bid.

i. If the Case Manager has made three attempts to obtain a written bid from a Home Modification Provider Agency and the Home Modification Provider Agency has not responded within 30 calendar days, the Case Manager may request approval of one bid. Documentation of the attempts shall be attached to the Home Modification request.

d. The Case Manager shall submit copies of the bid(s) and the OT/PT evaluation to the Department or its agent. The Department or its agent shall authorize the lowest bid that complies with the requirements of

Section 8.7525 and the recommendations of the OT/PT evaluation.

i. If a Member or homeowner requests a bid that is not the lowest of the submitted bids, the Case Manager shall request approval by submitting a written explanation with the Home Modification e. A revised bid and Change Order request shall be submitted according to the procedures described in this section for any changes from the original approved Prior Authorization Request (PAR) according to Department prescribed processes and procedures.

If a property to be modified is not owned by the Member, the Case Manager shall obtain signatures from the homeowner or property manager on the submitted bids authorizing the specific modifications described therein. Signatures may be completed using a digital signature based on preference of the individual signing the form.

a. Written consent of the homeowner or property manager, as evidenced by the above-mentioned signatures, is required for all projects that involve permanent installation within the Member’s residence or installation or modification of any equipment in a common or exterior area.

b. If the Member vacates the property, these signatures can be used as evidence that the homeowner or property manager agrees to allow the Member to leave the modification in place or remove the modification as the Member chooses. If the Member chooses to remove the modification, the property must be left equivalent or better to its pre-modified condition.

The homeowner or property manager may not hold any party responsible for removing all or part of a home modification project.

If the Case Management Agency does not comply with the process described above resulting in increased cost for a home modification, the Department may hold the Case Management Agency financially liable for the increased cost.
The Department or its agent may conduct on-site visits, or any other investigations deemed necessary prior to approving or denying the Home Modification request. 8.7525.F Home Accessibility Modifications and Adaptations Provider Agency 1. Home Modification Providers Agencies shall conform to Provider Agency regulations set forth in Section 8.7400.
Home Modification Provider Agencies shall be licensed in the city or county in which they propose to provide Home Modification services to perform the work proposed, if required by that city or county.
Home Modification Provider Agencies shall begin work within 60 days of signed approval from the Department. Upon request by Provider Agency, the the Division of Housing or the Department may grant an extension for circumstances outside of the Provider Agencies’ control. Requests must be received prior to the expiration of the 60-day deadline and be supported by documentation, including Member notification. Reimbursement may be reduced for delays in accordance with Section 8.7525.F.6.

a. If any changes to the approved scope of work are made without Department authorization, the cost of those changes will not be reimbursed.

b. Projects shall be completed within 30 days of beginning work. Upon request by a Provider Agency, the Division of Housing or the Department may grant an extension for circumstances outside of the Provider Agencies’ control. Requests must be received prior to the expiration of the 30-day deadline and be supported by documentation, including Member notification. Reimbursement may be reduced for delays.

The Home Modification Provider Agency shall provide a one-year written warranty on materials and labor from the date of final inspection on all completed work and perform work covered under that warranty at their expense.
The Home Modification Provider Agency shall comply with the Long Term Services and Supports Home Modification Benefit Construction Specifications developed by the Division of Housing, which may be found on the Department website, and with local, and state building codes.
All Home Modification projects within a Department-established sampling threshold shall be inspected upon completion by Division Of Housing, a state, local or county building inspector or a licensed engineer, architect, contractor or any other person as designated by the Department. Home Modification projects may be inspected by Division Of Housing upon request by the Member at any time determined to be reasonable by DOH or the Department. Members must provide access for inspections.

a. Division Of Housing shall perform an inspection within 14 days of receipt of notification of project completion or receipt of a Member’s reasonable b. Division of Housing shall produce a written inspection report within three days of performing an inspection that notes the Member’s specific Complaints. The inspection report shall be sent to the Member, Case Manager, and Provider Agency.

c. Home Modification Provider Agencies must repair or correct any noted deficiencies within 20 days, or the time required by the inspection, whichever is shorter. Upon request by the Provider Agency, the DOH or the Department may grant an extension for circumstances outside of the Provider Agencies’ control. Requests must be received prior to the original deadline and be supported by documentation, including Member notification. Reimbursement may be reduced for delays in accordance.

Copies of building permits and inspection reports shall be submitted to Division of Housing. If a permit is not required, the Home Modification Provider Agency shall formally attest in their initial bid that a permit is not required. Incorrectly attesting that a permit is not required shall be justification for recovery of payment by the 8.7525.G Home Accessibility Modifications and Adaptations Reimbursement 1. Payment for Home Modification services shall be the prior authorized amount, or the amount billed, whichever is lower. Reimbursement shall be made in two payments per Home Modification.
The Home Modification Provider Agency may submit a claim for an initial payment of no more than fifty percent of the project cost for materials, permits, and initial labor costs.
The Home Modification Provider Agency may submit a claim for final payment when the Home Modification project has been completed satisfactorily as shown by the submission of the documentation below to Division of Housing:

a. Signed lien waivers for all labor and materials, including lien waivers from subcontractors;

b. Required permits;

c. Photographs taken before and after the Home Modification has been completed;

d. One-year written warranty on materials and labor; and e. Documentation in the Member’s file that the Home Modification has been completed satisfactorily through:

i. Receipt of inspection report approving work from the building inspector or other inspector as referenced at Section 8.7525.F.6;

ii. Approval by the Member, Guardian, representative, or other designee;

iii. Approval by the homeowner or property manager; or iv. By conducting an on-site inspection.

If Division of Housing notifies a Home Modification Provider Agency that an additional inspection is required, the Home Modification Provider Agency may not submit a claim for final payment until DOH has received documentation of a satisfactory inspection report for that additional inspection.
The Home Modification Provider Agency shall only be reimbursed for materials and labor for work that has been completed satisfactorily and as described on the approved Home Modification Provider Bid form or Home Modification Provider Change Order form.

a. All recommended repairs noted on inspections shall be completed before the Home Modification Provider Agency submits a final claim for b. If a Home Modification Provider Agency has not completed work satisfactorily, Division of Housing shall determine the value of the work completed satisfactorily by the Provider Agency during an inspection. The Provider Agency shall only be reimbursed for the value of the work completed satisfactorily.

i. A Home Modification Provider Agency may request Division of Housing perform one redetermination of the value of the work completed satisfactorily. This request may be supported by an independent appraisal of the work, performed at the Provider Agency’s expense.

Reimbursement may be reduced at a rate of 1% of the total project amount every 7 calendar days beyond the deadlines required for project completion, including correction of all noted deficiencies and inspection deficiencies.

a. Upon request by a Provider Agency, the Division of Housing or the Department may grant an extension for circumstances outside of the Provider Agency’s control. Requests must be received within the original deadline period and be supported by documentation, including Member notification.

b. The Home Modification reimbursement reduced pursuant to this subsection shall be incorporated into the computation of the Member’s remaining money.

The Home Modification Provider Agency shall not be reimbursed for the purchase of DME available as a Medicaid state plan benefit to the Member. The Home Modification Provider Agency may be reimbursed for the installation of Durable Medical Equipment if such installation is outside of the scope of the Member’s Durable Medical Equipment benefit.
Work that was completed prior to Department approval is not eligible for 8.7526 Home Delivered Meals 8.7526.A Home Delivered Meals Eligibility 1. Home Delivered Meals is a covered benefit available to Members enrolled in CFC.
To obtain approval for Home Delivered Meals, the Member must demonstrate a need for the service, as follows:

a. The member is transitioning from an institutional setting to a home and community-based setting; and/or b. The member demonstrates the following three criteria:

i. The Member lacks or has limited access to outside assistance, services, or resources through which they can access meals; and ii. The Member is unable to prepare meals to sustain health, or has dietary restrictions, or has specific nutritional needs; and iii. The Member’s inability to access and/or prepare nutritious meals demonstrates a risk to the member’s health or safety, or risk of institutionalization; decreasing independence and increasing the need for human intervention or assistance. 8.7526.B Home Delivered Meals Definition 1. Home Delivered Meals means delivery of meals to Members who meet the eligibility criteria outlined in 8.7526.A. This service may also include nutritional counseling and meal planning. 8.7526.C Home Delivered Meals Inclusions 1. Home Delivered Meals may include:

a. Meals intended to support member wellness, which may include meals tailored to the member’s nutritional needs.

b. Meal planning developed for the Member’s individual needs which may include nutritional meal planning, nutritional counseling, selected meal types, and instructions for meal preparation and delivery. 8.7526.D Home Delivered Meals Service Requirements 1. The Member’s Provider Care Plan must specifically identify:

a. Any individualized nutritional counseling or nutritional meal plan requested by the Member, which describes the Member’s nutritional needs and selected meal types, and provides instructions for meal preparation and delivery; and b. The Member’s specifications for preparation and delivery of meals, and any other detail necessary to effectively implement the individualized meal 2. The service must be provided in the home or community and in accordance with the Member’s Person-Centered Support Plan. All Home Delivered Meal services shall be documented in the Provider Care Plan.

The assessed need is documented in the Member’s service plan as part of their skills acquisition process of gradually becoming capable of preparing their own meals or establishing the resources to obtain their needed meals.
Members may be approved for Home Delivered Meals for no more than 365 days. Home Delivered Meals may be authorized past 365 days on a case-bycase basis if there is a demonstrated need.
Meals are to be delivered up to two meals per day, with a maximum of 14 meals delivered per week.
Meals may include liquid, mechanical soft, or other medically necessary types.
Meals may include ethnic or cultural options.
Meals may be delivered hot, cold, frozen, or shelf-stable, depending on the Member’s or caregiver’s ability to complete the preparation of, and properly store the meal.
The Provider Agency shall confirm meal delivery, by attestation of the deliverer or carrier proof of delivery, to ensure the Member receives the meal in a timely fashion, and to determine whether the Member is satisfied with the quality of the meal.
The Home Delivered Meals provider will check in with the Member no less frequently than every 90 days to ensure the meals are satisfactory, that they promote the Member’s health, and that the service is meeting the Member’s 11. The case manager will review a Member's progress toward the nutritional goal(s) described in the Member’s Provider Care Plan no less frequently than once per calendar quarter, and more frequently, as needed. If the case manager has concerns regarding the Member’s progress toward the nutritional goal(s), they should refer back to the Home Delivered Meals provider to schedule a nutritional counseling session with a RD or RDN.
The RD or RDN shall make changes to the Nutritional Meal Plan if the quarterly assessment results show changes are necessary or appropriate.

a. The Home Delivered Meals provider will send the Nutritional Meal Plan to the Case Management Agency no less frequently than once per quarter to allow the Case Management Agency to verify the plan with the Member during the quarterly check-in. The case manager will make corresponding updates to the Person-Centered Support Plan, as needed. 8.7526.E Home Delivered Meals Exclusions and Limitations 1. Home Delivered Meals are not available when the Member resides in a providerowned or controlled setting.

Delivery must not constitute a full nutritional regimen and includes no more than two meals per day or 14 meals per week.
Home Delivered Meals services are not available when the Member's need may otherwise be met, including any item or service available under the State Plan, applicable HCBS waiver, Community First Choice program, or other available resources.
Meals not identified in the Nutritional Meal Plan or any item outside of the meals not identified in the meal plan, such as additional food items or cooking appliances are excluded.
Meal plans and meals provided are reimbursable when they benefit the Member, only. Services provided to someone other than the Member are not reimbursable. 8.7526.F Home Delivered Meals Provider Agency Requirements 1. A licensed provider enrolled with Colorado Medicaid to provide the Home Delivered Meal service must be a legally constituted domestic or foreign business entity registered with the Colorado Secretary of State Colorado and holding a Certificate of Good Standing to do business in Colorado.
Home Delivered Meal Provider Agencies must conform to all general Certification standards, conditions, and processes established in Section 8.7400.
The Provider Agency shall maintain licensure as required by the State of Colorado Department of Public Health and Environment (CDPHE) for the performance of the service or support being provided, including necessary Retail Food License and Food Handling License for staff; or be approved by Medicaid as a home delivered meals provider in their home state.
The Provider Agency must maintain a Registered Dietitian (RD) OR Registered Dietitian Nutritionist (RDN) on staff or under contract.
The Provider Agency shall maintain meals documentation in accordance with

Section 8.7405 and shall provide documentation to supervisor(s), program monitor(s) and auditor(s), and CDPHE surveyor(s) upon request. Required documentation includes:

a. Documentation pertaining to the Provider Agency, including employee files, claim submission documents, program and financial records, insurance policies, and licenses, including a Retail Food License and Food Handling License for Staff, or, if otherwise applicable, documentation of compliance and good standing with the City and County municipality in which this service is provided; and b. Documentation pertaining to services, including:

i. Documentation of any professionally recommended dietary restrictions or specific nutritional needs;

ii. Member demographic information;

iii. A Meal Delivery Schedule;

iv. Documentation of special diet requirements;

v. A determination of the type of meal to be provided (e.g. hot, cold, frozen, shelf stable);

vi. A record of the date(s) and place(s) of service delivery (e.g. through documented driver attestation or proof of carrier delivery);

vii. Monitoring and follow-up (contacting the Member after meal delivery to ensure the Member is satisfied with the meal); and viii. Provision of nutrition counseling or documentation of the Member declining nutrition counseling. 8.7526.G Home Delivered Meals Provider Agency Reimbursement 1. Home Delivered Meals services are reimbursed based on the number of units of service provided, with one unit equal to one meal.

Payment for Home Delivered Meals shall be the lower of the billed charges or the maximum rate of reimbursement.
Reimbursement is limited to services described in the Provider Care Plan. 8.7527 Homemaker Services 8.7527.A Homemaker Services Eligibility 1. Homemaker Services is a covered benefit available to Members enrolled in CFC. 8.7527.B Homemaker Services Definitions 1. Homemaker Provider Agency means a Provider Agency that is certified by the state fiscal agent to provide Homemaker Services.
Homemaker means services provided to an eligible Member that include general household activities to maintain a healthy and safe home environment for a 8.7527.C Homemaker Services Inclusions 1. Service shall be for the benefit of the Member and not for the benefit of other persons living in the home. Homemaker services, except for laundry, shopping, and Acquisition, Maintenance, and Enhancement of Skills (AME) must be completed within the permanent living space.
Homemaker tasks may include:

a. Routine light house cleaning, such as dusting, vacuuming, mopping, and cleaning bathroom and kitchen areas.

b. Meal preparation and menu planning.

c. Dishwashing.

d. Bedmaking.

e. Laundry.

f. Shopping.

g. Banking/Money Management.

i. For CDASS: caregivers cannot be reimbursed to provide money management tasks that would typically be completed by an authorized representative as defined in 8.7515.H.

h. Appointment Management.

i. Homemaker Services includes the option for the Acquisition, Maintenance, and Enhancement of Skills (AME) task when the support is related to functional skills training and is desired by the member to accomplish Homemaker tasks to increase their independence and reduce supports needed in the home and community.

i. Detailed, task-related goals shall be documented by case manager in the Person-Centered Support Plan, including documentation monitoring progress and any decrease in human assistance previously authorized.

ii. AME services shall include direct training and instruction to the Member in performing homemaker tasks.

iii. The provider or attendant shall be physically present to provide step-by-step verbal or physical instructions throughout the entire task.

All tasks must meet Age-Appropriate Task Standards for Children for Members under 18 or Task Standards for Adults for Members age 18 and older. If in 8.7607.A.
Authorization of Homemaker tasks for Members under age 18 must be limited to services that exceed those considered part of Parental or Legal Guardian of a Minor Responsibility as defined in section 8.7502.KK. 8.7527.D Homemaker Services Exclusions and Limitations 1. The CFC Homemaker service may NOT include:

a. Personal care services.

b. Services the person can perform independently.

c. Homemaker services provided in Uncertified Congregate Facilities.

d. Lawn care, snow removal, routine air duct cleaning, and animal care.

e. Billing for travel time to and from the Members’s home at the beginning and end of the visit is prohibited. Accompaniment of a Member by a Direct Care Worker in the community is reimbursable. Provider Agencies must follow all Department of Labor and Employment guidelines on time worked.

f. Services that do not meet the task definition for Homemaker.

When Homemaker services are provided by a Legally Responsible Person:

a. A Legally Responsible Person or member of the Member’s household may only be paid to furnish Extraordinary Care as defined in Section 8.7502.II.

b. Members may receive up to 364 hours of Homemaker services annually from a Legally Responsible Person. Additional hours may be authorized when services are provided by a non-Legally Responsible Person.

This service is subject to the following Annual CFC Service Soft Caps: Members shall not be authorized for more than 1,125 hours of Homemaker services per Person-Centered Support Plan year. Case Managers may request additional hours through the Department prescribed exception process as defined at

Section 8.7607.A.

Caregivers must adhere to the Weekly Caregiver Limit and Per Day Hourly Limit 8.7527.E Homemaker Services Provider Agency Requirements 1. All providers shall be certified by the Department as a Homemaker Provider 2. The Homemaker Provider Agency shall assure and document that all staff receive at least eight hours of training or have passed a skills validation test prior to providing unsupervised Homemaker services. Training or skills validation shall a. Tasks included in Section 8.7527.C Homemaker Inclusions.

b. Proper food handling and storage techniques.

c. Basic infection control techniques including Universal Precautions.

d. Informing staff of policies concerning emergency procedures.

All Homemaker Provider Agency staff shall be supervised by a person who, at a minimum, has received training or passed the skills validation test required of homemakers, as specified above. Supervision shall include, but not be limited to, the following activities:

a. Train staff on Agency policies and procedures.

b. Arrange and document training.

c. Oversee scheduling and notify Members of schedule changes.

d. Conduct supervisory visits to Member's homes at least every three months or more often as necessary for problem resolution, staff skills validation, observation of the home's condition and assessment of Member's satisfaction with services.

i. Supervision should be flexible to the needs of the Member and may be conducted via phone, video conference, telecommunication, or in-person.

If there is a safety concern with the services, the Provider Agency must make every effort to conduct an in-person assessment.
The Provider Agency must conduct Direct Care Worker (DCW) supervision to ensure that Member care and treatment are delivered in accordance with a plan of care that addresses the Member’s needs.

Agencies must ensure that each individual Caregiver adheres to the Weekly Caregiver Limit and Per Day Hourly Limit as defined at Section 8.7419. 8.7527.F Homemaker Provider Services Reimbursement Requirements:
Payment for Homemaker Services shall be the lower of the billed charges or the maximum rate of reimbursement set by the Department. Reimbursement shall be per unit of 15 minutes.
Payment does not include travel time to or from the Member’s residence.
If a visit by a home health aide from a Home Health Agency, as defined at

Section 8.520.1.L, includes Homemaker Services, only the home health aide visit shall be billed.

If a visit by a personal care provider from a personal care Provider Agency, as defined at 8.7001.A.12-B, includes Homemaker Services, the Homemaker Services shall be billed separately from the personal care services.
Reimbursement for Homemaker services provided by one or more Legally Responsible Persons is limited to a maximum of 364 total hours per year, per 6. Caregivers must adhere to the Weekly Caregiver Limit and Per Day Hourly Limit 8.7528 In-Home Support Services (IHSS) 8.7528.A In-Home Support Services Eligibility 1. In-Home Support Services (IHSS) is a covered benefit available to Members enrolled in CFC. 8.7528.B In-Home Support Services Definitions 1. Attendant means a person who is directly employed by an In-Home Support Services (IHSS) Agency to provide IHSS. A Family Member, including a spouse, may be an Attendant.
Authorized Representative means an individual designated by the Member, or by the Parent or Guardian of the Member, if appropriate, who has the judgment and ability to assist the Member in acquiring and receiving services under Title 25.5,

Article 6, Part 12, C.R.S. The Authorized Representative shall not be the eligible person’s service provider.

Care Plan means a written plan of care developed between the Member or the Member’s Authorized Representative, In-Home Support Services (IHSS) Agency and Case Management Agency that is authorized by the Case Manager.
Intentionally omitted 5. Inappropriate Behavior means documented verbal, sexual, or physical threats or abuse committed by the Member or Authorized Representative toward Attendants, Case Managers, or the In-Home Support Services (IHSS) Agency.
Independent Living Core Services means services that advance and support the independence of individuals with disabilities and to assist those individuals to live outside of Institutions. These services include but are not limited to information and Referral services, independent living skills training, peer and cross-disability peer counseling, individual and systems advocacy, transition services or diversion from nursing homes and Institutions to Home and Community-Based living, or upon leaving secondary education.
In-Home Support Services (IHSS) means services that are provided in the home and in the community by an Attendant under the direction of the Member or Member’s Authorized Representative, including Health Maintenance Activities and support for Activities of Daily Living or Instrumental Activities of Daily Living, Personal Care services and Homemaker services.
In-Home Support Services (IHSS) Agency means an Agency that is certified by the Colorado Department of Public Health and Environment, enrolled in the Medicaid program and provides Independent Living Core Services.
Licensed Health Care Professional means a state-licensed Registered Nurse (RN) who contracts with or is employed by the In-Home Support Services (IHSS) 8.7528.C In-Home Support Services Member Eligibility 1. To be eligible for In-Home Support Services (IHSS) the Member shall meet the following eligibility criteria:

a. Be enrolled in CFC.

b. Provide a signed Physician Attestation of Member Capacity form at enrollment and following any change in condition stating that the Member has sound judgment and the ability to self-direct care. If the Member is in unstable health with an unpredictable progression or variation of disability or illness, the Physician Attestation of Member Capacity form shall also include a recommendation regarding whether additional supervision is necessary and if so, the amount and scope of supervision requested.

i. Members under the age of 18 are not required to provide a signed Physician Attestation of Member Capacity as outlined in 8.7528.C.1.b and are required to have an Authorized Representative.

c. Members who elect or are required to have an Authorized Representative must appoint an Authorized Representative who has the judgment and ability to assist the Member in acquiring and using services.

d. Demonstrate a current need for covered Attendant support services.

In-Home Support Services (IHSS) eligibility for a Member will end if:

a. The Member is no longer enrolled in CFC b. The Member’s medical condition deteriorates causing an unsafe situation for the Member or the Attendant as determined by the Member's Licensed Medical Professional.

c. The Member refuses to designate an Authorized Representative when:

i. The Member is unable to direct their own care as documented by the Member's Licensed Medical Professional on the Physician Attestation of Member Capacity form, or ii. The Member is under the age of 18.

d. The Member provides false information or false records.

e. The Member no longer demonstrates a current need for Attendant support 8.7528.D In-Home Support Services (IHSS) Inclusions and Covered Services 1. Services are for the benefit of the Member. Services for the benefit of other persons are not reimbursable.

Service Inclusions:

a. Homemaker inclusions are set forth at Section 8.7527.C.

b. Personal Care inclusions are set forth at Section 8.7538.C.

c. Health Maintenance Activities inclusions are set forth at Section 8.7523.C. 8.7528.E In-Home Support Services (IHSS) Exclusions and Limitations 1. In-Home Support Services (IHSS) is a covered benefit for CFC members:

a. IHSS services must be documented on an approved IHSS Care Plan and prior authorized before any services are rendered. The IHSS Care Plan and Prior Authorization Request (PAR) must be submitted and approved by the Case Manager and received by the IHSS Agency prior to services being rendered. Services rendered in advance of approval and receipt of these documents are not reimbursable. All tasks must meet Age- Appropriate Task Standards for Children for Members under 18 or Task Standards for Adults for Members age 18 and older. If additional hours are needed beyond the Age-Appropriate Task Standards for Children for Members under 18 or Task Standards for Adults, Case Managers shall follow the CFC Direct Care Services Exception Request process described in 8.7607.A. Authorization of IHSS tasks must be limited to services that exceed those considered part of Parental or Legal Guardian of a Minor Responsibility as defined at Section 8.7502.KK.

b. Services rendered by an Attendant who shares living space with the Member or Family Members are reimbursable only when the Case Manager determines, prior to the services being rendered, that the services meet the definition of Extraordinary Care as defined at Section 8.7502.II.

c. Health Maintenance Activities may include related Personal Care and/or Homemaker services if such tasks are completed in conjunction with the Health Maintenance Activity and are secondary or contiguous to the Health Maintenance Activity.

i. Secondary means in support of the main task(s). Secondary tasks must be routine and regularly performed in conjunction with a Health Maintenance Activity. The Case Manager must document evidence that the secondary task is necessary for the health and safety of the Member. Secondary tasks do not add units to the ii. Contiguous means before, during or after the main task(s).

Contiguous tasks must be completed before, during, or after the Health Maintenance Activity. The Case Manager must document evidence that the contiguous task is necessary for the health and safety of the Member. Contiguous tasks do not add units to the iii. The IHSS Agency shall not submit claims for Health Maintenance Activities when only Personal Care and/or Homemaking services are completed.

d. Independent Living Core Services, Attendant training, and oversight or supervision provided by the IHSS Agencies Licensed Health Care Professional are not separately reimbursable. No additional compensation is allowable to IHSS Agencies for providing these services.

e. Billing for travel time to and from the Member’s home at the beginning and end of the visit is prohibited. Accompaniment of a Member by an Attendant in the community is reimbursable. IHSS Agencies must follow all Department of Labor and Employment guidelines on time worked.

f. Companionship is not a benefit of IHSS and shall not be reimbursed.

This service is subject to the following Annual CFC Service Soft Caps: Members shall not be authorized for more than 4,750 hours per PCSP of Health Maintenance Activities, 2,500 hours per PCSP of Personal Care, and/or 1,125 hours per PCSP of Homemaker services. Case Managers may request additional hours through the Department prescribed exception process as defined at

Section 8.7607.A. 8.7528.F In-Home Support Services (IHSS) Member and Authorized Representative Participation and Self-Direction 1. A Member or their Authorized Representative may self-direct the following aspects of service delivery:

a. Present a person(s) of their own choosing to the In-Home Support Services (IHSS) Agency as a potential Attendant. The Member must have adequate Attendants to assure compliance with all tasks in the Care Plan.

b. Train Attendant(s) to meet their needs.

c. Dismiss Attendants who are not meeting their needs.

d. Schedule, manage, and supervise Attendants with the support of the IHSS e. Determine, in conjunction with the IHSS Agency, the level of in-home supervision as recommended by the Member’s Licensed Medical Professional.

f. Transition to alternative service delivery options at any time. The Case Manager shall coordinate the transition and Referral process.

g. Communicate with the IHSS Agency and Case Manager to ensure safe, accurate and effective delivery of services.

h. Request a Reassessment, as defined at Section 8.7200.B.27, if Level of Care or service needs have changed.

An Authorized Representative is not allowed to be reimbursed for In-Home Support Services (IHSS) Attendant services for the Member they represent.
If the Member is required to or elects to have an Authorized Representative, the Authorized Representative shall meet the requirements:

a. Must be at least 18 years of age.

b. Has not been convicted of any crime involving exploitation, abuse, neglect, or assault on another person.

The Authorized Representative must attest to the above requirement on the Shared Responsibilities Form.
In-Home Support Services (IHSS) Members who personally require an Authorized Representative may not serve as an Authorized Representative for another IHSS Member.
The Member and their Authorized Representative must adhere to In-Home Support Services (IHSS) Agency policies and procedures. 8.7528.G In-Home Support Services Agency Eligibility 1. The In-Home Support Services (IHSS) Agency must be a licensed home care Agency. The IHSS Agency shall comply with all requirements of their Certification and licensure, in addition to requirements described in Section 8.7400.
Administrators or managers as defined at 6 C.C.R. 1011-1 Chapter 26 shall satisfactorily complete the Department authorized training on In-Home Support Services (IHSS) rules and regulations prior to Medicaid Certification and annually thereafter. Provider Agencies must upload the certificate of completion annually into the Medicaid Provider Portal. 8.7528.H In-Home Support Services (IHSS) Agency Responsibilities 1. The In-Home Support Services (IHSS) Agency shall assure and document that all Members are provided the following:

a. Independent Living Core Services i. An IHSS Agency must provide a list of the full scope of Independent Living Core Services provided by the Agency to each Member on an annual basis. The IHSS Agency must keep a record of each Member’s choice to utilize or refuse these services, and document services provided.

b. Attendant training, oversight and supervision by a licensed healthcare professional.

c. The IHSS Agency shall provide 24-hour back-up service for scheduled visits to Members at any time an Attendant is not available. At the time the Care Plan is developed the IHSS Agency shall ensure that adequate staffing is available. Staffing must include backup Attendants to ensure necessary services will be provided in accordance with the Care Plan.

The In-Home Support Services (IHSS) Agency shall adhere to the following:

a. If the IHSS Agency admits Members with needs that require care or services to be delivered at specific times or parts of day, the IHSS Agency shall ensure qualified staff in sufficient quantity are employed by the Agency or have other effective back-up plans to ensure the needs of the Member are met.

b. The IHSS Agency shall only accept Members for care or services based on a reasonable assurance that the needs of the Member can be met adequately by the IHSS Agency in the individual’s temporary or permanent home or place of residence.

i. There shall be documentation in the Care Plan or Member record of the agreed upon days and times of services to be provided based upon the Member’s needs that is updated at least annually.

c. If an IHSS Agency receives a Referral of a Member who requires care or services that are not available at the time of Referral, the IHSS Agency shall advise the Member or their Authorized Representative and the Case Manager of that fact.

i. The IHSS Agency shall only admit the Member if the Member or their Authorized Representative and Case Manager agree the recommended services can be delayed or discontinued.

d. The IHSS Agency shall ensure orientation is provided to Members or Authorized Representatives who are new to IHSS or request re-orientation through the Department’s prescribed process. Orientation shall include instruction in the philosophy, policies, and procedures of IHSS and information concerning Member rights and responsibilities.

e. The IHSS Agency will keep written service notes documenting the services provided at each visit.

The In-Home Support Services (IHSS) Agency is the legal employer of a Member’s Attendants and must adhere to all requirements of federal and state law, and to the rules, regulations, and practices as prescribed by the Department.
IHSS Agencies must ensure that each individual Attendant adheres to the Weekly Caregiver Limit and Per Day Hourly Limit as defined at Section 8.7419.
The In-Home Support Services (IHSS) Agency shall assist all Members in interviewing and selecting an Attendant when requested and maintain documentation of the IHSS Agency’s assistance and/or the Member’s refusal of such assistance.
The In-Home Support Services (IHSS) Agency will complete an intake Assessment following Referral from the Case Manager. Utilizing the authorized units provided on the Direct Care Services Calculatorprovided by the Case Manager, the IHSS Agency will develop a Care Plan in coordination with the Case Manager and Member. Any proposed services described in the Care Plan that differ from the authorized services and units must be submitted to the Case Manager for review. The Care Plan must be approved prior to the start of 7. The In-Home Support Services (IHSS) Agency shall ensure that a current Care Plan is in the Member’s record, and that Care Plans are updated with the Member at least annually or more frequently in the event of a Member’s change in condition. The IHSS Agency will send the Care Plan to the Case Manager for review and approval.

a. The Care Plan will include a statement of allowable Attendant hours and a detailed listing of frequency, scope, and duration of each service to be provided to the Member for each day and visit. The Care Plan shall be signed by the Member or the Member’s Authorized Representative and the IHSS Agency.

i. Secondary or contiguous tasks must be described on the care plan as required in Section 8.7528.E.3.a-b.

b. In the event of the observation of new symptoms or worsening condition that may impair the Member’s ability to direct their care, the IHSS Agency, in consultation with the Member or their Authorized Representative and Case Manager, shall contact the Member’s Licensed Medical Professional to receive direction as to the appropriateness of continued care. The outcome of that consultation shall be documented in the Member’s revised Care Plan, with the Member and/or Authorized Representative’s input and approval. The IHSS Agency will submit the revised Care Plan to the Case Manager for review and approval.

The In-Home Support Services (IHSS) Agencies Licensed Health Care Professional is responsible for the following activities:

a. Administer a skills validation test for Attendants who will perform Health Maintenance Activities. Skills validation for all assigned tasks must be completed prior to service delivery unless postponed by the Member or Authorized Representative to prevent interruption in services. The reason for postponement shall be documented by the IHSS Agency in the Member’s file. In no event shall the skills validation be postponed for more than thirty (30) days after services begin to prevent interruption in b. Verify and document Attendant skills and competency to perform IHSS and basic Member safety procedures.

c. Counsel Attendants and staff on difficult cases and potentially dangerous situations.

d. Consult with the Member, Authorized Representative or Attendant in the event a medical issue arises.

e. Investigate Complaints and Incidents within ten (10) calendar days as required in Section 8.7411.

f. Verify the Attendant follows all tasks set forth in the Care Plan.

g. Review the Care Plan and Physician Attestation of Member Capacity form (if applicable) upon initial enrollment, following any change of condition, and upon the request of the Member, their Authorized Representative, or the Case Manager.

h. Provide in-home supervision for the Member as recommended by their Licensed Medical Professional and as agreed upon by the Member or their Authorized Representative.

At the time of enrollment and following any change of condition, the In-Home Support Services (IHSS) Agency will review recommendations for supervision listed on the Physician Attestation of Member Capacity form (if applicable). This review of recommendations shall be documented by the IHSS Agency in the Member record.

a. The IHSS Agency shall collaborate with the Member or Member’s Authorized Representative to determine the level of supervision provided by the IHSS Agency’s Licensed Health Care Professional beyond the requirements set forth at Section 25.5-6-1203, C.R.S.

b. The Member may decline recommendations by the Licensed Medical Professional for in-home supervision. The IHSS Agency must document this choice in the Member record and notify the Case Manager. The IHSS Agency and their Licensed Health Care Professional, Case Manager, and Member or their Authorized Representative shall discuss alternative service delivery options and the appropriateness of continued participation in IHSS.

The In-Home Support Services (IHSS) Agency shall assure and document that all Attendants have received training in the delivery of IHSS prior to the start of services. Attendant training shall include:

a. Development of interpersonal skills focused on addressing the needs of persons with disabilities.

b. Overview of IHSS as a service-delivery option of consumer direction.

c. Instruction on basic first aid administration.

d. Instruction on safety and emergency procedures.

e. Instruction on infection control techniques, including Universal Precautions.

f. Mandatory reporting and Incident reporting procedures.

g. Skills validation test for unskilled tasks assigned on the care plan.

The In-Home Support Services (IHSS) Agency shall allow the Member or Authorized Representative to provide individualized Attendant training that is specific to their own needs and preferences.
With the support of the In-Home Support Services (IHSS) Agency, Attendants must adhere to the following:

a. Must be at least 16 years of age and demonstrate competency in caring for the Member to the satisfaction of the Member or Authorized Representative.

i. Minor attendants ages 16 to 17 will not be permitted to operate floor-based vertical powered patient/resident lift devices, ceilingmounted vertical powered patient/resident lift devices, and powered sit-to-stand patient/resident lift devices (lifting devices).

b. May be a Family Member subject to the reimbursement and service limitations in 8.7528.J.

c. Must be able to perform the assigned tasks on the Care Plan.

d. Shall not, in exercising their duties as an In-Home Support Services (IHSS) Attendant, represent themselves to the public as a licensed nurse, a certified nurse’s aide, a licensed practical or professional nurse, a registered nurse or a registered professional nurse pursuant to Section 25.5-6-1203(3), C.R.S.

e. Shall not have had their license as a nurse or certified nurse aide suspended or revoked or their application for such license or certification denied.

The In-Home Support Services (IHSS) Agency shall provide functional skills training to assist Members and their Authorized Representatives in developing skills and resources to maximize their independent living and personal management of health care. 8.7528.I In-Home Support Services (IHSS) Case Management Agency 1. The Case Manager shall provide information and resources about In-Home Support Services (IHSS) to eligible Members, including a list of IHSS Agencies in their service area and an introduction to the benefits and characteristics of participant-directed programs.
The Case Manager will initiate a Referral to the In-Home Support Services (IHSS) Agency of the Member or Authorized Representative’s choice, including an outline of approved services as determined by the Case Manager’s most recent Assessment. The Referral must include the Physician Attestation of Member Capacity (if applicable), Assessment information, and other pertinent documentation to support the development of the Care Plan, as listed on the Referral form.
The Case Manager must ensure that the following forms are completed prior to the approval of the Care Plan or start of services:

a. The Physician Attestation of Member Capacity form shall be completed upon enrollment and following any change in condition.

b. The Shared Responsibilities Plan shall be completed upon enrollment and following any change of condition. If the Member requires an Authorized Representative, the Shared Responsibilities Form must include the designation and attestation of an Authorized Representative.

Upon the receipt of the Care Plan, the Case Manager shall:

a. Review the Care Plan within five business days of receipt to ensure there is no disruption or delay in the start of services.

b. Ensure all required information is in the Member’s Care Plan and that services are appropriate given the Member’s medical or functional condition. If needed, request additional information from the Member, their Authorized Representative, the In-Home Support Services (IHSS) Agency, or Licensed Medical Professional regarding services requested.

c. Review the Care Plan to ensure there is delineation for all services to be provided; including frequency, scope, and duration.

d. Review the Licensed Medical Professional’s recommendation for in-home supervision as requested on the Physician Attestation of Member Capacity form (if applicable). The Case Manager will document the status of recommendations and provide resources for services outside the scope of the Member’s eligible benefits.

e. Collaborate with the Member or their Authorized Representative and the In-Home Support Services (IHSS) Agency to establish a start date for services. The Case Manager shall discontinue any services that are duplicative with IHSS.

f. Authorize cost-effective and non-duplicative services via the Prior Authorization Request (PAR). Provide a copy of the Prior Authorization Request (PAR) to the IHSS Agency in accordance with procedures established by The Department prior to the start of IHSS services.

g. Work collaboratively with the IHSS Agency, Member, and their Authorized Representative to mediate Care Plan disputes following The Department’s prescribed process.

i. Case Managers will complete the Long-Term Care Program Notice of Action (LTC-803) and provide the Member or the Authorized Representative with the reasons for denial of requested service frequency or duration, information about the Member’s rights to fair hearing, and appeal procedures.

The Case Manager shall ensure cost-effectiveness and non-duplication of services by:

a. Documenting the discontinuation of previously authorized Agency-based care, including Homemaker, Personal Care, and long-term home health services that are being replaced by In-Home Support Services (IHSS).

b. Documenting and justifying any need for additional in-home services including but not limited to acute or long-term home health services, hospice, traditional HCBS services, and private duty nursing.

i. A Member may receive non-duplicative services from multiple Attendants or agencies if appropriate for the Member’s Level of Care and documented service needs.

c. Ensuring the Member’s record includes documentation to substantiate all Health Maintenance Activities on the Care Plan and requesting additional information as needed.

d. Coordinating transitions from a hospital, nursing facility, or other Agency to IHSS. Assisting Members with transitions from IHSS to alternate services if appropriate.

e. Collaborating with the Member or their Authorized Representative and the IHSS Agency in the event of any change in condition. The Case Manager shall request an updated Physician Attestation of Member Capacity form (if applicable).The Case Manager may revise the Care Plan as appropriate given the Member’s condition and functioning.

f. Completing a Reassessment as defined at Section 8.7200.B.27 if requested by the Member if Level of Care or service needs have changed.

The Case Manager shall not authorize more than one consumer-directed program on the Member’s Prior Authorization Request (PAR).
The Case Manager shall participate in training and consultative opportunities with the Department’s Consumer-Directed Training and Support Contractor.
Additional requirements for Case Managers:

a. Contact the Member or Authorized Representative once a month during the first three months of receiving In-Home Support Services (IHSS) to assess their IHSS management, their satisfaction with Attendants, and the quality of services received.

b. Contact the Member or Authorized Representative quarterly, after the first three months of receiving IHSS, to assess their implementation of Care Plans, IHSS management, quality of care, IHSS expenditures and general satisfaction.

c. Contact the Member or Authorized Representative when a change in Authorized Representative occurs and continue contact once a month for three months after the change takes place.

d. Contact the IHSS Agency semi-annually to review the Care Plan, services provided by the Agency, and supervision provided. The Case Manager must document and keep record of the following:

i. In-Home Support Services (IHSS) Care Plans;

ii. In-home supervision needs as recommended by the Physician;

iii. Independent Living Core Services offered and provided by the IHSS Agency; and iv. Additional supports provided to the Member by the IHSS Agency.

Start of Services a. Services may begin only after the requirements of Sections 8.7528.C, 8.7528.H.6 , 8.7528.H.10 , and 8.7528.I.3 of this rule have been met.

b. The Case Manager shall follow the Department’s assessment process and receive authorization prior to authorizing a start date for Attendant services for Person-Centered Support Plans that;

i. Contain Health Maintenance Activities; or ii. Exceed the cost of care received in an institutional setting.

c. The Case Manager shall establish a service period and submit a Prior Authorization Request (PAR), providing a copy to the In-Home Support Services (IHSS) Agency prior to the start of services.

Case Managers must follow the Weekly Caregiver Limit Exception Request processes described in Section 8.7419. 8.7528.J In-Home Support Services (IHSS) Reimbursement and Service 1. In-Home Support Services (IHSS) Personal Care services must comply with the rules for reimbursement set forth at Section 8.7538 Personal Care. IHSS Homemaker services must comply with the rules for reimbursement set forth at

Section 8.7527 Homemaker Services.

The In-Home Support Services (IHSS) Agency shall not submit claims for services missing documentation of the services rendered, for services which are not on the Care Plan, or for services which are not on an approved Prior Authorization Request (PAR). The IHSS Agency shall not submit claims for more time or units than were required to render the service regardless of whether more time or units were prior authorized. Reimbursement for claims for such services is not allowable.
The In-Home Support Services (IHSS) Agency shall request a reallocation of previously authorized service units for 24-hour back-up care prior to submission of a claim.
Services by an Authorized Representative to represent the Member are not reimbursable. In-Home Support Services (IHSS) services performed by an Authorized Representative for the Member that they represent are not reimbursable.
IHSS Agencies must ensure that Attendants adhere to the Weekly Caregiver Limit and Per Day Hourly Limit as defined at Section 8.7419.
A Member cannot receive In-Home Support Services (IHSS) and Consumer Directed Attendant Support Services (CDASS) at the same time.
Reimbursement for Homemaker services provided by one or more Legally Responsible Persons is limited to a maximum of 364 total hours per year, per 8. Payment does not include travel time to or from the Member's residence. 8.7528.K In-Home Support Services (IHSS) Discontinuation and Termination 1. A Member may elect to discontinue In-Home Support Services (IHSS) or use an alternate service-delivery option at any time.
A Member may be discontinued from In-Home Support Services (IHSS) when equivalent care in the community has been secured.
The Case Manager may terminate a Member’s participation in In-Home Support Services (IHSS) for the following reasons:

a. The Member or their Authorized Representative fails to comply with IHSS program requirements as defined in Section 8.7528.F, or b. A Member no longer meets program criteria, or c. The Member provides false information, false records, or is convicted of fraud, or d. The Member or their Authorized Representative exhibits Inappropriate Behavior, and The Department has determined that the IHSS Agency has made adequate attempts at dispute resolution and dispute resolution has failed.

i. The IHSS Agency and Case Manager are required to assist the Member or their Authorized Representative to resolve the Inappropriate Behavior, which may include the addition of or a change of Authorized Representative. All attempts to resolve the Inappropriate Behavior must be documented prior to notice of termination.

When an In-Home Support Services (IHSS) Agency discontinues services, the Agency shall give the Member and the Member's Authorized Representative written notice of at least thirty days. Notice shall be provided in person, by certified mail or another verifiable-receipt service. Notice shall be considered given when it is documented that the Member or Authorized Representative has received the notice. The notice shall provide the reason for discontinuation. A copy of the 30-day notice shall be given to the Case Management Agency.

a. Exceptions will be made to the requirement for advanced notice when the In-Home Support Services (IHSS) Agency has documented that there is an immediate threat to the Member, IHSS Agency, or Attendants.

b. Upon In-Home Support Services (IHSS) Agency discretion, the Agency may allow the Member or their Authorized Representative to use the 30day notice period to address conflicts that have resulted in discontinuation.

If continued services are needed with another Agency, the current In-Home Support Services (IHSS) Agency shall collaborate with the Case Manager and Member or their Authorized Representative to facilitate a smooth transition between agencies. The IHSS Agency shall document due diligence in ensuring continuity of care upon discharge as necessary to protect the Member’s safety and welfare.
In the event of discontinuation or termination from In-Home Support Services (IHSS), the Case Manager shall:

a. Complete the Long-Term Care Program Notice of (LTC-803) and provide the Member or the Authorized Representative with the reasons for termination, information about the Member’s rights to fair hearing, and appeal procedures. Once notice has been given, the Member or Authorized Representative may contact the Case Manager for assistance in obtaining other home care services or additional benefits if needed. 8.7529 Independent Living Skills Training 8.7529.A Independent Living Skills Training Eligibility 1. Independent Living Skills Training is a covered benefit available to Members enrolled in the HCBS Brain Injury Waiver. 8.7529.B Independent Living Skills Training Descriptions and Definitions 1. Independent Living Skills Training (ILST) means services designed and developed based on the Member’s ability to independently sustain themselves physically, emotionally, and economically in the community. ILST may be provided in the Member’s residence or in the community.

ILST Care Plan means a person-centered plan that describes the ILST services necessary to enable the Member to independently sustain themselves physically, emotionally, and economically in the community. This plan is developed with the Member and the Provider Agency.
ILST Trainers are individuals trained in accordance with guidelines listed below and tasked with providing the service to the Member. 8.7529.C Independent Living Skills Training Inclusions 1. Reimbursable services are limited to the assessment, training, maintenance, supervision, assistance, or continued supports of the following skills:

a. Self-care, including but not limited to basic personal hygiene;

b. Medication supervision and reminders;

c. Household management;

d. Time management skills training;

e. Safety awareness skill development and training;

f. Task completion skill development and training;

g. Communication skill building;

h. Interpersonal skill development;

i. Socialization, including but not limited to acquiring and developing appropriate social norms, values, and skills;

j. Recreation, including leisure and community integration activities;

k. Sensory motor skill development;

l. Benefits coordination, including activities related to the coordination of Medicaid services;

m. Resource coordination, including activities related to coordination of community transportation, community meetings, neighborhood resources, and other available public and private resources;

n. Financial management, including activities related to the coordination of financial management tasks such as paying bills, balancing accounts, and basic budgeting.

All ILST shall be documented in the ILST Care Plan. Reimbursement is limited to services described in the ILST Care Plan. 8.7529.D Independent Living Skills Exclusions and Limitations 1. Members who reside in a Supportive Living Program (SLP) as defined in

Section 8.7550 are not eligible for Independent Living Skills services.

Travel to and from the Member’s home is not reimbursable. 8.7529.E Independent Living Skills Training Provider Agency Requirements 1. Provider Agencies must have valid licensure and certification as well as appropriate professional oversight.

a. Agencies seeking to provide ILST services must have a valid Home Care Agency Class A or B license or an Assisted Living Residency license and Transitional Living Program Certification from the Department of Public Health and Environment.

b. Agencies must employ an ILST coordinator with at least 5 years of experience working with individuals with disabilities on issues relating to life skills training, Brain Injury, and a degree within a relevant field.

i. This coordinator must review ILST Care Plans to ensure Member plans are designed and directed at the development and maintenance of the Member's ability to independently sustain himself/herself physically, emotionally, and economically in the c. Any component of the ILST Care Plan that may contain activities outside the scope of the ILST trainer must be created by the appropriate licensed professional within their scope of practice to meet the needs of the Member. These professionals must hold licenses with no limitations in one of the following professions:

i. Occupational Therapist;

ii. Physical Therapist;

iii. Registered Nurse;

iv. Speech Language Pathologist;

v. Psychologist;

vi. Neuropsychologist;

vii. Medical Doctor;

viii. Licensed Clinical Social Worker;

ix. Licensed Professional Counselor.

d. Professionals providing components of the ILST Care Plan may include individuals who are Members of Provider Agency staff, contracted staff, or external licensed and certified professionals who are fully aware of duties conducted by ILST trainers.

e. All ILST Care Plan containing any professional activity must be reviewed and authorized at least every 6 months, or as needed, by professionals responsible for oversight as referenced in 8.7529.E.1.c.i-iii 2. ILST trainers must meet one of the following education, experience, or certification requirements:

a. Licensed health care professionals with experience in providing functionally based assessments and skills training for individuals with b. Individuals with a bachelor’s degree and one (1) year of experience working with individuals with disabilities; or c. Individuals with an associate degree in a social service or human relations area and two (2) years of experience working with individuals with d. Individuals currently enrolled in a special education, occupational therapy, therapeutic recreation, and/or teaching degree program with at least three (3) years of experience providing services similar to ILST services; or e. Individuals with four (4) years direct care experience teaching or working with individuals with a Brain Injury or other cognitive disability either in a home setting, hospital setting, or rehabilitation setting.

The Provider Agency shall administer a series of training programs to all ILST trainers.

a. Prior to delivery of and reimbursement for services, ILST trainers must complete the following trainings:

i. Person-centered care approaches;

ii. HIPAA and Member confidentiality;

iii. Basics of Brain Injury including at a minimum:

Basic neurophysiology;
Impact of a Brain Injury on an individual;
Epidemiology of Brain Injury;
Common physical, behavioral, and cognitive impairments and interactions strategies;
Best practices in Brain Injury recovery; and 6) Screening for a history of Brain Injury.

iv. On-the-job coaching by an incumbent ILST trainer;

v. Basic safety and de-escalation techniques;

vi. Training on community and public resource availability;

vii. Understanding of current brain injury recovery guidelines; and viii. First aid.

b. ILST trainers must also receive ongoing training, required annually, in the following areas:

i. Cultural awareness;

ii. Updates on Brain Injury recovery guidelines; and iii. Updates on resource availability. 8.7529.F Independent Living Skills Training Provider Agency Reimbursement 1. ILST shall be reimbursed according to the number of units billed, with one (1) unit equal to fifteen (15) minutes of service. Payment and billing may not include travel time to and from the Member’s residence. 8.7530 Life Skills Training 8.7530.A Life Skills Training Eligibility 1. Life Skills Training is a covered benefit available to Members enrolled in one of a. Community Mental Health Supports Waiver b. Complementary and Integrative Health Waiver c. Elderly, Blind, and Disabled Waiver d. Supported Living Services Waiver 8.7530.B Life Skills Training Definitions 1. Life Skills Training means individualized training designed and directed with the Member to develop and maintain their ability to independently sustain themselves physically, emotionally, socially and economically in the community.

Life Skills Training Trainer means the person(s) that directly supports the Member by designing with the Member an individualized LST service plan.

Trainers implement the plan to develop and maintain the Members’ ability to independently sustain themselves physically, emotionally, socially and economically in the community.

The LST coordinator means the person that reviews the Member’s LST service plan to ensure it is designed to meet the needs of the Member in order to enable them to independently sustain themselves physically, emotionally, and economically in the community. 8.7530.C Life Skills Training Inclusions 1. HCBS Elderly, Blind, and Disabled (EBD) Waiver; Community Mental Health Supports (CMHS) Waiver; Complementary and Integrative Health (CIH) Waiver;

Supported Living Services (SLS) Waiver 2. Life Skills Training includes Assessment, training, maintenance, supervision, assistance, or continued supports of the following skills:

a. Problem-solving;

b. Identifying and accessing mental and behavioral health services;

c. Self-care and Activities of Daily Living;

d. Medication reminders and supervision, not including medication administration;

e. Household management;

f. Time management;

g. Safety awareness;

h. Task completion;

i. Communication skill building;

j. Interpersonal skill development;

k. Socialization, including, but not limited to: acquiring and developing skills that promote healthy relationships, assistance with understanding social norms and values, and support with acclimating to the community;

l. Recreation, including leisure and community engagement;

m. Assistance with understanding and following plans for occupational or sensory skill development;

n. Accessing resources and benefit coordination, including activities related to coordination of community transportation, community meetings, community resources, housing resources, Medicaid services, and other available public and private resources;

o. Financial management, including activities related to the coordination of financial management tasks such as paying bills, balancing accounts, and basic budgeting; and p. Acquiring and utilizing assistive technology when appropriate and not duplicative of training covered under other services.

q. Life Skills Training (LST) may be provided in the Member’s residence or in the community. 8.7530.D Life Skills Training Service Access and Authorization 1. To obtain approval for Life Skills Training, the Member must demonstrate a need for the service as follows:

a. The Member demonstrates a need for training designed and directed to develop and maintain their ability to sustain themselves physically, emotionally, socially and economically in the community;

b. The Member identifies skills for which training is needed and demonstrates that without the skills, the Member risks their health, safety, or ability to live in the community;

c. The Member demonstrates that without training they could not develop the skills needed; and d. The Member demonstrates that with training they have the ability to acquire these skills or services necessary within 365 days.

To establish eligibility for Life Skills Training, the Member must satisfy general criteria for accessing the service:

b. The Member demonstrates a need to develop or sustain independence to live or remain in the community upon their transitioning; and c. The Member demonstrates that they need the service to establish community support or resources where they may not otherwise exist. 8.7530.E Life Skills Training Service Requirements 1. The Member’s Case Manager must not authorize Life Skills Training for more than 365 days. The Department, in its sole discretion, may grant an exception based on extraordinary circumstances.

The LST coordinator must share the LST CarePlan with the Member’s providers of other HCBS services that support or implement any LST services. The LST coordinator will seek permission from the Member prior to sharing the LST Care Plan, or any portion of it, with other providers; and 3. Any component of the LST Care Plan that may contain activities outside the scope of the LST trainer’s scope of expertise or licensure must be created by the appropriately licensed professional within his/her scope of practice.
All LST Care Plans containing any professional activity must be reviewed and authorized monthly during the service period, or as needed, by professionals responsible for oversight.
All LST Provider Agencies must maintain a LST CarePlan that includes:

a. Monthly skills training plans to be developed and documented;

b. Skills training plans that include goals, goals achieved or failed, and progress made toward accomplishment of continuing goals;

c. The start and end time/duration of service provision;

d. The nature and extent of service;

e. A description of LST activities;

f. Progress toward Care Plan goals and objectives; and g. The provider’s signature and date.

The LST Care Plan shall be sent to the Case Management Agency responsible for the Person-Centered Support Plan on a quarterly basis, or as requested by 7. The LST Care Plan shall be shared, with the Member’s permission, with the Member’s other HCBS Provider Agencies. 8.7530.F Life Skills Training Service Exclusions and Limitations 1. Members may utilize LST up to 24 units (six hours) per day, for no more than 160 units (40 hours) per week, for no more than 365 days following the first day the service is provided.
LST is not to be delivered simultaneously during the direct provision of Adult Day Services, Group Behavioral Counseling, Consumer Directed Attendant Support Services (CDASS), Health Maintenance Activities, Homemaker, In-Home Support Services (IHSS), Mentorship, Peer Mentorship, Personal Care, Prevocational Services, Respite, Specialized Habilitation, Supported Community Connections, or Supported Employment.

a. LST services may be provided in conjunction with Non-Medical Transportation if it is described in the Member’s LST Care Plan. Services are billable only when provided by an enrolled NMT Provider Agency, who is not the LST Provider Agency.

LST does not include services offered through State Plan or other Waiver Services, except those that are incidental to the LST training activities or purposes or are incidentally provided to ensure the Member’s health and safety during the provision of LST. 8.7530.G Life Skills Training Service Provider Agency Requirements 1. The Provider Agency must employ an LST coordinator with at least 5 years of experience working with individuals with disabilities on issues relating to life skills training, or a degree within a relevant field; and 2. The Provider Agency must ensure any component of the LST plan that may contain activities outside the scope of the LST trainer’s expertise or licensure must be created by an appropriately licensed professional acting within his/her scope of practice.

a. The professional must hold a license with no limitations in the scope of practice appropriate to meet the Member’s LST needs. The following licensed professionals are authorized to furnish LST training:

i. Occupational Therapist;

ii. Physical Therapist;

iii. Registered Nurse;

iv. Speech Language Pathologist;

v. Psychologist;

vi. Neuropsychologist;

vii. Medical Doctor;

viii. Licensed Clinical Social Worker ix. Licensed Professional Counselor; or x. Board Certified Behavior Analyst (BCBA).

b. An appropriately licensed professional providing a component(s) of the LST Care Plan may be a Provider Agency staff member, contract staff member, or external licensed and certified professionals who are fully aware of duties conducted by LST trainers.

A Provider Agency must maintain a Class A or B Home Care Agency License issued by the Colorado Department of Public Health and Environment if that Agency chooses to provide training on Personal Care as defined at Section 8.7538 4. The Provider Agency must employ one or more LST Trainers to directly support Members, one-on-one, by designing with the Member their LST care plan and implementing the plan for the Member’s training.

a. An individual is qualified to be an LST trainer only if they are:

i. A licensed healthcare professional with experience in providing functionally based assessments and skills training for individuals with disabilities;

ii. An individual with a bachelor’s degree and one (1) year of experience working with individuals with disabilities;

iii. An individual with an associate’s degree in a social service or human relations area and two (2) years of experience working with individuals with disabilities;

iv. An individual currently enrolled in a degree program related directly to special education, occupational therapy, therapeutic recreation, and/or teaching with at least three (3) years of experience providing services similar to LST services;

v. An individual with four (4) years direct care experience teaching or working with needs of individuals with disabilities; or vi. An individual with four (4) years of lived experience transferable to training designed and directed with the Member to develop and maintain their ability to sustain himself/herself physically, emotionally, socially and economically in the community. The Provider Agency must ensure that this individual receives Member-specific training sufficient to enable the individual to competently provide LST to the Member consistent with the LST b. Prior to delivery of and reimbursement for any services, LST trainers must complete the following trainings:

i. Person-centered support approaches;

ii. HIPAA and Member’s confidentiality;

iii. Basics of working with the population to be served;

iv. On-the-job coaching by the provider or an incumbent LST trainer on the provision of LST training;

v. Basic safety and de-escalation techniques;

vi. Community and public resource availability; and vii. Recognizing emergencies and knowledge of emergency procedures including basic first aid, home and fire safety.

c. The Provider Agency must ensure that staff acting as LST trainers receive ongoing training within 90 days of unsupervised contact with a Member, and no less than once annually, in the following areas:

i. Cultural awareness;

ii. Updates on working with the population to be served; and iii. Updates on resource availability. 8.7530.H Life Skills Training Service Provider Agency Reimbursement 1. LST may be billed in 15-minute units. Members may utilize LST up to 24 units (six hours) per day, no more than 160 units (40 hours) per week, for up to 365 days following the first day the service is provided.

Payment for LST shall be the lower of the billed charges or the maximum rate of 3. LST may include escorting Members if doing so is incidental to performing an authorized LST service. However, costs for transportation in addition to those for accompaniment may not be billed LST services. If accompaniment and transportation are provided through the same Agency, the person providing transportation may not be the same person who provided accompaniment as a LST benefit to the Member. 8.7531 Massage Therapy 8.7531.A Massage Therapy Eligibility 1. Massage Therapy is a covered benefit available to Members enrolled in one of a. Children with Complex Health Needs Waiver b. Children’s Extensive Support Waiver c. Children's Habilitation Residential Program d. Complementary and Integrative Health Waiver e. Supported Living Services Waiver 8.7531.B Massage Therapy Definition 1. Massage Therapy means the systematic manipulation of the soft tissues of the body, (including manual techniques of gliding, percussion, compression, vibration, and gentle stretching) for the purpose of bringing about beneficial physiologic, mechanical, and psychological changes. 8.7531.C Massage Therapy Inclusions 1. Massage therapy shall only be used for the treatment of conditions related to the Member’s illness, medical need, or behavioral need as identified on the Person- 2. Massage therapy includes the physical manipulation of muscles to ease muscle contractures or spasms, increase extension and muscle relaxation and decrease muscle tension, and WATSU.
Massage Therapy shall be provided in a licensed massage therapist’s office, an approved outpatient setting, or in the Member’s residence.
HCBS Complementary and Integrative Health Waiver (CIH); Support Living Services (SLS)

a. Members receiving massage therapy services may be asked to participate in an independent evaluation to determine the effectiveness of the 8.7531.D Massage Therapy Exclusions and Limitations 1. Massage therapy is not available if it is available under the Medicaid State Plan, EPSDT or from a Third-Party Resource.

HCBS Support Living Services (SLS) Waiver; Children’s Extensive Services (CES) Waiver; Children with Complex Health Needs (CwCHN) Waiver; Children's Habilitation Residential Program (CHRP) Waiver:

a. The following items are excluded and are not eligible for reimbursement:

i. Acupuncture;

ii. Chiropractic care; and iii. Experimental treatments or therapies.

Massage Therapy Service Limitations:

a. HCBS Children with Complex Health Needs Waiver:

i. Massage Therapy shall be limited to the Member’s assessed need up to a maximum of 24 hours per annual certification period.

b. HCBS Complementary and Integrative Health Waiver:

i. A maximum of 408 combined units of Acupuncture, Chiropractic, and Massage Therapy Waiver Services may be covered as a benefit during the support plan year. 8.7531.E Massage Therapy Provider Agency Requirements 1. Massage Therapy providers shall be licensed and in good standing pursuant to § 12-235-101, et seq., (C.R.S.)

HCBS Supported Living Services (SLS) Waiver, HCBS Children’s Extensive Services (CES) Waiver; Children's Habilitation Residential Program (CHRP)

a. The Medicaid State Plan therapist or physician identifies the need for the service, establishes the goal for the treatment and monitors the progress of that goal at least quarterly.

HCBS Complementary and Integrative Health Waiver a. Massage Therapy providers shall have at least year of experience practicing Massage Therapy at a rate of 520 hours per year; OR year of experience working with individuals with paralysis or other long term physical disabilities.

b. Massage Therapy Provider Agencies shall:

i. Determine the appropriate modality, amount, scope, and duration of the massage therapy service within the established limits at

Section 8.7531.D.3.2.a.

ii. Recommend only services that are necessary and appropriate in a iii. Provide only services in accordance with the Member’s prior authorized units. 8.7532 Mental Health Transitional Living Homes 8.7532.A Mental Health Transitional Living Homes Definitions 1. Mental Health Transitional Living Home (MHTL) Endorsement means documentation from the Behavioral Health Administration (BHA) recommending endorsement to the Department after the Provider Agency has met all licensing and regulatory requirements of the BHA and is licensed as a Mental Health Transitional Living Home.

Protective Oversight is as defined at Section 8.7506.B.2. 8.7532.B Mental Health Transitional Living Homes Member Eligibility 1. Mental Health Transitional Living Homes (MHTL) service is a covered benefit available to Members who meet the following requirements:

a. Members are determined functionally eligible for Community Mental Health Supports (CMHS) waiver by a Case Management Agency;

b. Members are enrolled in the HCBS Community Mental Health Supports Waiver; and c. Members require the specialized services provided under the Mental Health Transitional Living Homes as determined by assessed need. 8.7532.C Mental Health Transitional Living Homes Inclusions 1. The Mental Health Transitional Living service assists the Member to reside in the most integrated setting appropriate to their needs. Staff shall be specifically trained to support Members with a severe and persistent mental illness and who may be experiencing a mental health crisis or episode.

This residential service includes the following:

a. Protective Oversight and supervision as defined at Section 8.7506.B.2.;

b. Assistance with administering medication and medication management;

c. Assistance with community participation and support in accessing the community;

d. Assistance with recreational and social activities;

e. Housing planning and navigation services as appropriate for Members experiencing homelessness/at risk for homelessness;

f. Life skills training as defined at 8.7530.B; and g. Activities of Daily Living support as needed.

Room and board are not benefits of Mental Health Transitional Living services.

Members are responsible for room and board in an amount not to exceed the Department’s established rate.

Additional services that are available as a State Plan benefit or other HCBS Community Mental Health Supports Waiver service shall not be provided under the Mental Health Transitional Living service.
Member engagement opportunities shall be provided by the Mental Health Transitional Living home as outlined in 8.7001. 8.7532.D Mental Health Transitional Living Homes Member Rights 1. Mental Health Transitional Living Homes shall inform Members of their rights, according to Section 8.7001. Any modification of those rights shall be in accordance with Section 8.7001.B.4. , Mental Health Transitional Living Homes shall ensure the policy on resident rights is posted in a visible location so that it is always available to Members and visitors.
Mental Health Transitional Living Homes shall inform Members of all policies specific to the Mental Health Transitional Living setting upon admission to the setting, and when changes to policies are made, rules and/or policies shall apply consistently to the administrator, staff, volunteers, and Members residing in the home and their family or friends who visit. Member acknowledgement of rules and policies must be documented in the service plan or a resident agreement.
If requested by the Member, the Mental Health Transitional Living home shall provide bedroom furnishings, including but not limited to a bed, bed and bath linens, a lamp, chair and dresser and a way to secure personal possessions. 8.7532.E Mental Health Transitional Living Provider Agency Eligibility 1.
Applicants for Mental Health Transitional Living Certification shall meet the applicable standards of the rules for building, fire, and life safety code enforcement as adopted by the Colorado Division of Fire Prevention and Control.
Mental Health Transitional Living Provider Agencies must receive from the BHA a BHE license and MHTL endorsement.
No recommendation for Mental Health Transitional Living Certification shall be issued if the owner, applicant, or administrator of the Mental Health Transitional Living home has been convicted of a felony or misdemeanor involving a crime of moral turpitude or that involves conduct that the Department determines could pose a risk to the health, safety, or welfare of the members residing in the Mental Health Transitional Living home.
Provider Agencies must be certified and enrolled with the Department prior to rendering services. 6. 8.7532.F Mental Health Transitional Living Provider Agency Roles and 1. Service Requirements a. The Mental Health Transitional Living Provider Agencies shall provide Protective Oversight and Mental Health Transitional Living services to Members every day of the year, 24 hours per day.

b. Mental Health Transitional Living Provider Agencies shall maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter XXIV (2025) which is hereby incorporated by reference. Such incorporation excludes later amendments to or editions of the referenced material. Pursuant to C.R.S. § 24-4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at https://www.sos.state.co.us/CCR/DisplayRule.do?action=ruleinfo&ruleId=3 052&deptID=16&agencyID=144&deptName=Department%20of%20Public %20Health%20and%20Environment&agencyName=Health%20Facilities% 20and%20Emergency%20Medical%20Services%20Division%20(1011,%2 01015%20Series)&seriesNum=6%20CCR%201011-1%20Chapter%2026} c. Mental Health Transitional Living Provider Agencies shall not discontinue services to a Member unless documented efforts have been ineffective to resolve the conflict leading to the discontinuance of services in accordance with Section 8.7001.B. 4.

d. The Provider Agency shall encourage and assist Members’ participation in engagement opportunities and activities within the Mental Health Transitional Living home community and the wider community, when appropriate.

e. The Provider Agency shall develop emergency policies that address, at a minimum, a plan that ensures the availability of, or access to, emergency power for essential functions and all member-required medical devices or auxiliary aids.

Provider Agency Service Plan a. The service plan must outline the goals, choices, preferences, and needs of the Member. Medical information must also be included, specifically:

i. If the Member is taking any medications and how they are administered, with reference to the Medication Administration Record (MAR);

ii. Supports needed with Activities of Daily Living;

iii. Special dietary needs, if any; and iv. Incorporation of any documented physician orders.

b. Even if recommended by the Member’s physician or other practitioner, staff interventions that interfere with the Member’s choice of food, freedom to determine their own activities, or exercise of any other rights are Rights Modifications that must comply with Section 8.7001.B.

c. The service plan must contain evidence that the Member and/or their Guardian or other Legally Authorized Representative has had the opportunity to participate in the development of the plan, as evidenced by the Member’s and/or their Guardian’s or other Legally Authorized Representative’s signature on the plan. The signature may be physical or digital that includes a date and time stamp. If the Member is unable to sign the service plan because of a medical condition, any mark the Member is capable of making shall be accepted in lieu of a signature. If the Member is not capable of making a mark or performing a digital signature, the physical or digital signature of a Guardian or other Legally Authorized Representative shall be accepted.

Environmental Standards a. The Mental Health Transitional Living Provider Agency shall adhere to regulations established by the BHA in sections 2.6 and 2.26 of 2 CCR 502-1 (2025) which is hereby incorporated by reference. Such incorporation excludes later amendments to or editions of the referenced material. Pursuant to C.R.S. § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at [https://www.sos.state.co.us/CCR/DisplayRule.do?action=ruleinfo&ruleId= 2157&deptID=9&agencyID=70&deptName=Department%20of%20Human %20Services&agencyName=Behavioral%20Health&seriesNum=2%20CC R%20502-1} 4. Staffing a. The Mental Health Transitional Living home must have appropriate staffing levels to meet the individual acuity, needs and level of assistance required of the Members in the setting.

b. Staff must be trained to meet the following requirements under 2 CCR 502-1 (including those applicable to general behavioral health entity (BHE) and any additional requirements applicable to MHTLs) and for certification under Section 8.7400 prior to working independently with Members:

i. Training specific to the particular needs of the populations served, including the provision of person-centered, trauma-informed, harm reduction-focused, physically and programmatically accessible, and culturally and linguistically responsive services;

ii. Infection Control;

iii. Emergency preparedness, including de-escalation of potentially dangerous situations, including but not limited to threats of violence, acts of violence, and abuse/mistreatment of an individual;

iv. Critical Incident Reporting;

v. Suicide prevention;

vi. Individual rights of the population served;

vii. Confidentiality, including individual privacy and records privacy and security;

viii. BHE policies and procedures;

ix. Mandatory reporting requirements for suspected abuse or neglect in accordance with 2 CCR 502-1 §(2)(A) and Section 8.7411 (2025). 2 CCR 502-1 § (2)(A) (2025) hereby incorporated by reference. Such incorporation excludes later amendments to or editions of the referenced material. Pursuant to C.R.S. § 24-4- 103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave, Suite 1100, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at [https://www.sos.state.co.us/CCR/DisplayRule.do?action=ruleinfo &ruleId=2157&deptID=9&agencyID=70&deptName=Department% 20of%20Human%20Services&agencyName=Behavioral%20Healt h&seriesNum=2%20CCR%20502-1}; and x. Understanding of basic pharmacology and medications that are relevant to the treatment type and population served by the agency, including but not limited to medication-assisted treatment (MAT) services and medications for opioid use disorders (MOUD). 8.7532.G Mental Health Transitional Living Homes Reimbursement 1. Mental Health Transitional Living services are reimbursed on a per diem basis, as determined by the Department.

Additional Charges a. Provider Agencies shall not bill supplemental charges to any Members, except for amounts designated as copayments by the Department. 8.7533 Mentorship 8.7533.A Mentorship Eligibility 1. Mentorship is a covered benefit available to Members enrolled in the HCBS Supported Living Services Waiver. 8.7533.B Mentorship Definition 1. Mentorship means services that are provided to Members to promote selfadvocacy through methods such as instructing, providing experiences, modeling, and advising. 8.7533.C Mentorship Inclusions 1. Assistance in interviewing potential providers.
Assistance in understanding complicated health and safety issues.
Assistance with participation on private and public boards, advisory groups, and commissions.
Training in child and infant care for Members who are parenting children. 8.7533.D Mentorship Exclusions and Limitations 1. Mentorship services shall not duplicate Case Management or other HCBS-SLS Waiver Services.
Mentorship services are limited to 192 units (48 hours) per service-plan year.

One unit is equal to 15 minutes of service. 8.7533.E Mentorship Reimbursement 1. Training to a Member that exceeds the 192-unit limit must be authorized by the Department prior to delivery. 8.7534 Movement Therapy 8.7534.A Movement Therapy Eligibility 1. Movement Therapy is a covered benefit available to Members enrolled in one of a. Children’s Extensive Support Waiver b. Children's Habilitation Residential Program c. Supported Living Services Waiver 8.7534.B Movement Therapy Definition 1. Movement Therapy means the use of music therapy and/or dance therapy as a therapeutic tool for the habilitation, rehabilitation, and maintenance of behavioral, developmental, physical, social, communication, pain management, cognition, and gross motor skills. 8.7534.C Movement Therapy Inclusions 1. Movement Therapy includes the use of music therapy and/or dance therapy when it addresses an assessed need in the Person-Centered Support Plan. 8.7534.D Movement Therapy Exclusions and Limitations 1. Movement Therapy shall be recommended or prescribed by a therapist or physician who is an enrolled Medicaid Provider. The recommendation must include the medical or behavioral need to be addressed and expected outcome(s) from the therapy. The recommending therapist or physician must monitor the progress and effectiveness of the movement therapy at least quarterly.

Movement therapy is only authorized as a treatment strategy for a specific medical or behavioral need and identified in the Member’s care plan.
Movement Therapy is not available under the waiver if it is available under the Medicaid State Plan, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) or from a Third-Party Resource.
HCBS Children’s Extensive Services (CES) Waiver a. The following items are excluded and are not eligible for reimbursement:

i. Fitness training (personal trainer);

ii. Warm water therapy;

iii. Experimental treatments or therapies; and iv. Yoga.

HCBS Supported Living Services (SLS) Waiver:

a. The following items are excluded and are not eligible for reimbursement:

i. Acupuncture;

ii. Chiropractic care;

iii. Fitness trainer;

iv. Equine therapy;

v. Art therapy;

vi. Warm water therapy;

vii. Experimental treatments or therapies; and viii. Yoga. 8.7534.E Movement Therapy Provider Agency Requirements 1. Movement therapy shall be provided by a licensed, certified, registered, or accredited professional. Intervention shall be related to an identified medical and/or behavioral need. Movement therapy shall be reimbursed only when:

a. The provider is licensed, certified, registered or accredited, and be in good standing, by an appropriate national accreditation association.

b. The Medicaid State Plan therapist or physician identifies the need for the service, establishes the goal for the treatment and monitors the progress of that goal at least quarterly. 8.7535 Non-Medical Transportation 8.7535.A Non-Medical Transportation Eligibility 1. Non-medical Transportation (NMT) is a covered benefit available to Members a. Brain Injury Waiver b. Community Mental Health Supports Waiver c. Complementary and Integrative Health Waiver d. Developmental Disabilities Waiver e. Elderly, Blind, and Disabled Waiver f. Supported Living Services Waiver 8.7535.B Non-Medical Transportation Definition 1. Non-medical Transportation (NMT) services means transportation which enables eligible Members to gain physical access to non-medical community services and supports, as required by the Person-Centered Support Plan to prevent institutionalization. 2, Non-Medical Transportation Provider (provider) means a Provider Agency that has met all standards and requirements as specified in Section 8.7535.E. 8.7535.C Non-Medical Transportation Inclusions 1. Non-Medical Transportation is authorized for Organized Health Care Delivery System (OHCDS), for the reimbursement only for purchased bus tickets and passes.

HCBS Elderly, Blind, Disabled (EBD) Waiver; Complementary and Integrative Health (CIH) Waiver; Community Mental Health Supports (CMHS) Waiver; Brain Injury (BI) Waiver:

a. Non-Medical Transportation services shall include, but not be limited to, transportation between the Member's home and non-medical services or supports such as Adult Day Centers, shopping, activities that encourage community integration, counseling sessions not covered by State Plan, and other services as required by the care plan to prevent institutionalization.

HCBS Developmental Disabilities (DD) Waiver:

a. Non-Medical Transportation enables Members to gain access to Day Habilitation Services and Supports, Prevocational Services and Supported Employment Services to include a member’s workplace.

HCBS Supported Living Services (SLS) Waiver:

a. Non-Medical Transportation enables Members to gain access to the community, Day Habilitation Services and Supports, Prevocational Services and Supported Employment Services. 8.7535.D Non-Medical Transportation Exclusions and Limitations 1. HCBS Elderly, Blind, and Disabled (EBD) Waiver; Complementary and Integrative Health (CIH) Waiver; Community Mental Health Supports (CMHS)

Waiver; Brain Injury (BI) Waiver; HCBS Developmental Disabilities (DD) Waiver;

HCBS Supported Living Services (SLS) Waiver:

a. Non-Medical Transportation services shall not be used to substitute for Non-Emergent Medical Transportation (NEMT, as defined in Section 8.014.1 and as required under 42 C.F.R. 440.170, defined at 42 C.F.R.

Section 440.170(a)(4).

b. Whenever possible, family, neighbors, friends, or community agencies that can provide this service without charge must be utilized and documented in the Person-Centered Support Plan.

c. Non-Medical Transportation services shall only be used after the Case Manager has determined that free transportation is not available to the d. A bus pass or other public conveyance may be used only when it is more cost effective than, or comparable to, the applicable service type and duration. Costs cannot exceed the total Wheelchair Van, Mileage Band 1 allowable per service plan. The most current HCBS Rate Schedule can be found on the Department website.

e. HCBS Elderly, Blind, Disabled (EBD) Waiver; Complementary and Integrative Health (CIH) Waiver; Community Mental Health Supports (CMHS) Waiver; Brain Injury (BI) Waiver:

i. A Member is allowed no more than 104 round trip services (208 units), per support plan year, unless otherwise authorized by the f. HCBS Developmental Disabilities (DD) Waiver:

i. A Member is allowed no more than 254 round trip services (508 units) to and from Day Habilitation Services and Supports, Prevocational Services and Supported Employment Services, per certification period.

ii. Transportation acquisition services refers to the purchase or provision of transportation for participants receiving day program services under comprehensive services which enables them to gain access to programs and other community services and resources required by their Individualized Plan/Plan of Care.

Funding for transportation activities incidental to the Residential Program are included in the Residential rate.

g. HCBS Supported Living Services (SLS) Waiver:

i. A Member is allowed no more than 254 round trip services (508) units) to and from Day Habilitation Services and Supports, Prevocational Services and Supported Employment Services, per support plan year.

ii. Transportation in addition to Day Habilitation Services and Supports, Prevocational Services and Supported Employment Services is limited to no more than 104 round trip services (208 units), per support plan year and will be reimbursed at Mileage Band 1. 8.7535.E HCBS Non-Medical Transportation Provider Agency Requirements 1. Provider Agencies shall maintain all appropriate limits of auto insurance liability as specified in Provider Agency Requirements pursuant to Sections 8.7406(C-D).

Provider Agencies shall ensure that each driver rendering NMT meets the following requirements:

a. Drivers must be 18 years of age or older to render services;

b. Have at least one year of driving experience;

c. Possess a valid Colorado driver’s license;

d. Provide a copy of their current Colorado motor driving vehicle record, with the previous seven years of driving history; and e. Complete a Colorado or National-based criminal history record check.

Drivers shall be disqualified from serving as drivers for any program Members for any of the following:

a. A conviction of substance abuse occurring within the seven (7) years preceding the date the criminal history record check is completed;

b. A conviction in the State of Colorado, at any time, of any Class 1 or 2 felony under Title 18, C.R.S.;

c. A conviction in the State of Colorado, within the seven (7) years preceding the date the criminal history record check is completed, of a crime of violence, as defined in C.R.S. § 18-1.3-406(2);

d. A conviction in the State of Colorado, within the four (4) years preceding the date the criminal history record check is completed, of any Class 4 felony under Articles 2, 3, 3.5, 4, 5, 6, 6.5, 8, 9, 12, or 15 of Title 18, C.R.S.;

e. A conviction of an offense in any other state that is comparable to any offense listed in subparagraphs (f)(II)(A) through (D) within the same time periods as listed in subparagraphs (f)(II)(A) through (D) of Rules Regulating Transportation by Motor Vehicle, 4 C.C.R. 723-6; § 6114;

f. A conviction in the State of Colorado, at any time, of a felony or misdemeanor unlawful sexual offense against a child, as defined in § 18- 3- 411, C.R.S., or of a comparable offense in any other state or in the United States at any time;

g. A conviction in Colorado within the two (2) years preceding the date the criminal history record check is completed of driving under the influence, as defined in § 42-4-1301(1)(f), C.R.S.; driving with excessive alcohol content, as described in §42-4-1301(1)(g), C.R.S;

h. A conviction within the two (2) years preceding the date the criminal

history record check is completed of an offense comparable to those included in subparagraph (f)(III)(B), 4 C.C.R. 723-6; § 6114 in any other state or in the United States; and i. For purposes of 4 C.C.R. 723-6; § 6114(f)(IV), a deferred judgment and sentence pursuant to § 18-1.3-102, C.R.S., shall be deemed to be a conviction during the period of the deferred judgment and sentence.

Vehicles used during the provision of NMT must be safe and in good working order. To ensure the safety and proper functioning of the vehicles, vehicles must pass a vehicle safety inspection prior to it being used to render services.

a. Safety inspections shall include the inspection of items as described in Rules Regulating Transportation by Motor Vehicle, 4 C.C.R. 723-6; § 6104.

b. Vehicles must be inspected on a schedule commensurate with their age:

i. Vehicles manufactured within the last five (5) years: no inspection.

ii. Vehicles manufactured within the last six (6) to ten (10) years: inspected every 24 months.

iii. Vehicles manufactured eleven (11) years or longer: inspected annually.

iv. Vehicles for wheelchair transportation: inspected annually, regardless of the manufacture date of vehicle.

c. The vehicle inspector must be trained to conduct the inspection and be employed by an automotive repair company authorized to do business in Colorado.

Transportation providers who maintain a certificate or permit through the Public Utilities Commission (PUC) are not required to meet the above requirements.

PUC certificate and permit holders shall submit a copy of the Certification to the Department for verification of provider credentials. 8.7535.F Non-Medical Transportation Provider Agency Reimbursement 1. Reimbursement for Non-Medical Transportation shall be the lower of billed charges or the prior authorized unit cost at a rate not to exceed the cost of providing medical transportation services.

A Provider Agency's submitted charges shall not exceed those normally charged to the general public, other public or private organizations, or non-subsidized rates negotiated with other governmental entities.
Provider Agency charges shall not accrue when the recipient is not physically present in the vehicle.
Providers shall not bill for services before they are an approved Medicaid Provider Agency and may bill only for those NMT services performed by a qualified driver utilizing a qualified vehicle. 8.7536 Palliative/Supportive Care 8.7536.A Palliative/Supportive Care Eligibility 1. Palliative/Supportive Care is a covered benefit available to Members enrolled in the HCBS Children with Complex Health Needs Waiver. 8.7536.B Palliative/Supportive Care Definition 1. Palliative/Supportive Care means a specific program of specialized medical care for Members offered by a licensed healthcare facility or provider that is specifically focused on the provision of organized palliative care services.

Palliative care shall be focused on providing Members with relief from the symptoms, pain, and stress of serious illness, whatever the diagnosis. The goal shall be to improve the quality of life for both the Member and the family.

Palliative care may be provided to Members of any age and at any stage in a member’s illness. Palliative care services shall be provided by a Hospice or Home Care Agency staff who have received additional training in palliative care concepts such as adjustment to illness, advance care planning, symptom management, and grief/loss. For the purpose of the CwCHN waiver, Palliative Care shall include Care Coordination and Pain and Symptom Management. 8.7536.C Palliative/Supportive Care Inclusions 1. Palliative/Supportive Care may be provided together with curative treatment and includes:

a. Care Coordination i. Care Coordination includes development and implementation of a care plan, home visits for regular monitoring of the health and safety of the Member and central coordination of medical and psychological services.

ii. A Care Coordinator will organize an array of services. This approach will enable the Member to receive all medically necessary care in the community with the goal of avoiding institutionalization in an acute care hospital.

iii. Additionally, a key function of the Care Coordinator shall be to manage the majority of the responsibility, otherwise placed on the Parents, for condensing, organizing, and making accessible to providers critical information that is related to the care and necessary for effective medical management.

iv. Care Coordination does not include Case Management Agency or Case Manager responsibilities.

b. Pain and Symptom Management i. Pain and Symptom Management means nursing care in the home by a registered nurse to manage the Member’s symptoms and pain. Management includes regular, ongoing pain and symptom Assessments to determine efficacy of the current regimen and available options for optimal relief of symptoms.

ii. Management also includes as needed visits to provide relief of suffering, during which, nurses assess the efficacy of current pain management and modify the regimen if needed to alleviate distressing symptoms and side effects using pharmacological, non-pharmacological and complementary/supportive therapies. 8.7536.D Palliative/Supportive Care Provider Agency Requirements 1. Individuals providing Palliative/Supportive Care services shall be employed by or working under a formal contract with a qualified Medicaid hospice or Home Health Agency.

The services shall be provided by Hospice or Home Care Agency staff who have received additional training in palliative care concepts such as adjustment to illness, advance care planning, symptom management, and grief/loss. 8.7537 Peer Mentorship 8.7537.A Peer Mentorship Eligibility 1. Peer Mentorship is a covered service available to Members enrolled in one of the a. Brain Injury Waiver b. Community Mental Health Supports Waiver c. Complementary and Integrative Health Waiver d. Developmental Disabilities Waiver e. Elderly, Blind, and Disabled Waiver f. Supported Living Services Waiver 8.7537.B Peer Mentorship Definition 1. Peer Mentorship means support provided by peers to promote self-advocacy and encourage community living among Members by instructing and advising on issues and topics related to community living, describing real-world experiences as examples, and modeling successful community living and problem-solving. 8.7537.C Peer Mentorship Inclusions 1. HCBS Elderly, Blind, and Disabled (EBD) Waiver; Community Mental Health Supports (CMHS) Waiver; Complementary and Integrative Health (CIH) Waiver;

Brain Injury (BI) Waiver; Supported Living Services (SLS) Waiver, Developmental Disabilities (DD) Waiver:

Peer Mentorship means support provided by peers of the Member on matters of community living, including:

a. Problem-solving issues drawing from shared experience.

b. Goal Setting, self-advocacy, community acclimation and integration techniques.

c. Assisting with interviewing potential providers, understanding complicated health and safety issues, and participating on private and public boards, advisory groups and commissions.

d. Activities that promote interaction with friends and companions of choice.

e. Teaching and modeling of social skills, communication, group interaction, and collaboration.

f. Developing community-Member relationships with the intent of building social capital that results in the expansion of opportunities to explore personal interests.

g. Assisting the person in acquiring, retaining, and improving self-help, socialization, self-advocacy, and adaptive skills necessary for community living.

h. Support for integrated and meaningful engagement and awareness of opportunities for community involvement including volunteering, selfadvocacy, education options, and other opportunities identified by the individual.

i. Assisting Members to be aware of and engage in community resources. 8.7537.D Peer Mentorship Service Access and Authorizations 1. To obtain approval for Peer Mentorship, a Member must demonstrate:

a. A need for soft skills, insight, or guidance from a peer;

b. That without this service he/she may experience a health, safety, or institutional risk; and c. There are no other services or resources available to meet the need.

To establish eligibility for Peer Mentorship, the Member must satisfy general criteria for accessing service:

a. The Member is transitioning from an institutional setting to a Home and Community-Based setting, or is experiencing a qualifying change in life circumstance that affects a Member's stability and endangers their ability to remain in the community, b. The Member demonstrates a need to develop or sustain independence to live or remain in the community upon their transitioning; and c. The Member demonstrates that they need the service to establish community support or resources where they may not otherwise exist. 8.7537.E Peer Mentorship Exclusions and Limitations 1. Members may utilize Peer Mentorship up to 24 units (six hours) per day, for no more than 160 units (40 hours) per week, for no more than 365 days.

Services covered under the State Plan, another waiver service, or by other resources are excluded.

a. Services or activities that are solely diversional or recreational in nature are excluded.

b. Peer Mentorship shall not be provided by a peer who receives programming from the same residential location, day program location, or employment location as the Member. 8.7537.F Peer Mentorship Provider Agency Requirements 1. The Provider Agency must ensure services are delivered by a peer mentor staff who:

a. Has lived experience transferable to support a Member with acclimating to community living through providing them Member advice, guidance, and encouragement on matters of community living, including through describing real-world experiences, encouraging the Member’s selfadvocacy and independent living goals, and modeling strategies, skills, and problem-solving.

b. Is qualified to furnish the services customized to meet the needs of the Member as described in their Person-Centered Support Plan or Provider Care P;

c. Has completed training from the Provider Agency consistent with core competencies. Core competencies include:

i. Understanding boundaries;

ii. Setting and pursuing goals;

iii. Advocacy for Independence Mindset;

iv. Understanding of Disabilities, both visible and non-visible, and how they intersect with identity; and v. Person-centeredness. 8.7537.G Peer Mentorship Documentation 1. All documentation, including but not limited to, employee files, activity schedules, licenses, insurance policies, claim submission documents and program and financial records, shall be maintained according to Section 8.7405 and provided to supervisor(s), program monitor(s) and auditor(s), and CDPHE surveyor(s) upon request, including:

a. Start and end time/duration of services;

b. Nature and extent of services;

c. Mode of contact (face-to-face, telephone, other);

d. Description of peer mentorship activities such as accompanying Members to complicated medical appointments or to attend board, advisory and commissions meetings, and support provided interviewing potential providers;

e. Progress toward support and care plan goals and objectives; and f. Provider’s signature and date. 8.7537.H Peer Mentorship Provider Agency Reimbursement 1. Peer Mentorship services are reimbursed based on the number of units billed, with one (1) unit equal to 15 minutes of service.

Payment for Peer Mentorship shall be the lower of the billed charges or the maximum rate of reimbursement.
Reimbursement is limited to services described in the care plan. 8.7538 Personal Care 8.7538.A Personal Care Eligibility 1. Personal Care is a covered benefit available to Members enrolled in CFC. 8.7538.B Personal Care Definition 1. Personal Care means services provided to an eligible Member to meet the Member's physical, maintenance, and supportive needs through hands-on assistance, supervision and/or cueing. These services do not require a nurse’s supervision or physician's orders. 8.7538.C Personal Care Inclusions 1. Tasks included in Personal Care:

a. Eating/feeding which includes assistance with eating by mouth using common eating utensils such as spoons, forks, knives, and straws;

b. Respiratory assistance with cleaning or changing oxygen equipment tubes, filling distilled water reservoirs, and moving a cannula or mask to or from the Member’s face;

c. Preventative skin care when skin is unbroken, including the application of non-medicated/non-prescription lotions, sprays and/or solutions, and monitoring for skin changes.

d. Bladder/Bowel Care:

i. Assisting Member to and from the bathroom;

ii. Assistance with bed pans, urinals, and commodes;

iii. Changing incontinence clothing or pads;

iv. Emptying Foley or suprapubic catheter bags, but only if there is no disruption of the closed system;

v. Emptying ostomy bags; and vi. Perineal care.

e. Personal hygiene:

i. Bathing including washing, shampooing;

ii. Grooming;

iii. Shaving with an electric or safety razor;

iv. Combing and styling hair;

v. Filing and soaking nails; and vi. Basic oral hygiene and denture care.

f. Dressing assistance with ordinary clothing and the application of nonprescription support stockings, braces and splints, and the application of artificial limbs when the Member is able to assist or direct.

g. Transferring a Member when the Member has sufficient balance and strength to reliably stand and pivot and assist with the transfer. Adaptive and safety equipment may be used in transfers, provided that the Member and Direct Care Worker are fully trained in the use of the equipment and the Member can direct and assist with the transfer.

h. Mobility assistance when the Member has the ability to reliably balance and bear weight or when the Member is independent with an assistive device.

i. Positioning when the Member is able to verbally or nonverbally identify when their position needs to be changed including simple alignment in a bed, wheelchair, or other furniture.

j. Medication Reminders when medications have been preselected by the Member, a Family Member, a nurse or a pharmacist, and the medications are stored in containers other than the prescription bottles, such as medication minders, and:

i. Medication reminders are clearly marked with the day, time, and dosage and kept in a way as to prevent tampering;

ii. Medication reminding includes only inquiries as to whether medications were taken, verbal prompting to take medications, handing the appropriately marked medication minder container to the Member and opening the appropriately marked medication minder if the Member is unable to do so independently.

k. Accompanying includes the following:

i. Going with the Member to medical appointments, as indicated on the support plan, to provide one or more personal care tasks, or assist with communication, documentation, verbal prompting, and/or hands-on assistance when the task cannot be completed without the support of the Direct Care Worker; and/or ii. Going with the Member to run errands such as grocery shopping or banking and providing one or more personal care tasks as needed during the trip.

l. Homemaker Services, as described at Section 8.7527, may be provided by personal care staff, if provided during the same visit as personal care.

m. Cleaning and basic maintenance of durable medical equipment.

n. Protective Oversight means providing active line of sight supervision during which immediate intervention is required to prevent harm when a member’s disability, memory, or cognitive functioning-related behaviors or impairment place the member, others, or property at risk. Protective Oversight includes intervention time including, but limited to, verbal redirection, blocking access to hazards, removing dangerous items, or hands-on guidance. Protective Oversight shall only be approved when there is documented evidence of recurring disability-related risks requiring regular and predictable intervention within the last 12 months. The members’ service plan must include the frequency, scope and duration of intervention required..

a. For children under age 18, Protective Oversight may be authorized only when the level of supervision requiring intervention is substantially greater than what is typical for a child of the same age without disabilities. Protective Oversight cannot be authorized for routine childcare, typical parental monitoring or supervision that is age-appropriate and expected for children of the same age.

b. Protective Oversight Exclusions:

i. Protective Oversight shall not be authorized for purposes of companionship, childcare, general supervision, reassurance, emergency or crisis intervention, maintaining line of sight supervision without an intervention, or routine monitoring that is not necessary to address a disability-related safety risk.

ii. Protective Oversight shall not include any restrictive practices unless a documented Rights Modification per 8.7001.A.17. is in place prior to the provision of services.

iii. Protective Oversight alone cannot be the sole reason for the visit/services.

o. Personal Care Services includes the option for the Acquisition, Maintenance, and Enhancement of Skills (AME) task when the support is related to functional skills training and is desired by the member to accomplish Personal Care tasks to increase their independence and reduce supports needed in the home and i. Detailed, task-related goals shall be documented by case manager in the Person-Centered Support Plan, including documentation monitoring progress and any decrease in human assistance previously authorized.

ii. AME services shall include direct training and instruction to the Member in performing Personal Care tasks.

iii. The provider or attendant shall be physically present to provide step-by-step verbal or physical instructions throughout the entire task.

All tasks must meet Age-Appropriate Task Standards for Children for Members under 18 or Task Standards for Adults for Members age 18 and older. If in Section 8.7607.A.
Authorization of Personal Care tasks for Members under 18 must be limited to services that exceed those considered part of Parental or Legal Guardian of a Minor Responsibility as defined in Section 8.7502.KK. 8.7538.D Personal Care Exclusions and Limitations 1. Personal Care services shall not include any skilled care. Skilled care is available through Health Maintenance Activities services and is defined in

Section 8.7523. Health Maintenance Activities shall not be provided as Personal Care services under CFC regardless of the level of the training, certification, or supervision of the Personal Care employee.

All hours provided and reimbursed by Medicaid must be for covered services and must be necessary to meet the Member's needs.
Personal Care Provider Agencies may decline to perform any specific task, if the supervisor or the personal care staff feels uncomfortable about the safety of the Member or the personal care staff, regardless of whether the task may be included in the definition above.
Family Members must provide Personal Care in accordance with the following:

a. Family Members may be employed by Personal Care Agencies that are licensed and certified, as applicable to programs offered by the agency, to provide Personal Care Services to relatives enrolled a waiver subject to the conditions below.

b. The Family Member shall meet all requirements for employment by a Personal Care Agency that is licensed and certified, as applicable to programs offered by the agency, and shall be employed and supervised by the Personal Care Agency.

c. The Family Member providing personal care shall be reimbursed, an hourly rate, by the Personal Care Agency which employs the Family Member, with the following restrictions:

i. The reimbursement for Personal Care units shall cover the Personal Care Agency’s costs for unemployment insurance, worker's compensation, FICA, training and supervision, and all other administrative costs.

ii. When CFC funds are utilized for reimbursement of Personal Care services provided by the Member’s family, the home care allowance may not be used to reimburse the family.

Billing for travel time to and from the Member’s home at the beginning and end of the visit is prohibited. Accompaniment of a Member by a Direct Care Worker in the community is reimbursable. Provider Agencies must follow all Department of Labor and Employment guidelines on time worked.
This service is subject to the following Annual CFC Service Soft Caps: Members shall not be authorized for more than 2,500 hours of Personal Care per PCSP year. Case Managers may request additional hours through the Department prescribed exception process as defined at Section 8.7607.A.
Caregivers must adhere to the Weekly Caregiver Limit and Per Day Hourly Limit 8.7538.E Personal Care Provider Agency Requirements 1. In addition to the training requirements described in Section 8.7409 HCBS Provider Agency Requirements, Personal Care Provider Agencies must be licensed and certified, as applicable to programs offered by the agency, through Colorado Department of Public Health and Environment. Personal Care Provider Agencies shall assure and document that all Personal Care staff have received at least twenty hours of training, or have passed a skills validation test, in the provision of unskilled Personal Care as described in Sections 8.7538.C and 8.7538.D. Training, or skills validation, shall include the areas of bathing, skin care, hair care, nail care, mouth care, shaving, dressing, feeding, assistance with ambulation, exercises and transfers, positioning, bladder care, bowel care, medication reminding, homemaking, and Protective Oversight. Training shall also include instruction in basic first aid, and training in infection control techniques, including Universal Precautions. Training or skills validation shall be completed prior to service delivery, except for components of training that may be provided in the Member's home, in the presence of the supervisor.

a. All employees providing personal care shall be supervised by a person who, at a minimum, has received the training, or passed the skills validation test, required of personal care staff, as specified above.

Supervision shall include, but not be limited to, the following activities:

i. Orientation of staff to Agency policies and procedures.

ii. Arrangement and documentation of training.

iii. Informing staff of policies concerning advance directives and emergency procedures.

iv. Oversight of scheduling, and notification to Members of changes; or close communication with scheduling staff.

v. Written assignment of duties on a Member-specific basis.

vi. Meetings and conferences with staff as necessary.

vii. Supervisory visits to Member's homes at least every three months, or more often as necessary, for problem resolution, skills validation of staff, Member specific or procedure-specific training of staff, observation of Member's condition and care, and Assessment of Member's satisfaction with services. At least one of the assigned personal care staff must be present at supervisory visits at least once every three months.

Supervision should be flexible to the needs of the member and may be conducted via phone, video conference, telecommunication, or in person.

a) If there is a safety concern with the services, the Provider Agency must make every effort to conduct an in-person Assessment.

b) The Provider Agency must conduct Direct Care Worker (DCW) supervision to ensure that Member care and treatment are delivered in accordance with a plan of care that addresses the Member’s needs.

viii. Investigation of Complaints and Incidents.

ix. Counseling with staff on difficult cases, and potentially dangerous situations.

x. Communication with the Case Managers, the physician, and other providers on the care plan, as necessary to assure appropriate and effective care.

xi. Oversight of record keeping by staff.

b. A Personal Care Agency may be denied or terminated from participation in Colorado Medicaid, according to Section 8.7403. Additionally, personal care agencies may be terminated for the following:

i. Improper Billing Practices:

Billing for visits without documentation to support the claims billed. Acceptable documentation for each visit billed shall include the nature and extent of services, the care provider's signature, the month, day, year, and the exact time in and time out of the Member's home. Providers shall submit or produce requested documentation in accordance with rules at Section 8.7400.
Billing for excessive hours that are not justified by the documentation of services provided, or by the Member's medical or functional condition. This includes billing all units prior authorized when the allowed and needed services do not require as much time as that authorized.
Billing for time spent by the personal care provider performing any tasks that are not allowed according to regulations in Section 8.7538. This includes but is not limited to companionship, financial management, transporting of Members, skilled personal care, or delegated nursing tasks.
Unbundling of home health aide and personal care or homemaker services, which is defined as any and all of the following practices by any personal care/homemaker Agency that is also certified as a Medicaid Home Health Agency, for all time periods during which regulations were in effect that defined the unit for home health aide services as one visit up to a maximum of two and one-half hours:

a) One employee makes one visit, and the Agency bills Medicaid for one home health aide visit and bills all the hours as personal care or homemaker.

b) One employee makes one visit, and the Agency bills for one home health aide visit, and bills some of the hours as personal care or homemaker, when the total time spent on the visit does not equal at least 2 1/2 hours plus the number of hours billed for personal care and homemaker.

c) Two employees make contiguous visits, and the Agency bills one visit as home health aide and the other as personal care or homemaker, when the time spent on the home health aide visit was less than 2 1/2 hours.

d) One or more employees make two or more visits at different times on the same day, and the Agency bills one or more visits as home health aide and one or more visits as personal care or homemaker, when any of the aide visits were less than 2 1/2 hours and there is no reason related, to the Member's medical condition or needs that required the home health aide and personal care or homemaker visits to be scheduled at different times of the day.

e) One or more employees make two or more visits on different days of the week, and the Agency bills one or more visits as home health aide and one or more visits as personal care or homemaker, when any of the aide visits were less than 2 1/2 hours and there is no reason related to the Member's medical condition or needs that required the home health aide and personal care or homemaker visits to be scheduled on different days of the week.

f) Any other practices that circumvent these rules and result in excess Medicaid payment through unbundling of home health aide and personal care or homemaker services.

For all time periods during which the unit of reimbursement for home health aide is defined as hour and/or half-hour increments, all the practices described in 4 above shall constitute unbundling if the home health aide does not stay for the maximum amount of time for each unit billed.
Billing for travel time Accompaniment of a Member by a Direct Care Worker in the community is reimbursable.

Provider Agencies must follow all Department of Labor and Employment guidelines on time worked.

ii. Refusal to Provide Necessary and Allowed Personal Care or Homemaker Services Without Also Receiving Payment for Home Health Services.

A personal care/homemaker agency that is also certified as a Medicaid Home Health Agency may be terminated from Medicaid participation if the agency refuses to provide necessary and allowed HCBS personal care or homemaker services to Members who do not need Home Health services or who receive their Home Health services from a Home Health Agency not affiliated with the personal care/homemaker agency.

iii. Prior Termination from Medicaid Participation.

A personal care/homemaker agency shall be denied or terminated from Medicaid participation if the agency or its owner(s) have been previously involuntarily terminated from Medicaid participation, regardless of the provider type of the entity that was terminated.

iv. Abrupt Prior Closure 1) A personal care/homemaker agency may be denied or terminated from Medicaid participation if the agency or its owner(s) have abruptly closed without proper prior Member notification regardless of the provider type of the entity that closed abruptly.

A personal care/homemaker agency may be denied or terminated from Medicaid participation if:

a. The agency scheduled or reimbursed a single caregiver for more than 16 hours of care in a calendar day for one or more members collectively across Personal Care, Homemaker, Health Maintenance Activities, Private Duty Nursing, and/or Long-Term Home Health except in an Emergency Situation as defined at Section 8.7419.

b. The agency scheduled or reimbursed a single caregiver for more than 56 hours of direct care per week per member across Personal Care, Homemaker, Health Maintenance Activities, LTHH-Home Health Aide, and/or LTHH-Nursing Services except with an approved or pending Weekly Caregiver Limit Exception Request or in an Emergency Situation 8.7538.F Personal Care Reimbursement Requirements 1. Payment for personal care services shall be the lower of the billed charges or the maximum rate of reimbursement. Reimbursement shall be per unit of 15 minutes.

The maximum unit rate shall be adjusted by the State as funding becomes 2. Payment does not include travel time to or from the Member's residence.

When personal care services are used to provide respite for unpaid primary caregivers, the exact services rendered must be specified in the documentation.
If a visit by a personal care staff includes some homemaker and personal care services, the visit shall be billed separately in accordance with services provided.
If a visit by a Home Health Aide from a Home Health Agency includes unskilled personal care, as defined in this section, only the Home Health Aide visit shall be billed.
There shall be no reimbursement under this section for personal care services provided in certified, uncertified, licensed, or unlicensed Congregate Facilities. 8.7539 Prevocational Services 8.7539.A Prevocational Service Eligibility 1. Prevocational services are available as a covered benefit to Members enrolled in a. Developmental Disabilities Waiver b. Supported Living Services Waiver 8.7539.B Prevocational Service Definition 1. Prevocational services are provided to prepare a Member for paid community employment by increasing general employment skills. Prevocational Services are directed to habilitative rather than explicit employment objectives and are provided in a variety of locations separate from the Member’s private residence or other residential living arrangement. 8.7539.C Prevocational Service Inclusions 1. Prevocational Services consist of teaching concepts associated with performing compensated work including attendance, task completion, problem solving, and safety skills. 8.7539.D Prevocational Service Access and Authorizations 1. Prevocational Services are provided to support the Member to obtain paid community employment within five (5) years. Prevocational services may continue longer than five (5) years when documentation in the annual Person- Centered Support Plan demonstrates this need based on an annual assessment.
A comprehensive assessment and review for each person receiving Prevocational Services shall occur at least once every five (5) years to determine whether or not the person has developed the skills necessary for paid community employment.
Documentation shall be maintained in the file of each Member that the service is not available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (IDEA) (20 U.S.C.

Section 1400 et seq.). 8.7539.E Prevocational Service Requirements 1. Members shall be compensated for work in accordance with applicable federal laws and regulations and at less than fifty (50) percent of the minimum wage.

Providers that pay less than minimum wage shall ensure compliance with the Department of Labor Regulations and § 8-6-108.7 C.R.S. 8.7539.F Prevocational Service Exclusions and Limitations 1. Prevocational Services are not primarily directed at teaching job specific skills.

One unit is equal to fifteen minutes of service. The following unit limitations apply:

a. Supported Living Services Waiver:

i. Prevocational services, in combination with other Day Habilitation services as defined at Section 8.7517 and Supported Employment services, are limited to 7,112 units per support plan year.

b. Developmental Disabilities Waiver:

i. Prevocational services, in combination with Day Habilitation services as defined in Section 8.7517, are limited to four thousand eight hundred (4,800) units.

ii. When used in combination with Supported Employment services as defined in Section 8.7549, the total number of units available for Prevocational services in combination with Day Habilitation services will remain at 4,800 units, and the cumulative total, including Supported Employment services, may not exceed 7,112 8.7539.F Prevocational Service Provider Agency Requirements 1. Providers of Prevocational Services Program Management shall have either:

a. Baccalaureate or higher degree from an accredited college or university in the area of Vocational Rehabilitation, Education, Social Work, Psychology, or related field and one year of successful experience in human services, b. An associate’s degree from an accredited college and two years of successful experience in human services, or c, Four years successful experience in human services. 8.7540 Primary Caregiver Education 8.7540.A Primary Caregiver Education Eligibility 1. Primary Caregiver Education is a covered benefit available to Members enrolled in the HCBS Children’s Extensive Support Waiver. 8.7540.B Primary Caregiver Education Definition 1. Primary Caregiver Education provides education in techniques that enhance the ability of Parents and other primary caregivers to support a Member's needs and strengths. 8.7540.C Primary Caregiver Education Inclusions 1. Primary Caregiver Education is authorized for Organized Health Care Delivery System (OHCDS). 2, Primary Caregiver Education includes:

a. Consultation and direct service costs for training Parents or other primary caregivers in techniques to assist in caring for the Member’s needs, including sign language training, b. Special resource materials, c. Cost of registration for Parents or other primary caregivers to attend conferences or educational workshops that are specific to the Member’s disability, and d. Cost of membership to caregiver support or information organizations and publications designed for Parents and primary caregivers of children with disabilities. 8.7540.D Primary Caregiver Education Exclusion/Limitations 1. The maximum service limit for Primary Caregiver Education is $1,000 per support plan year.

The following items are specifically excluded and not eligible for reimbursement:

a. Transportation;

b. Lodging;

c. Food; and d. Membership to any political organizations or any organization involved in lobby activities. 8.7541 Residential Habilitation Service and Supports 8.7541.A Residential Habilitation Service and Supports Eligibility 1. Residential Habilitation Service and Supports is a covered benefit available to Members enrolled in the HCBS Developmental Disabilities Waiver. 8.7541.B Residential Habilitation Service and Supports Definition 1. Residential Habilitation Service and Supports (RHSS) provide service, supports, and supervision up to 24 hours per day. 8.7541.C Residential Habilitation Service and Supports Inclusions 1. Services are provided to ensure the health, safety and welfare of the Member, and to provide training and habilitation services or a combination of training (i.e., instruction, skill acquisition) and supports in the areas of personal, physical, mental and social development and to promote independence, self-sufficiency and community inclusion. Services and supports are designed to meet the unique needs of each Member determined by the assessed needs, personal goals, and other input provided by the Member Identified Team and to provide access to and participation in typical activities and functions of community life.

Members receiving Residential Habilitation Service and Supports must have up to 24-hour supervision. Supervision may be on-site (direct service provider or caregiver is present) or accessible (direct service provider or caregiver is not on site but available to respond when needed). Staffing arrangements must be adequate to meet the health, safety and welfare of the Member and the needs of the Member as determined by the Person-Centered Support Plan. The Provider Agency is responsible for verifying that any direct care provider they employ or contract with has the capacity to serve the Members in their care, as described in the care plan.
Members are presumed able to manage their own funds and possessions unless otherwise documented in the Person-Centered Support Plan and Provider Care 4. Residential Habilitation Service and Supports includes medical and health care services that are integral to meeting the daily needs of the Member.

a. Individual Residential Support Services (IRSS)

i. IRSS includes skilled care that may be performed by a Certified Nursing Assistant (CNA) or lower.

b. Group Residential Services and Supports (GRSS)

ii. GRSS includes nursing services set forth at 6 C.C.R. 1011-1

Chapter 8, Part 16. 8.7541.D Residential Habilitation Service and Supports Provider Agency 1. The Provider Agency must send documented notification to the Member, Guardians, other Legally Authorized Representatives, and the Case Manager at least 30 days prior to proposed changes in setting placements.

a. If an immediate move is required for the protection of the Member, the Provider Agency must send documented notification to the Member, Guardians, other Legally Authorized Representatives, and the Case Manager as soon as possible before the move or no later than three days after the move.

b. The Provider Agency must include the Member, Guardians, and other Legally Authorized Representatives, as appropriate, in planning subsequent placements. Any Member of the Member Identified Team may request a meeting to discuss the change in placement.

c. When a Member moves settings or providers, all residential providers involved must be present for the move, or designate a Legally Authorized Representative to be present, and must ensure all possessions, medications, money and pertinent records are transferred to the Member within 24 hours.

d. A Member, Guardians, or other Legally Authorized Representative, as appropriate, wishes to contest a change in setting shall follow the Grievance procedure of the Agency.

The Provider Agency is responsible for monitoring conditions at the setting to ensure compliance and must provide oversight and guidance to safeguard the health, safety, and welfare of the Member.
The Provider Agency must provide for and document the regular on-site monitoring of Residential Habilitation Service and Supports. Provider’s must conduct an on-site visit of each IRSS or GRSS setting before a Member moves in, and at a minimum once every quarter, with at least one visit annually that is unscheduled. On-site monitoring of IRSS and GRSS settings must include, but not be limited to:

a. Inspection of all smoke alarms and carbon monoxide detectors;

b. Ensuring all exits are free from blockages to egress;

c. Review of each Member’s emergency and disaster Assessment; and d. Medication administration records and physician orders. 8.7542 Individual Residential Service and Supports (IRSS) 8.7542.A Individual Residential Service and Supports (IRSS) Eligibility 1. Individual Residential Service and Supports (IRSS) is a covered benefit available to Members enrolled in the HCBS Developmental Disabilities Waiver. 8.7542.B Individual Residential Service and Supports (IRSS) Definitions 1. Individual Residential Service and Supports (IRSS) use a variety of living arrangements to meet the unique needs for support, guidance and habilitation of each Member.

a. IRSS settings include, but are not limited to:

i. A setting owned, leased or controlled by the Provider Agency;

ii. A setting of a Family member;

iii. The Member’s own setting; or iv. A Host Home.

The Host Home is the primary setting of the provider, which means that the Host Home provider occupies the setting 75 percent of the time. The Host Home provider may not contract to provide services to more than three Members, inside or outside of the Host Home, at any given time. 8.7542.C Individual Residential Service and Supports (IRSS) Provider Agency 1. Oversight a. The Provider Agency is responsible for controlling the daily operations and management of the Provider Agency and all residential settings in which the Provider Agency employees or contractors provide services. The provider must provide sufficient oversight and guidance and have established written procedures to ensure that the health and medical needs of the Member are addressed. This includes:

i. Each Member must have a primary physician;

ii. Each Member must receive a medical evaluation at least annually unless a greater or lesser frequency is specified by their primary physician. If the physician specifies an annual evaluation is not needed, a medical evaluation must be conducted no less frequently than every two years;

iii. Each Member must be encouraged and assisted in getting a dental evaluation annually;

iv. Other medical and dental assessments and services must be completed as the need for these is identified by the physician, dentist, other medical support personnel or the Member Identified Team; and v. Records must contain documentation of:

medical services provided;
results of medical evaluations/assessments and of follow-up services required, if any;
acute illness and chronic medical problems; and, 4) weight taken annually or more frequently, as needed.

b. The Provider Agency shall make available to Members nutritionally balanced meals. Based on an Assessment of the Members capabilities, preferences and nutritional needs, the provider may provide guidance and support to monitor nutritional adequacy.

i. Therapeutic diets must be prescribed by a licensed physician or dietician.

ii. Even if recommended by the Member’s physician or other practitioner, staff interventions that interfere with the Member’s choice of food, freedom to determine their own activities, or exercise of any other rights are Rights Modifications that must comply with Section 8.7001.B.

c. IRSS may be provided to no more than three Members in a single setting.

For each Member in a setting, the Provider Agency must ensure the following criteria are met and documented:

i. The Members involved elect to live in the setting;

ii. Each Member must have their own bedroom, unless they elect to share a bedroom with a roommate of their choice, which must be documented in the service plan;

iii. Back-up providers are identified, available and agreed upon by the Member and provider. When a back-up provider is not available, the Provider Agency assumes responsibility for identifying a provider;

iv. The Provider Agency and Case Management Agency of each Member in the setting must be involved in the coordination of placement of each Member;

v. Members are afforded regular opportunities for community inclusion of their choice;

vi. Members are afforded individual choice, including preference to live near family;

vii. Distance from other settings (e.g., apartments, houses) of Members is examined so that persons with Developmental Disabilities are not grouped in a conspicuous manner;

d. For the placement of a Member into a three-person setting, the following factors must be examined and documented to determine reasonableness of the placement:

i. Level of Care and needs of each Member in the setting;

ii. Availability to support and provide supervision to Members; and, iii. Each Member's ability to evacuate.

e. When three Members reside in a single setting, the Provider Agency must conduct monthly monitoring of the setting.

f. Upon enrollment in services, the Provider Agency must assess each Member's ability to care for their safety needs and take appropriate action in case of an emergency. The Assessment must be kept up to date and, at a minimum, address the following emergencies and disasters:

i. Fire;

ii. Severe weather and other natural disasters;

iii. Serious accidents and illness;

iv. Assaults; and, v. Intruders.

g. There must be a written plan for each Member addressing how the emergencies specified above will be handled. The plans must be based on an assessment, maintained current and shall, at minimum, address:

i. Specific responsibilities/actions to be taken by the Member, approved caregivers or other providers of supports and services in case of an emergency;

How the Member will evacuate in case of fire by specifying, at minimum, two exit routes from floors used for sleeping and the level of assistance needed; and 2) Telephone access (by the Member or with assistance) to the nearest poison control center, police, fire and medical h. Safety plans and evacuation procedures must be reviewed and practiced at sufficient frequency and varying times of the day, but no less than once a quarter, to ensure all persons with responsibilities for carrying out the plan are knowledgeable about the plan and capable of performing it. All safety plans must be on site at the setting and be reviewed by the Provider Agency during each on-site monitoring visit.

i. Each Provider Agency must provide quarterly housing and Member updates to the Department or its agent through a specified data collection platform. Failure to provide these quarterly updates may result in payment suspension.

Contracts a. The Provider Agency must have a written contract with each direct service provider that is not directly employed by the Provider Agency and is providing IRSS under the Provider Agency’s authority, regardless of the setting type. This includes but is not limited to Host Home providers and Family caregivers not directly employed by the Provider Agency.

i. A current list of the above-mentioned contracted IRSS providers and their accompanying contracts must be on file with the program approved Provider Agency and a copy must be provided to the Department or its agent upon request.

ii. Each contract must be in writing and contain the following information:

Name of contracted IRSS provider;
Responsibilities of each party to the contract, including, but not limited to, responsibility for the safety and accessibility of the physical environment of the setting;
An agreement outlining the living arrangements, monitoring of the home, IRSS provider’s duties, and any limitations on the IRSS providers duties;
Expectations that Members be provided opportunities for informed choice over a variety of daily choices similar to those exercised by non-Members;
Process for correcting non-compliance;
Process for termination of the contract;
Process for modification or revision of the contract;
Process for relocation of the Member if they are in immediate jeopardy of actual or potential for serious injury or harm;
Process for coordinating the care of the Member;
Payment rate and method;
Beginning and ending dates; and 12) A clause that states the contracted IRSS provider shall not sub-contract with any entity to perform in whole the work or services required under the IRSS benefit.

iii. If a contract is terminated with a contracted IRSS provider due to health, safety or welfare concerns, the provider must report to the following parties:

Within four days to the Department or its agent regarding the cited reason for termination of a contracted IRSS provider.
Within four days to the Guardian or other Legally Authorized Representative and Case Manager of the Member.

iv. The Provider Agency must require each contracted direct service provider providing IRSS to document each approved caregiver(s) and report to the Provider Agency the names of all persons that reside in the setting. Members and/or Guardians have a right to request and receive from the rendering provider a list of all direct service and backup providers that are approved to provide them services. No backup provider may be hired without provider approval. The Provider Agency must ensure criminal background checks are completed for any non-Member over the age of eighteen (18) who lives in the setting.

v. The IRSS direct service provider is prohibited from conduct that would pose a risk to the health, safety and welfare of the Member including the Members mental health.

Living Environment a. The Provider Agency has the responsibility for the living environment, regardless of the setting type.

b. Settings of Members must, at minimum, meet standards set forth in the Colorado Division of Housing (DOH) IRSS Inspection Protocol. The following setting types must pass the Division of Housing IRSS Inspection Protocol every two years:

i. All Host Homes; and ii. All IRSS settings that are owned or leased by a provider.

All IRSS settings must be announced to and recorded by Division of Housing within 90 days of activation by a provider and the placement of a Member 2) An inspection by Division of Housing is not required prior to the placement of a Member if the setting has been inspected by the provider and passes all residential safety c. The Provider Agency must have a protocol in place for the emergency placement of the Member if a setting is deemed not safe by the Division of Housing (DOH)

d. The setting (exterior and interior) and grounds must:

i. Be maintained in good repair;

ii. Protect the health, comfort and safety of the Member; and iii. Be free of offensive odors, accumulation of dirt, rubbish and dust.

e. There must be two means of exit from floors with rooms used for sleeping.

Exits must remain clear and unobstructed.

f. The Provider Agency must ensure entry to the setting and an emergency exit is accessible to Members, including Members utilizing a wheelchair or other mobility device.

g. Bedrooms must meet minimum space requirements (single 100 square feet, double 80 square feet per person). (Not applicable for studio apartments.)

h. Adequate and comfortable furnishings and supplies must be provided and maintained in good condition.

i. A fire extinguisher must be available in each setting. Presence of an operational fire extinguisher shall be confirmed by the provider during each on-site monitoring visit.

i. Provider Agencies must follow manufacturer specifications and expiration dates for all fire extinguishers.

j. Smoke alarms and carbon monoxide detectors must be installed in the proper locations in each home to meet Housing and Urban Development (HUD) requirements and/or local ordinances. Smoke and carbon monoxide detectors shall be tested during each on-site monitoring visit by the provider. 8.7543 Group Residential Services and Supports (GRSS) 8.7543.A Group Residential Services and Supports Eligibility 1. Group Residential Services and Supports (GRSS) is a covered benefit available to Members enrolled in the HCBS Developmental Disabilities Waiver. 8.7543.B Group Residential Services and Supports Definitions 1. Group Residential Services and Supports (GRSS) means residential habilitation provided in group living environments of four (4) to eight (8) Members receiving services who live in a single residential setting, which is licensed by the Colorado Department of Public Health and Environment (CDPHE) as a residential care facility or residential community setting for Members with Developmental a. GRSS is a licensed setting and must comply with all regulations set forth at 6 C.C.R. 1011-1 Chapter 8. 8.7543.C Group Residential Services and Supports Provider Reimbursement 1. Reimbursement for GRSS does not include the cost of normal facility maintenance, upkeep and improvement, other than such costs for modifications or adaptations to a facility required to assure the health and safety of Members or to meet the requirements of the applicable life safety code.

Reimbursement does not include room and board. 8.7544 Remote Supports 8.7544.A Remote Supports Eligibility 1. Remote Supports is a covered benefit available to Members enrolled in CFC. 8.7544.B Remote Support Definitions 1. Backup Support Person means the person who is responsible for responding in the event of an emergency or when a Member receiving Remote Supports otherwise needs assistance or the equipment used for delivery of Remote Supports stops working for any reason.
Monitoring Base means the off-site location from which the Remote Supports Provider monitors the Member.
Remote Supports means the provision of support by staff at a HIPAA compliant Monitoring Base who engage with a Member through live two-way communication to provide prompts and respond to the Member’s health, safety, and other needs identified through a Person-Centered Support Plan to increase their independence in their home and community when not engaged in other HCBS services.
Remote Supports Service Plan means a document that describes the Member’s need for remote support, devices that will be used, number of service hours, emergency contacts, and a safety plan developed between the Member and Remote Supports Provider Agency in consultation with their Case Manager.
Remote Supports Provider means the Provider Agency selected by the Member to provide Remote Supports. This provider supplies the monitoring base, the remote support staff who monitor a Member from the monitoring base, and the remote support technology equipment necessary for the receiving Remote Supports, 6. Sensor means equipment used to notify the Remote Supports Provider of a situation that requires attention or activity which may indicate deviations from routine activity and/or future needs. Examples include but are not limited to, seizure mats, door sensors, floor sensors, motion detectors, heat detectors, and smoke detectors. 8.7544.C Remote Supports Inclusions 1. Remote Supports that help a Member with Activities of Daily Living and Instrumental Activities of Daily Living tasks that can be completed through virtual two-way live communication with prompts, supervision, or coaching from a Remote Supports Provider are a covered benefit.
Remote Supports includes prompting, coaching, and virtual supervision with Activities of Daily Living and Instrumental Activities of Daily Living either in a Member’s home or community that are documented in the Member’s Remote Supports Service Plan.
Remote Supports Technology services shall include but are not limited to the following technology options:

a. Motion sensing system;

b. Radio frequency identification;

c. Live audio feed;

d. Web-based system; or, e. Another device that facilitates two-way communication.

Remote Supports includes the following general provisions:

a. Remote Supports shall only be approved when it is the Member’s preference and will reduce the assessed need for in-person care.

b. The Member, their Case Manager, and the selected Remote Supports Provider shall determine whether Remote Supports is sufficient to ensure the Member's health and welfare.

c. Remote Supports shall be provided in real time by awake staff at a Monitoring Base using the appropriate technology. While Remote Supports is being provided, the Remote Supports staff shall not have duties other than the provision of Remote Supports. 8.7544.D Remote Supports Exclusions and Non-Benefit Items 1. Remote Supports shall be authorized for Members who have the physical and mental capacity to utilize the particular system(s) that meet needs identified during the person-centered planning process, and which the Member prefers to be met with virtual support. .

Remote Supports shall not be authorized under CFC if the service or device is available as a state plan Medicaid benefit.
Remote Supports shall not be performed concurrently or be duplicative of any other HCBS benefit or service. 4, Remote Supports shall not provide any service that is authorized for Telehealth at

Section 8.7562.

Remote Supports Technology shall only be used for the delivery of Remote Supports.
Remote Supports is available to Members to foster developmentally appropriate independence and not to replace informal support.
Video or audio monitoring and recording is not allowed. Interactions between the Remote Support Provider and the Member should be through live, two-way communication that is on-demand, scheduled, or alerted by a sensor as agreed to by the Member in the Remote Supports Service Plan.
Devices used for communication shall not be mounted in a bedroom or bathroom and must be able to be moved by the Member to a location of their choice.
The following are not benefits of Remote Supports:

a. The cost of meals, household supplies, cell phones, internet access, landline telephone lines, and cellular phone voice or data plans.

b. Augmentative communication devices and communication boards;

c. Hearing aids and accessories;

d. Phonic ears;

e. Environmental control units;

f. Computers and computer software unrelated to the provision of Remote Supports;

g. Wheelchair lifts for automobiles or vans;

h. Exercise equipment, such as exercise cycles;

i. Hot tubs, Jacuzzis, or similar items. 8.7544.E Remote Supports Provider Agency Requirements 1. The Remote Supports Provider must comply with the Provider Agency Regulations at Section 8.7400 et seq. and the provider enrollment agreement.

The Remote Supports Provider shall meet with the Member to identify Remote Supports service needs and develop services in a Remote Supports Service Plan that will be sent to the Member’s Case Manager. The Remote Supports Care Plan must include:

a. The location(s) where the Member will receive the service, b. A description of tasks/services the Remote Supports Provider will perform for the Member, c. The technology devices determined necessary to help the Member meet their identified need d. Family or providers with whom the Member has authorized the Remote Supports Provider to share information with and a safety plan that includes emergency contact information and medical conditions, if any, that should be shared with emergency response personnel if the provider must contact them, and e. An up-to-date list of Backup Support Person(s). Backup support may be provided on an unpaid basis by a Family Member, friend, or other person selected by the Member or on a paid basis by an Agency provider.

Remote Supports Providers shall conform to the following standards for electronic monitoring services:

a. Properly trained individuals shall install all equipment, materials, or appliances, and the installer and/or provider of electronic monitoring shall train the Member in the use of the device.

b. All equipment, materials, or appliances shall be tested for proper functioning at the time of installation, and at periodic intervals after that, and be maintained based on the manufacturer’s recommendations. Any malfunction shall be promptly repaired, and equipment replaced when necessary, including buttons and batteries.

c. All telephone calls generated by monitoring equipment shall be toll-free, and all Members shall be allowed to run unrestricted tests on their equipment.

d. Remote Supports Providers shall send written information to each Member's Case Manager about the system, how it works, and how it will be maintained in the Remote Support Plan.

e. The Remote Support Provider shall provide a Member who receives Remote Supports with initial and ongoing training on how to use the Remote Supports system(s) including regular confirmation that the Member knows how to turn systems on and off.

The Remote Supports Provider shall provide initial and ongoing training to its staff to ensure they know how to use the Monitoring Base System.
The Remote Supports Provider shall have a backup power system (such as battery power and/or generator) in place at the Monitoring Base in the event of electrical outages. The Remote Supports Provider shall have additional backup systems and additional safeguards in place which shall include, but are not limited to, contacting the Backup Support Person in the event the Monitoring Base System stops working for any reason.
The Remote Support Provider shall have an effective system for notifying emergency personnel in the event of an emergency.
If a known or reported emergency involving a Member arises, the Remote Supports Provider shall immediately assess the situation and call emergency personnel first, if that is deemed necessary, and then contact the Backup Support Person. The Remote Supports Provider shall maintain contact with the Member during an emergency until emergency personnel or the Backup Support Person arrives.
The Backup Support Person shall verbally acknowledge receipt of a request for assistance from the Remote Supports Provider. Text messages, email, or voicemail messages will not be accepted as verbal acknowledgment.
When a Member requests in-person assistance, the Backup Support Person shall arrive at the Member's location within a reasonable amount of time based on team agreement to be specified in documentation maintained by the Remote Support Provider.
When a Member needs assistance, but the situation is not an emergency, the Remote Supports Provider shall:

a. Address the situation from the Monitoring Base, or, b. Contact the Member’s Backup Support Person if necessary.

The Remote Support Provider shall maintain detailed and current written protocols for responding to a Member's needs, including contact information for the Backup Support Person to provide assistance.
The Remote Support Provider shall maintain documentation of the protocol to be followed should the Member request that the equipment used for delivery of Remote Supports be turned off.
The Remote Supports Provider shall maintain daily service provision documentation that shall include the following:

a. Type of Service, b. Date of Service, c. Place of Service, d. Name of Member receiving service, e. Medicaid identification number of Member receiving service, f. Name of Remote Supports Provider, g. Identify the Backup Support Person and their contact information, if/when utilized.

h. Begin and end time of the Remote Supports service, i. Begin and end time of the Remote Supports service when a Backup Support Person is needed on site, j. Begin and end time of the Backup Support Person when on site, whether paid or unpaid, k. Number of units of Remote Supports service delivered per calendar day, l. Description and details of the outcome of providing Remote Supports, and any new or identified needs that are outside of the Member’s current Person-Center Support Plan, which shall be communicated to the Member’s Case Manager. 8.7544.F Remote Supports Reimbursement 1. For Remote Supports, the reimbursement unit shall include one unit per installation/equipment purchase and/or the units as designated on the Department’s fee schedule and/or billing manuals for ongoing Remote Supports 2. Remote Supports in Provider -Owned, -Controlled, or Congregate Facility settings are not eligible for reimbursement by the Colorado Medicaid program. 8.7545 Adult Respite 8.7545.A Adult Respite Eligibility 1. Adult Respite is a covered benefit available to Members enrolled in one of the a. Brain Injury Waiver b. Community Mental Health Supports Waiver c. Complementary and Integrative Health Waiver d. Elderly, Blind, and Disabled Waiver e. Supported Living Services Waiver 8.7545.B Adult Respite Definition 1. Adult Respite care means services provided to an eligible Member on a shortterm basis because of the absence or need for relief of those persons who normally provide the care. 8.7545.C Adult Respite Inclusions 1. HCBS Elderly, Blind, Disabled (EBD) Waiver; Complementary and Integrative Health (CIH) Waiver;

a. A nursing facility shall provide all the skilled and maintenance services b. An Alternative Care Facility shall provide all the Alternative Care Facility services as listed at Section 8.7506, which are required by the individual respite Member.

c. Respite may be provided in the Member’s home, the home of the respite provider, or in the community.

HCBS Brain Injury (BI) Waiver a. A nursing facility shall provide all the skilled and maintenance services b. Respite may be provided in the Member’s home, home of the respite provider, or in the community.
HCBS Community Mental Health Supports (CMHS) Waiver a. A nursing facility shall provide all the skilled and maintenance services b. An Alternative Care Facility shall provide all the Alternative Care Facility services as listed at Section 8.7506, which are required by the individual respite Member.
HCBS Supported Living Services (SLS) Waiver a. Respite may be provided in the Member’s home;

b. The private residence of a respite care provider; or c. In the community. 8.7545.D Adult Respite Exclusions and Limitations 1. HCBS Elderly, Blind, Disabled (EBD) Waiver; Complementary and Integrative Health (CIH) Waiver; Community Mental Health Supports (CMHS) Waiver a. An individual Member shall be authorized for no more than (30) days of respite care in each support plan year unless otherwise authorized by the b. Alternative care facilities shall not admit individuals for respite care who are not appropriate for alternative care facility placement, as specified at 8.7506.

c. Only those portions of the facility that are Medicaid certified for nursing facility or alternative care facility services may be utilized for respite 2. HCBS Brain Injury (BI) Waiver a. An individual Member shall be authorized for no more than a cumulative total of 30 days of respite care in each certification period unless otherwise authorized by the Department. This total shall include respite care provided in both the home and in a nursing facility.

i. A mix of delivery options is allowable if the aggregate amount of services is less than 30 days, or 720 hours, of respite care.

ii. In-home respite is limited to no more than eight hours per day.

iii. Nursing facility respite is billed on a per diem.

iv. Only those portions of the facility that are Medicaid certified for nursing facility services may be utilized for respite Members.

HCBS Supported Living Services (SLS) Waiver a. Overnight group respite may not substitute for other services provided by the provider such as personal care, behavioral services or services not covered by the HCBS-SLS Waiver.

b. Respite shall be reimbursed according to a unit rate or daily rate, whichever results in lesser reimbursement.

c. The total amount of respite days provided in one support plan year may not exceed thirty (30) days. 8.7545.E Adult Respite Provider Agency Requirements 1. HCBS Elderly, Blind, Disabled (EBD) Waiver; Complementary and Integrative Health (CIH) Waiver; Community Mental Health Supports (CMHS) Waiver a. Respite care standards and procedures for nursing facilities are as i. The nursing facility must have a valid contract with the State as a Medicaid certified nursing facility. The contract shall constitute automatic Certification for respite care. A respite care provider billing number shall automatically be issued to all certified nursing facilities.

ii. The nursing facility does not have to maintain or hold open separately designated beds for respite Members but may accept respite Members on a bed available basis.

iii. For each HCBS-BI/EBD/CIH/CMHS respite Member, the nursing facility must provide an initial nursing Assessment, which will serve as the plan of care, must obtain physician treatment orders and diet orders; and must have a chart for the Member. The chart shall identify the Member as a respite Member. If the respite stay is for 14 days or more, the Minimum Data Set (MDS) shall be completed.

iv. An admission to a nursing facility under HCBS-BI/EBD/CIH/CMHS respite does not require a new Level of Care Screen, Pre- Admission Screening and Resident Review (PASRR) review, an AP-5615 form, a physical, a dietitian Assessment, a therapy Assessment, or lab work as required on an ordinary nursing facility admission. The MDS does not have to be completed if the respite stay is shorter than 14 days.

v. The nursing facility shall have written policies and procedures available to staff regarding respite care Members. Such policies could include copies of these respite rules, the facility’s policy regarding self-administration of medication, and any other policies and procedures which may be useful to the staff in handling respite care Members.

vi. The nursing facility shall obtain a copy of the Level of Care Screen and the approved Prior Authorization Request (PAR) form from the Case Manager prior to the respite Member's entry into the facility.

b. Respite care standards and procedures for alternative care facilities are as i. The alternative care facility shall have a valid contract with the Department as a Medicaid certified HCBS-EBD/CMHS Alternative Care Facility Provider Agency. Such contract shall constitute Certification for HCBS-BI/EBD/CIH/CMHS respite care.

ii. For each respite care Member, the Alternative Care Facility shall follow normal procedures for care planning and documentation of services rendered.

c. Individual respite care providers shall be employees of certified personal care agencies. Family Members providing respite services shall meet the same competency standards as all other providers and be employed by the certified Provider Agency.

HCBS Brain Injury (BI) Waiver a. Respite care standards and procedures for nursing facilities are as i. The nursing facility must have a valid contract with the State as a Medicaid certified nursing facility. The contract shall constitute automatic Certification for respite care. A respite care provider billing number shall automatically be issued to all certified nursing facilities.

ii. The nursing facility does not have to maintain or hold open separately designated beds for respite Members but may accept respite Members on a bed available basis.

iii. For each HCBS-BI/EBD/CIH/CMHS respite Member, the nursing facility must provide an initial nursing assessment, which will serve as the plan of care, must obtain physician treatment orders and diet orders; and must have a chart for the Member. The chart must identify the Member as a respite Member. If the respite stay is for 14 days or longer, the MDS must be completed.

iv. An admission to a nursing facility under HCBS-BI/EBD/CIH/CHMS respite does not require a Level of Care Screen, a Pre-Admission Screening and Resident Review (PASRR) review, an AP-5615 form, a physical, a dietitian assessment, a therapy assessment, or lab work as required on an ordinary nursing facility admission. The MDS does not have to be completed if the respite stay is shorter than 14 days.

v. The nursing facility shall have written policies and procedures available to staff regarding respite care Members. The policies could include copies of these respite rules, the facility’s policy regarding self-administration of medication, and any other policies and procedures which may be useful to the staff in handling respite care Members.

vi. The nursing facility shall obtain a copy of the Level of Care Screen and the approved Prior Authorization Request (PAR) form from the Case Manager prior to the respite Member’s entry into the facility.

b. Individual respite care providers shall be employees of certified personal care agencies. Family Members providing respite services shall meet the same competency standards as all other providers and be employed by the certified Provider Agency 8.7545.F Adult Respite Provider Reimbursement Requirements 1. For the HCBS Brain Injury (BI); Elderly, Blind, and Disabled (EBD);

Complementary and Integrative Health (CIH); and Community Mental Health Supports (CMHS) Waivers:

a. Respite care reimbursement to nursing facilities shall be as follows:

i. The nursing facility shall bill using the facility's assigned respite provider number, and on the HCBS-BI/EBD/CIH/CMHS claim form according to fiscal agent instructions.

ii. The unit of reimbursement shall be a unit of one day. The day of admission and the day of discharge may both be reimbursed as full days, provided that there was at least one full twenty-four-hour day of respite provided by the nursing facility between the date of admission and the date of discharge. There shall be no other payment for partial days.

iii. Reimbursement shall be the lower of billed charges or the average weighted rate for administrative and health care for Class I nursing facilities in effect on July 1 of each year.

iv. Respite care reimbursement to Alternative Care Facilities shall be as follows:

The unit of reimbursement shall be a unit of one day. The day of admission and the day of discharge may both be reimbursed as full days, provided that there was at least one full twenty-four-hour day of respite provided by the alternative care facility between the date of admission and the date of discharge. There shall be no other payment for partial days.

v. Reimbursement shall be the lower of billed charges; or the maximum Medicaid rate for alternative care services, plus the standard alternative care facility room and board amount prorated for the number of days of respite.

b. Individual respite providers shall bill according to a unit rate or daily institutional Nursing Facility rate, whichever is less.

c. The respite care provider shall provide all the respite care that is needed, and other HCBS-BI/EBD/CIH/CMHS services shall not be reimbursed during the respite stay.

d. There shall be no reimbursement provided under this section for respite care in Uncertified Congregate Facilities.

HCBS Supported Living Services (SLS) Waiver:

a. Respite shall be provided according to individual, overnight group, or group rates as defined below:

i. Individual: the Member receives respite in a one-on-one situation.

There are no other Members in the setting also receiving respite ii. Overnight Group: the Member receives respite in a setting which is defined as a facility that offers 24-hour supervision through supervised overnight group accommodations. The total cost of overnight group within a 24-hour period shall not exceed the respite daily rate.

iii. Group: the Member receives care along with other individuals, who may or may not have a disability. The total cost of the group rate within a 24-hour period shall not exceed the respite daily rate. 8.7546 Child Respite 8.7546.A Child Respite Eligibility 1. Child Respite is a covered benefit available to Members enrolled in one of the a. Children with Complex Health Needs Waiver b. Children’s Extensive Support Waiver c. Children's Habilitation Residential Program 8.7546.B Child Respite Definition 1. Child Respite care means services provided to an eligible Member on a shortterm basis because of the absence or need for relief of those persons who normally provide the care.

Unskilled Respite means services provided to an eligible Member by a trained and unlicensed support staff.
Skilled Respite means services provided to an eligible Member by a licensed RN/LPN/or CNA. These services must qualify as skilled care as prescribed by a Licensed Medical Professional.
Therapeutic Respite means services provided to an eligible Member by a specially-trained and certified support provider for ongoing behavioral support 8.7546.C Child Respite Inclusions 1. HCBS Children’s Extensive Supports (CES) Waiver a. Respite may be provided in the Member home or private residence;

b. The private residence of a respite care provider; or c. In the community.

HCBS Children with Complex Health Needs (CwCHN) Waiver a. Respite care may be provided in the home;

b. In the community; or c. In an approved respite center location of a Member.

HCBS Children's Habilitation Residential Program Waiver (CHRP) Waiver a. Respite services may be provided in a Certified Foster Care Home;

b. Kinship Foster Care Home;

c. Licensed Residential Child Care Facility;

d. Licensed Specialized Group Facility, Licensed Child Care Center (less than 24 hours);

e. in the Family home; or f. or in the community.

g. Overnight out of home Respite must be in a Foster Care Home, Kinship Home, Group Home, or Residential Child Care Facility (RCCF). 8.7546.D Child Respite Exclusions and Limitations 1. HCBS Children’s Extensive Supports (CES) Waiver a. Respite is to be provided in an age-appropriate manner. Respite is not a covered benefit for Member 11 years of age and younger during the time the primary caregiver is at work, pursuing continuing education or engaging in volunteer activities.

b. When the cost of care during the time the caregiver at work is more for a Member 11 years of age or younger, than it is for same age peers, respite may be used to pay the difference in costs. Caregivers shall be responsible for the basic and typical costs of childcare.

HCBS Children with Complex Health Needs (CwCHN) Waiver a. Respite care shall not be provided at the same time as Home Health or Palliative/Supportive Care services. 8.7546.E Child Respite Provider Reimbursement Requirements 1. HCBS Children’s Extensive Supports (CES) Waiver a. Respite shall be provided according to an individual or group rates as defined below: Individual: the Member receives respite in a one-on-one situation. There are no other Members in the setting also receiving respite b. Unskilled Individual day: the Member receives respite in a one-on-one situation for cumulatively more than 10 hours in a 24-hour period. A full day is 10 hours or greater within a 24-hour period.

c. Skilled and Therapeutic Individual day: the Member receives respite in a one-on-one situation for cumulatively more than four hours in a 24-hour period. A full day is four hours or greater within a 24-hour period.

d. Overnight group: the Member receives respite in a setting which is defined as a facility that offers twenty-four (24) hour supervision through supervised overnight group accommodations. The total cost of overnight group within a twenty-four (24) hour period shall not exceed the respite daily rate.

e. Group: the Member receives care along with other individuals, who may or may not have a disability. The total cost of the group rate within a twentyfour (24) hour period shall not exceed the respite daily rate. The following limitations to respite service shall apply:

f. The total amount of respite provided in one support plan year may not exceed an amount equal to 30 day units and 1,880 15-minute units. The Department may approve a higher amount based on a need due to a documented increase in medical or behavioral needs.

g. Overnight group respite may not substitute for other services provided by the provider such as Personal Care, Behavioral Services or other services not covered by the HCBS-CES waiver.

h. Respite shall be reimbursed according to a unit rate or daily rate, whichever is less. The daily overnight or group respite rate shall not exceed the respite daily rate.

i. The purpose of respite is to provide the primary caregiver a break from the certified nurse aide services, personal care, homemaker, health j. Respite may not be provided by the Member’s legal guardian, primary caregiver, or Legally Responsible Person.

HCBS Children with Complex Health Needs (CwCHN) Waiver a. Respite is not to exceed thirty (30) days per support plan year, as determined by the Department approved assessment. The Department may approve a higher amount based on a need due to a documented increase in medical or behavioral needs.

b. The purpose of respite is to provide the primary caregiver a break from the certified nurse aide services, personal care, homemaker, health c. Respite may not be provided by the Member’s Legal Guardian, primary caregiver, or a Legally Responsible Person.

HCBS Children's Habilitation Residential Program Waiver (CHRP) Waiver a. Respite is provided at an individual or group rate, defined as follows:

Individual: the Member receives respite in a one-on-one situation. There are no other Members receiving respite at the same time in the same setting. Group: the Member receives respite with other individuals, who may or may not have a disability. The total cost services provided in a group setting must not exceed the respite daily rate.

b. The total amount of respite provided in one support plan year may not exceed an amount equal to thirty (30) day units and one thousand eight hundred eighty (1,880) individual units, where one unit is equal to 15 minutes. The Department may approve a higher amount when needed due to a documented increase in medical or behavioral needs.

c. During the time when Respite is occurring, the Foster Care or Kinship respite home must be in compliance with all applicable rules and requirements for Family Foster Care Homes.

d. Respite is available for children or youth living in the Family home and may not be utilized while the Member is receiving Habilitation services.

e. Overnight group respite may not substitute for other services provided by the provider such as Behavioral Services or other services not covered by the HCBS-CHRP waiver.

f. Respite shall be reimbursed according to a unit rate or daily rate, whichever is less.

g. The purpose of respite is to provide the primary caregiver a break from the certified nurse aide services, personal care, homemaker, home h. Respite may not be provided by the Member’s Legal Guardian, primary caregiver, or a Legally Responsible Person. 8.7547 Specialized Medical Equipment and Supplies 8.7547.A Specialized Medical Equipment and Supplies Eligibility 1. Specialized Medical Equipment and Supplies (SMES) is a covered benefit available to Members enrolled in one of the following HCBS waivers:

a. Brain Injury Waiver b. Children’s Extensive Support Waiver c. Developmental Disabilities Waiver d. Supported Living Services Waiver 8.7547.B Specialized Medical Equipment and Supplies Definition 1. Specialized Medical Equipment and Supplies means devices, controls, or appliances that help the Member perceive, control, or communicate with their environment to increase their ability to perform Activities of Daily Living or remain safely in their home and community. 8.7547.C Specialized Medical Equipment and Supplies Inclusions 1. Specialized Medical Equipment and Supplies is authorized for Organized Health Care Delivery System (OHCDS).

Specialized Medical Equipment and Supplies include devices, controls, or appliances that help the Member perceive, control, or communicate with their environment to increase their ability to perform Activities of Daily Living or remain safely in their home and community.
Devices, controls or appliances that enable the Member to increase their ability to perform Activities of Daily Living, 4. Devices, controls or appliances that enable the Member to perceive, control or communicate within their environment, 5. Items necessary to address physical conditions along with ancillary supplies and equipment necessary to the proper functioning of such items;
Durable and non-durable medical equipment not available under the Medicaid State Plan that is necessary to Member’s needs assessed in the Person- Centered Support Plan;
Necessary medical supplies in excess of Medicaid State Plan limitations or not available under the Medicaid State Plan.
Maintenance and upkeep of specialized medical equipment purchased through the HCBS waiver.
All items shall meet applicable standards of manufacture, design and installation.
HCBS Supported Living Services Waiver, Children’s Extensive Supports Waiver a. Kitchen equipment required for the preparation of special diets if this results in a cost savings over prepared foods;

b. Specially designed clothing for a Member if the cost is over and above the costs generally incurred for a Member’s clothing. 8.7547.D Specialized Medical Equipment and Supplies Exclusions and 1. Specialized Medical Equipment and Supplies excludes those items that are not of direct medical or remedial benefit to the Member as assessed through their Person-Centered Support Plan.

Durable and non-durable medical equipment available under the Medicaid State Plan 3. Items that are not of direct medical or remedial benefit to the Member include vitamins, food supplements, any food items, prescription or over the counter medications, topical ointments, exercise equipment, hot tubs, water walkers, resistance water therapy pools, experimental items and wipes for any purpose other than incontinence are not covered under this service. 8.7548 Substance Use Counseling 8.7548.A Substance Use Counseling Eligibility 1. Substance Use Counseling is a covered benefit available to Members enrolled in the HCBS Brain Injury Waiver. 8.7548.B Substance Use Counseling Definition 1. Substance Use Counseling services shall be designed to support the Member in managing and/or overcoming substance use. These services are in addition to counseling services available through State Plan services and are not intended to replace these services. 8.7548.C Substance Use Counseling Inclusions 1. Outpatient individual, group, and Family counseling services may be provided in the home, community, or provider’s office.
Substance abuse services are provided in a non-residential setting and must include Assessment, development of an intervention plan, implementation of the plan, ongoing education and training of the waiver Member, Family or caregivers when appropriate, periodic Reassessment, education regarding appropriate use of prescription medication, culturally responsive individual and group counseling, Family counseling for persons if directly involved in the support system of the Member, interdisciplinary care coordination meetings, and an aftercare plan staffed with the Case Manager.
Counseling services are limited to 30 units of individual, group, family, or a combination of counseling services. The Department may authorize additional units based on needs identified in the Person-Centered Support Plan or care 8.7548.D Substance Use Counseling Exclusions and Limitations 1. Inpatient treatment is not a covered benefit. 8.7548.E Substance Use Counseling Provider Agency Requirements 1. Substance abuse services may be provided by any Provider Agency or individual licensed by the Behavioral Health Administration (BHA) and certified by the Department of Health Care Policy and Financing (HCPF).
Providers must demonstrate a fully developed plan entailing the method by which coordination will occur with existing community agencies and support programs to provide ongoing support to Members with substance abuse problems. The provider shall promote training to improve the ability of the community resources to provide ongoing support to Members living with a Brain Injury.
Counselors shall be certified at the Certified Addiction Specialist, Licensed Addictions Counselor level or a doctoral level psychologist with the same level of experience in substance abuse counseling. All counseling professionals within the substance abuse area shall receive specialized training prior to providing services to any Member with a Brain Injury or their Family Members. 8.7548.F Substance Use Counseling Reimbursement 1. There are three separate counseling services allowable under HCBS-BI counseling services including Family Counseling (if the Member is present), Individual Counseling, and Group Counseling each reimbursed on a 1 unit = 1 hour basis 8.7549 Supported Employment 8.7549.A Supported Employment Service Eligibility 1. Supported Employment is a covered benefit available to Members enrolled in a. Developmental Disabilities Waiver b. Supported Living Services Waiver 8.7549.B Supported Employment Service Definition 1. Supported Employment services assist members to obtain and maintain employment in their community. The outcome of Supported Employment services shall be sustained paid employment in a job that meets the member’s personal and career goals;

a. Supported Employment services are delivered in settings where members regularly interact with individuals without disabilities, other than paid staff.

The member sustains paid employment at or above minimum wage, with a preferred outcome of Competitive Integrated Employment (CIE).

b. Supported Employment services are intended to promote member independence and result in the gradual reduction of paid staff supports over time, consistent with the member’s Person-Centered Support Plan.

c. Supported Employment services may be provided on an individual or group basis, as authorized, and includes Job Development, Job Coaching, Employment Related Tools and Supplies, Workplace Assistance, and other employment-related supports and incentives as described in these 2. Customized Employment is a service delivery approach. Customized Employment means a flexible process designed to personalize the employment relationship between a job seeker and an employer in a way that meets the needs of both, consistent with Competitive Integrated Employment requirements.

Competitive Integrated Employment (CIE) means work that:

a. Is performed on a full-time or part-time basis, including self-employment;

b. Is compensated at a rate that:

i. Is not less than the higher of the rate specified in section 6(a)(1) of the Fair Labor Standards Act of 1938 (29 U.S.C. § 206(a)(1)) or the applicable State or local minimum wage law;

ii. Is not less than the customary rate paid by the employer for the same or similar work performed by employees without disabilities who are similarly situated; and iii. In the case of self-employment, yields income comparable to that earned by individuals without disabilities who are self-employed in similar occupations or tasks; and a. Is eligible for the level of benefits provided to other employees; and b. Is performed at a location:

i. Typically found in the community;

ii. Where the employee with a disability interacts with coworkers, customers, vendors, and others without disabilities to the same extent as employees without disabilities in comparable positions;

iii. That presents opportunities for advancement similar to those available to employees without disabilities in comparable positions.

Supported Employment Fading means the intentional, individualized, and gradual reduction of direct job coaching supports to promote member independence by:

a. Building job-related skills and competencies;

b. Leveraging natural workplace supports, including coworkers and supervisors;

c. Encouraging self-management and autonomy; and d. Using systematic instruction, assistive strategies, technology, and workplace accommodations, as appropriate.

e. Supported Employment Fading includes active involvement of the member in planning and implementation to build confidence and ensure supports are reduced at a pace consistent with the member’s needs, with the goal of sustaining the job without continuous paid support. 8.7549.C General Supported Employment Service Inclusions 1. Supported Employment services include the following service types and related supports, as authorized in the member’s Person-Centered Support Plan:

a. Group Supported Employment, as described in Section 8.7549.01, and applicable subsections of this section;

b. Individual Supported Employment, as described in Section 8.7549.02, and applicable subsections of this section;

c. Workplace Assistance, as described in Section 8.7558;

d. Employment Related Tools and Supplies, as described in this section and other applicable provisions of these regulations.

Employment Related Tools and Supplies are items or supports that are necessary for a member to begin, maintain, or advance in employment:

a. Employment Related Tools and Supplies may be provided when the item directly relates to either the member’s disability-related employment needs or when the item is specific to the member’s job. Prior to authorization, other funding sources must be explored as described elsewhere in these b. Employment Related Tool and Supplies may include uniforms, footwear, equipment, technology, tools, or other employment-specific supports required for the member to perform job duties.

c. Employment Related Tools and Supplies are reimbursed based on the actual cost of the item, using a unit value of one (1) unit equals one dollar ($1.00), consistent with reimbursement methodologies used for specialized equipment, supplies, and similar waiver services.

Unless otherwise specified, the general provisions of this section apply to all Supported Employment service types. 8.7549.D General Supported Employment Service Access and Authorizations 1.
Documentation must be maintained that Supported Employment services are not available through programs funded under section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (IDEA).

a. Evidence of a referral to the Colorado Department of Labor and Employment’s Division of Vocational Rehabilitation (DVR) must be confirmed by the member’s Case Manager and documented in the member’s record.

b. Supported Employment Provider records must reflect attempts to engage the member with DVR, evidence of DVR’s involvement with the member for relevant time periods, and/or the member’s current status with DVR.

This can be captured via official letters or by informal correspondence such as email.

c. The Department may provide standardized templates or guidance to support consistent documentation of DVR engagement.

If a member is employed, the supervision the member needs while at work shall be clearly documented in their Person-Centered Support Plan. A member’s supervision level at work must be based on the member’s specific work-related support needs.

a. The level of supervision by paid caregivers may be lower at work than in other community settings without impacting the Level of Care (LOC), and the member shall not be over-supported or limited by their ability to work based on supervision needs identified for other settings. 8.7549.E General Supported Employment Service Exclusions and Limitations 1. Supported Employment services do not include:

a. Payment for typical employer responsibilities, including members' wages, supervision, training, general safety measures, adaptations available to other workers without disabilities or workplace accommodations available under the Americans with Disabilities Act of 1990, Title 1, 42 U.S.C. §§ 12111-12117;

b. Volunteer work;

c. Incentive payments, subsidies, or unrelated vocational training expenses;

d. Services that duplicate those provided through the Division of Vocational Rehabilitation (DVR); or e. Facility-based work furnished in specialized facilities that are not part of general community workplaces.

Employers shall not use any HCBS reimbursement to pay members’ wages or to maintain the business's solvency.
Employment Related Tools and Supplies are not covered when:

a. The item is the responsibility of the employer under the Americans with Disabilities Act (ADA);

b. The item is available through the Division of Vocational Rehabilitation, the Individuals with Disabilities Education Act, or another funding source;

c. The item is medical in nature and can be accessed through the Medicaid State Plan, including Durable Medical Equipment or Early and Periodic Screening, Diagnosis and Treatment (EPSDT), as applicable, or may be covered by Assistive Technology through Medicaid Waivers; or d. The member can obtain the item without hardship.

Nothing in this section is intended to prohibit providers from employing members in Competitive Integrated Employment, including within provider-operated businesses. HCBS reimbursement shall not be used to directly subsidize member wages or to offset general business expenses unrelated to the delivery of authorized services. 8.7549.F Supported Employment Service Provider Agency Requirements 1. Provider agencies must meet all general Home and Community Based Services (HCBS) provider requirements.
Provider agencies delivering Supported Employment must demonstrate that direct managers/ supervisors of staff delivering Supported Employment services have:

a. Baccalaureate or higher degree from an accredited college or university in the area of Vocational Rehabilitation, Education, Social Work, Psychology, or a related field, and one (1) year of successful experience in job development, job placement, job coaching, or vocational rehabilitation;

b. An associate degree from an accredited college and four (4) years of successful experience in job development, job placement, job coaching, or vocational rehabilitation; or c. Four (4) years of successful experience in employment counseling, job placement, job coaching, or vocational rehabilitation, and either the Association of Community Rehabilitation Educators (ACRE) Professional Employment Services certification or the Association of People Supporting Employment First (APSE) Credentialed Employment Support Professional (CESP) certification.

Provider qualifications are verified by the Department of Health Care Policy and Financing and the Department of Public Health and Environment at enrollment and revalidation, and through periodic surveys. 8.7549.G Group Supported Employment 1. Group supported employment definition a. Group Supported Employment is a transitional service designed to help members prepare for Competitive Integrated Employment, which is the preferred outcome for all HCBS waiver members. Group Supported Employment services are provided to groups of two (2) to eight (8) members who, because of their disabilities, need ongoing support to obtain and maintain employment in regular business, industry, or community settings.

i. Group Supported Employment may include mobile crews and other business-based workgroups, and includes any arrangements that meet the Group Employment Setting definition.

ii. Wages in Group Supported Employment shall not be less than the higher of the rate specified in section 6(a)(1) of the Fair Labor Standards Act of 1938 (29 U.S.C. § 206(a)(1)) or the applicable State or local minimum wage law.

Group Employment Setting means a workplace where two (2) or more members are supported in the same type of job, during the same timeframe, at the same work site, and where the structure of the employment arrangement includes one or more of the following characteristics:

a. Employer of Record: The Provider Agency, or one of its subsidiaries, that delivers Supported Employment services, is also the Employer of Record for the member.

b. Supervision Responsibilities: The Provider Agency employs the job supervisor who also provides Supported Employment services to the c. Hiring Authority: The Provider Agency controls or has primary authority over the hiring or termination of the member and provides the Supported Employment services.

d. Purpose of the Business: A central purpose of the business is to employ multiple individuals with disabilities.

e. Physical Location: The job is located at a site owned, leased, or otherwise controlled by the same Provider Agency that provides the Supported Employment services; or f. Employment Dependency: The employment positions are created, arranged, or maintained primarily through the Provider Agency, and the availability of the positions is dependent upon the Provider Agency’s involvement, including through provider-managed contracts with community businesses or through a business operated by the Provider 8.7549.H. Group Supported Employment Service Inclusions 1. Group Supported Employment includes:

a. Group Job Development; and b. Group Job Coaching.

Group Job Development consists of services and activities that assist a member in identifying, pursuing, and obtaining employment. Group Job Development includes job placement activities necessary to secure employment consistent with the member’s identified career goals. Group Job Development may include discovery, career exploration, assessment, setting workplace expectations, support with job applications and interviews, and pursuing employment opportunities.
Group Job Coaching consists of services and supports that assist a member in learning job tasks, meeting employer expectations, and maintaining acceptable job performance and workplace behaviors. Group Job Coaching also includes developing skills and building confidence and awareness that can benefit the member when pursuing Competitive Integrated Employment. 8.7549.I. Group Supported Employment Service Access and Authorizations 1. Group Supported Employment services may be included in a member’s Person- Centered Support Plan in combination with other day services; however, different day services billable units may not overlap.
Group Supported Employment services, when combined with Day Habilitation Services and Supports, Workplace Assistance, and Prevocational Services, are limited to a cumulative total of 7,112 units per support plan year. One (1) unit equals fifteen (15) minutes of service. Individual Supported Employment units are not included in this limitation.
Members may receive Group Supported Employment and Individual Supported Employment concurrently if seeking or maintaining separate employment opportunities; however, services may not be delivered at the same time. 8.7549.J. Transition to Outcome-Based Individual Supported Employment 1. Effective August 14, 2026, Individual Supported Employment services shall be reimbursed in accordance with the Outcome-Based reimbursement model described in the following section, including but not limited to:

a. Career Profile and Supplemental Career Profile;

b. Job Coaching phases;

c. Job Fading Plan; and d. Incentive and Milestone Payments. 8.7549.K. Individual Supported Employment 1. Individual Supported Employment Service Definition a. Individual Supported Employment services are provided to members who, because of their disabilities, need ongoing support to obtain and maintain Competitive Integrated Employment (CIE), including self-employment, in the general workforce. The outcome of Supported Employment services shall be sustained paid employment in a job that meets the member’s personal and career goals and aligns with CIE.

b. Individual Supported Employment consists of one-to-one services and supports provided to a single member to obtain, maintain, advance in, or change employment in a competitive integrated setting. Individual Supported Employment services also include milestone payments that encourage member longevity and Employment First best practices.

c. Individual Supported Employment services are delivered in integrated settings in the general workforce and are intended to increase member independence and result in the fading of paid support over time, consistent with the member’s Person-Centered Support Plan and as referenced in the Supported Employment Fading definition in the General Supported Employment section of these rules. 8.7549.L. Individual Supported Employment Service Inclusions 1. Individual Supported Employment includes:

a. Individual Job Development;

b. Individual Job Coaching; and c. Supported Employment milestone payments tied to state-defined employment outcomes.

Individual Supported Employment services:

a. Support members in positions where members regularly interact with individuals without disabilities, other than paid staff, to the degree that is typical for the industry/position;

b. Support sustained paid employment at or above minimum wage that aligns with Competitive Integrated Employment; and i. Include activities necessary to support job acquisition, job performance, and job retention, including Individual Job Development and Individual Job Coaching.

c. Individual Job Development consists of services and activities that assist a member in identifying, pursuing, and obtaining Competitive Integrated Employment. Individual Job Development includes job placement activities necessary to secure employment consistent with the member’s identified career goals. Individual Job Development may include discovery, career exploration, assessment, employer engagement, negotiation, and support with job applications and interviews.

i. Individual Job Development includes the creation or updating of a Basic Career Profile and, when authorized, a Supplemental Career Profile.

d. Individual Job Coaching consists of services and supports that assist a member in learning, performing, and maintaining job tasks and workplace behaviors; developing natural supports; and increasing independence at work through the gradual fading of paid supports. Individual Job Coaching may also include assisting the member in navigating the social, environmental, and unexpected concerns that may arise at work.

i. Individual Job Coaching includes the creation and updating of a Job Fading Plan.

ii. Individual Job Coaching consists of three (3) phases: Initial Job Retention, Extended Job Coaching, and Job Coaching Maintenance.

The duration, reimbursement methodology, and documentation requirements applicable to each phase are described in Section 8.7549.02.F.

Individual Supported Employment also promotes state-defined employment outcomes, such as member longevity and having qualified providers, by offering milestone payment opportunities for Supported Employment providers.
Individual Supported Employment may support self-employment, including work as an independent contractor. Medicaid funds may not be used to defray business start-up or operating expenses. 8.7549.M. Supported Employment Service Access and Authorizations 1. Individual Job Development, Individual Job Coaching, Supported Employment milestone payments, and Employment Related Tools and Supplies are authorized separately from Group Supported Employment and are not included in the cumulative annual unit limit described in Section 8.7549.I.
For Individual Job Development, Case Managers may authorize one (1) unit for the Career Profile per member over the life of the Waiver.

a. A Supplemental Career Profile, one (1) unit per member per Service Plan year, may be approved if the member is seeking new employment or additional employment.

i. In cases where a member may need an additional Supplemental Career Profile in the same service plan year because they are looking for new or additional work, one additional unit for the Supplemental Career Profile may be approved with Case Management Agency supervisor-level approval.

The number of combined units available for the Initial Job Retention and Extended Job Coaching phases is 7,200 units per service plan year.
For Job Coaching Maintenance, a Case Manager may authorize up to 12 units paid monthly, per member, per year, per job.

a. If additional units are needed because the member has multiple jobs, up to an additional 12 Job Coaching Maintenance units may be approved with Case Manager supervisor-level approval, for a maximum of 24 units of Job Coaching Maintenance per year, subject to verification of the member's multiple jobs.

Milestone payments are equal to one (1) unit per Milestone achieved per member per job.

a. Milestone payments may be authorized once the Case Manager receives the required documentation as defined further in this section.

Individual Supported Employment services may be included in a member’s Person-Centered Support Plan in combination with other day services; however, different day services may not be billed during the same time period.
Members may receive Individual Job Development and Individual Job Coaching concurrently if seeking or maintaining separate employment opportunities; however, services may not be delivered at the same time.
HCBS Individual Supported Employment services may not be delivered concurrently with Workplace Assistance services for the same job. When a member’s support needs exceed the scope of Job Coaching Maintenance, the Case Manager may determine that Workplace Assistance, as described in

Section 8.7558, is more appropriate.

Authorization and documentation processes shall align with Department-issued guidance and standardized tools. 8.7549.N. Individual Supported Employment Service Exclusions and 1. Individual Supported Employment does not include:

a. Employment settings designed to support small groups of members, such as group employment settings, including mobile work crews;

b. Facility-based or other vocational services furnished in specialized facilities that are not part of the general workforce. 8.7549.O. Individual Job Development Reimbursement 1. General Requirements a. Individual Job Development services are available to members who want to pursue Competitive Integrated Employment and need support to explore their options and seek employment opportunities.

b. Individual Job Development shall support members in identifying the conditions for their job success, including the ability to fade paid supports over time and increase member independence.

c. Once a referral for DVR services has been made and confirmed by the Case Manager, Individual Job Development services may be authorized.

All deliverables for reimbursement must be received by the Case Manager within 10 business days of the member's signing of the DVR-Individual Plan for Employment.

i. Required Documentation - Career Profile d. The Department’s approved Career Profile is a base document that supports the collection and analysis of information related to a member’s education, work, and volunteer history, interests, skills, support needs, and potential workplace accommodations.

e. Career Profile components are Department-approved sections, tools, or supporting documents used to capture a member’s employment-related information and are used to inform and support job development activities.

Career Profile components shall be selected in collaboration with the member and shall support the identification of the member’s job conditions for success, including interests, skills, support needs, and workplace preferences.

f. Career Profile components may be topic-specific, Department-created, or individualized Department-recognized documents or tools, such as resumes. Components may be embedded within the Career Profile or maintained as separate documents, as specified by the Department.

g. Proof of the member’s referral to the Division of Vocational Rehabilitation (DVR) is required prior to Case Manager authorization of any career profile services, unless otherwise approved by the Department.

Supported Employment providers may submit claims and required documentation for a flat rate reimbursement for completion of the Career Profile, which shall include:

a. Completion of the Department-approved base Career Profile;

b. Completion of a minimum of four (4) Career Profile components, selected based on the member’s needs and employment goals, specifically including at least three (3) industries or employers of interest to inform job development activities; and c. Supporting documentation as required by the Department.

Reimbursement for the Career Profile shall be based on tiered rates aligned with the member’s support needs.
Required Documentation - Supplemental Career Profile a. The Supplemental Career Profile is an optional Individual Job Development service that expands upon or updates a previously completed Career Profile b. The Supplemental Career Profile may be authorized for members who:

i. Require additional support due to limited work history or more complex support needs; or ii. Have completed the Career Profile during the current waiver cycle and are seeking a new or different Competitive Integrated Employment opportunity.

c. The Supplemental Career Profile shall be authorized in conjunction with, or following completion of, the Career Profile.

d. Supported Employment providers may submit claims and required documentation for a flat rate reimbursement for completion of the Supplemental Career Profile, which shall include:

i. Updating, revising, or supplementing existing Career Profile and components, as applicable, to reflect changes in a member’s employment status, interests, skills, support needs, or job conditions for success; and ii. Completion of a minimum of three (3) additional, Departmentapproved Career Profile components, selected based on the member’s current employment goals and support needs.

e. For the Supplemental Career Profile, Department-approved personcentered thinking documents and tools may be used as Career Profile components when they support:

i. Increased understanding of the member’s preferences, motivations, strengths, communication style, and support needs;

ii. Identification of conditions that contribute to the member’s success, satisfaction, and engagement at work and in the community; and iii. Development of strategies to increase career awareness, career exploration, community integration, and effective workplace supports, as specified by the Department.

f. When a member has previously completed a Career Profile, reimbursement for Individual Job Development services may be claimed through the Supplemental Career Profile to support the update, revision, or expansion of existing Career Profile documentation and the completion of additional Career Profile components, in accordance with Department g. Reimbursement for the Supplemental Career Profile shall be based on tiered rates aligned with the member’s support needs. 8.7549.P. Individual Job Coaching Reimbursement 1. General Requirements a. Individual Job Coaching services are available to members who have obtained Competitive Integrated Employment and require on-site or remote support to maintain employment.

b. Individual Job Coaching shall be delivered in three (3) phases based on the duration of employment:

i. Initial Job Retention (phase 1);

ii. Extended Job Coaching (phase 2); and iii. Job Coaching Maintenance (phase 3).

c. When services from the Division of Vocational Rehabilitation are available, HCBS Individual Job Coaching shall begin once DVR has determined the member is stable and has closed the case.

d. When DVR is unavailable or operating under an Order of Selection, the Case Manager may authorize Individual Job Coaching upon confirmation that the job meets Community Integrated Employment requirements and that DVR services were attempted.

Required Documentation - Job Fading Plan Requirements a. The Department-approved Job Fading Plan is a document that summarizes the member’s employment situation, career goals, and the type, intensity, and anticipated reduction of job coaching supports necessary to promote increasing independence and sustained Competitive Integrated Employment.

b. The Supported Employment provider shall complete or update a Job Fading Plan:

i. At the initiation of each Individual Job Coaching phase; and ii. Annually, in conjunction with the member’s annual service plan meeting, when the member is receiving Job Coaching Maintenance services.

c. The Supported Employment provider shall:

i. Maintain the Job Fading Plan in the member’s file;

ii. Provide a copy of the most recent Job Fading Plan to the member;

iii. Provide a copy of the most recent Job Fading Plan to the Case Manager; and iv. Make the Job Fading Plan available to state agencies upon request for review, monitoring, or audit.

d. Completion and maintenance of the Job Fading Plan, in accordance with this section, is required for reimbursement of Individual Job Coaching 3. General Individual Job Coaching Documentation and Reporting Requirements a. The Supported Employment provider shall maintain documentation verifying the total number of hours worked by the member for each month in which reimbursement is claimed for Individual Job Coaching services.

b. Acceptable documentation includes employer-generated records such as pay stubs, employer-certified timecards, employer-certified work schedules, or shift rosters.

c. For each month in which reimbursement is claimed, providers shall document and report the following information within the timelines and methods identified by the Department:

i. Total monthly hours worked by the member;

ii. Total hours of direct, face-to-face Job Coaching support delivered during that month; and iii. Total hours of remote Job Coaching support delivered during that d. The monthly totals required under this section shall correspond to the month for which reimbursement is sought and are not required to be submitted on a per-claim or per-service basis unless otherwise specified by the Department.

e. The Supported Employment provider shall maintain documentation of all direct, face-to-face and remote Job Coaching services delivered.

Documentation shall clearly distinguish between direct and remote services and reflect the duration of each service delivered.

f. Documentation required under this section shall be retained in the member’s file and made available to the Department upon request for monitoring, review, or audit.

Initial Job Retention (phase 1)

a. Initial Job Retention applies to the first one (1) through ninety (90) days of Individual Job Coaching.

b. Reimbursement shall be based on tiered rates aligned with the member’s support needs and the total hours worked by the member during the c. Providers may submit claims in fifteen (15) minute units for the total time the member worked and received wages during the Initial Job Retention time period.

Extended Job Coaching (phase 2)

a. Extended Job Coaching applies from day ninety-one (91) through the end of month eighteen (18) of Individual Job Coaching.

Job Coaching Maintenance (phase 3)

a. Job Coaching Maintenance begins at month nineteen (19) and may continue as long as:

i. The member sustains the job;

ii. The member chooses to continue receiving support from the provider of their choice; and iii. The member continues to benefit from Individual Job Coaching b. When the member requires sustained in-person support due to identified safety-related needs that extend beyond the scope of Job Coaching Maintenance, the Case Manager may determine that Workplace Assistance, as described in Section 8.7558, is more appropriate.

Workplace Assistance shall only be authorized when the criteria set forth in that section are met. A Member shall not receive reimbursement for Job Coaching Maintenance and Workplace Assistance for the same job during the same period of time.

c. If a member has a change either to the job conditions, like new job tasks or a change in manager, or the member has had a life change that may affect the member’s ability to sustain the job without temporary increased Job Coaching support, the Case Manager may approve an additional 30 days of Extended Job Coaching.

i. If the Member continues to demonstrate risk of job loss after the initial thirty (30) day extension, an additional period of up to thirty (30) calendar days of Extended Job Coaching may be authorized with Department approval. Reimbursement shall be based on tiered rates aligned with the member’s support needs.

d. Providers may submit claims for a monthly flat rate, provided the member worked and received wages during the month.

e. Documentation verifying the total hours worked by the member is required for reimbursement under this phase; however, payment is not calculated based on the number of hours worked. 8.7549.Q. Incentive and Milestone Payments 1. General Requirements a. Incentive and Milestone Payments are optional flat payments intended to reward:

i. Achievement of defined employment milestones; or ii. Provider implementation of identified Supported Employment best practices.

b. Incentive and Milestone Payments shall:

i. Be prior authorized by the Case Manager before reimbursement;

ii. Comply with the documentation requirements set forth in this

Section.

Documentation requirements - Longevity Milestones a. Milestone Payment 1: Member has achieved Twelve (12) Months of Employment.

i. This payment may be authorized when a member has maintained continuous employment in a single job for twelve (12) months.

ii. Authorization requires employer-certified documentation verifying the member’s employment duration.

iii. Acceptable documentation includes, but is not limited to:

Employer-certified proof of employment, including the member’s start date and report date;
Member's annual evaluation by their employer;
Paystub records demonstrating continuous employment.

iv. Reimbursement shall occur only after Case Manager approval and prior authorization.

b. Milestone Payment 2: Member has achieved Twenty-four (24) Months of Employment.

i. This payment may be authorized when a member has maintained continuous employment in a single job for twenty-four (24) months.

ii. Authorization requires employer-certified documentation verifying the member’s employment duration.

iii. Acceptable documentation includes the same items identified for Milestone Payment 1.

iv. Reimbursement shall occur only after Case Manager approval and prior authorization.

Documentation Requirements - Milestone 3 Training with Intent a. The Training with Intent Milestone payment is intended to recognize provider investment in structured training, mentorship, and competency development of Supported Employment Professionals.

b. For the purpose of Milestone 3 eligibility, the relevant date shall be the date on which the member completes ninety (90) calendar days of employment in a single job during which Initial Job Retention services are authorized and delivered. This shall be the date used to determine whether the Supported Employment Professional assigned to that member has met the training and competency requirements set forth in this section.

c. For the purpose of this section, “Supported Employment Program Manager” means the individual designated by the Provider Agency to be responsible for the agency’s Supported Employment program or to oversee Supported Employment Professionals, including supervision, performance evaluation, and competency verification.

d. The Supported Employment Program Manager shall hold either:

i. A certification from the Association of Community Rehabilitation Educators (ACRE); or ii. A Credentialed Employment Support Professional (CESP) credential through the Association of People Supporting Employment First (APSE)

e. For purposes of this section, “competency” means the verified and documented demonstration of required skills, knowledge, and professional judgment within an Association of Community Rehabilitation Educators (ACRE) Competency Domain, as applied in real-world supported employment settings.

i. Competency shall be determined by a certified Supported Employment Program Manager using performance-based criteria and shall be based on observed practice and documented evidence. Completion of training hours or coursework alone shall not constitute competency.

ii. Community-based mentorship may be provided by qualified individuals internal or external to the Provider Agency; however, competency verification shall remain the responsibility of the Supported Employment Program Manager.

iii. The Supported Employment Program Manager shall utilize the Department’s approved form to document training, mentorship hours, and competency verification.

The documentation of the Supported Employment Professional’s competency shall be maintained in the employee’s record and made available upon request.

f. For Supported Employment Professionals within their first twelve (12) months of employment in that role with the Provider Agency, the following benchmarks must be met:

i. At three (3) months of employment: completion of at least six (6) hours of community-based mentorship; and all Health Care Policy and Financing (HCPF) training required for Direct Support Professionals.

ii. At six (6) months of employment: completion of at least twelve (12) hours of community-based mentorship and demonstrated competency in at least two (2) of the four (4) ACRE Competency iii. At nine (9) months of employment: completion of at least eighteen (18) hours of community-based mentorship and demonstrated competency in three (3) of the four (4) ACRE Competency iv. At twelve (12) months of employment: completion of at least twenty-four (24) hours of community-based mentorship and demonstrated competency in all four (4) ACRE Competency g. If the Supported Employment Professional assigned to the member holds an ACRE certification or CESP credential and has more than twelve (12) months of prior experience in their role with the Provider Agency before August 14, 2026, the Supported Employment Professional shall be deemed to have met the competency required for Milestone 3.

h. If the Supported Employment Professional holds an active ACRE certification or CESP credential but has been employed by the Provider Agency for less than twelve (12) months, the Supported Employment Professional shall not be required to repeat ACRE Competency Domains; however, in order to be eligible for the Milestone 3 payment, the Supported Employment Professional shall complete community-based mentorship consistent with the mentorship benchmarks established in

section 8.7549.Q. to support alignment with:

i. Agency policies and practices;

ii. Colorado-specific requirements; and iii. Employment First best practices.

i. The Supported Employment Provider Agency shall be eligible for Milestone 3 Training with Intent when all of the following are met:

i. The member has completed ninety (90) calendar days of employment in the same job during which Initial Job Retention services were authorized and delivered;

ii. The Supported Employment Professional assigned to the member meets the training and competency criteria set forth in this section as of the member’s ninety (90) day employment;

iii. The Supported Employment Program Manager meets the credential requirements set forth in this section; and iv. The required documentation has been completed and verified by the Supported Employment Program Manager.

j. The Supported Employment Provider Agency shall submit the required documentation to the Case Manager within two (2) weeks of the member reaching ninety (90) calendar days of employment.

k. The Case Manager may authorize Milestone Payment 3 upon verification that the member has reached ninety (90) calendar days of employment during the Initial Job Retention phase and that the applicable benchmarks based on the Supported Employment Professional’s tenure have been satisfied.

i. Outcome-Based Reimbursement shall occur only after Case Manager approval and prior authorization. 8.7550 Supported Living Program 8.7550.A Supported Living Program Eligibility 1. Supported Living Program is a covered benefit available to Members enrolled in the HCBS Brain Injury Waiver 8.7550.B Supported Living Program Definitions 1. The Supportive Living Program (SLP) means an Assisted Living Residence as defined at 6 C.C.R. 1011-1, Chapter VII, Section 2, which has been licensed by the Colorado Department of Public Health and Environment (CDPHE) and has been certified by the Department to provide Supportive Living Program services to Medicaid Members. The Supportive Living Program is a specialized assisted living service for Members with brain injuries. Settings are certified. Services include 24-hour oversight, Assessment, training and supervision of self-care, medication management, behavioral management, and cognitive supports. They also include interpersonal and social skills development. 8.7550.C Supported Living Program Inclusions 1. Supportive Living Program services consist of structured services designed to provide:

a. Assessment;

b. Protective Oversight and supervision as defined at Section 8.7506.B.2;

c. Behavioral Management and Education;

d. Independent Living Skills Training in a group or individualized setting to support:

i. Interpersonal and social skill development;

ii. Improved household management skills; and iii. Other skills necessary to support maximum independence, such as financial management, household maintenance, recreational activities and outings, and other skills related to fostering independence.

e. Community Participation;

f. Transportation between therapeutic activities in the community;

g. Activities of Daily Living (ADLs);

h. Personal Care and Homemaker services; and i. Health Maintenance Activities.

j. The Supportive Living Program provider shall ensure that each Member is furnished with their own personal hygiene and care items. These items are to be considered basic in meeting a Member's need for hygiene and remaining healthy. Any additional items may be selected and purchased by the Member at their discretion.

Servic Planning a. Supportive Living Program Provider Agencies must comply with the Person-Centered Support Planning process. Providers must work with Case Management agencies to ensure coordination of a Member’s Person-Centered Support Plan and Provider Care Plan. Additionally, Supportive Living Program providers must provide the following actionable plans for all Brain Injury (BI) waiver Members, updated every six (6) months:

i. Transition Planning; and ii. Goal Planning.

b. These elements of a care plan are intended to ensure the Member actively engages in their care and activities and is able to transition to any other type of setting or service when desired. 8.7550.D Supported Living Program Exclusions and Limitations 1. The following are not included as components of the Supportive Living Program:

a. Room and board shall not be a benefit of Supportive Living Program services, as set forth at Section 8.7413.

b. Additional services which are available as a State Plan benefit or other Brain Injury waiver service. Examples include, but are not limited to physician visits, mental health counseling, substance abuse counseling, specialized medical equipment and supplies, physical therapy, occupational therapy, long-term home health, and private duty nursing. 8.7550.E Supported Living Program Provider Agency Requirements 1. Staffing a. The Supportive Living Program Provider Agency shall ensure sufficient staffing levels to meet the needs of Members.

b. The operator, staff, and volunteers who provide direct Member care or Protective Oversight as defined at 8.7506.B.2 must be trained in precautions and emergency procedures, including first aid, to ensure the safety of the Member. Within one month of the date of hire, the Supportive Living Program Provider Agency shall provide adequate training for staff on each of the following topics:

i. Crisis prevention;

ii. Identifying and dealing with difficult situations;

iii. Cultural competency;

iv. Infection control; and v. Grievance and Complaint procedures.

c. In addition to the requirements of 6 C.C.R. 1011-1 Ch. 7, the Department requires that the program director shall have an advanced degree in a health or human service-related profession plus two years of experience providing direct services to persons with a Brain Injury. A bachelor's or nursing degree with three years of similar experience, or a combination of education and experience shall be an acceptable substitute.

d. The Supportive Living Program shall ensure that provision of services is not dependent upon the use of Members to perform staff functions.

Volunteers may be utilized in the home but shall not be included in the Provider Agency’s staffing plan in lieu of employees.

Environmental and Maintenance Requirements a. Supportive Living Program providers shall develop and implement procedures for the following:

i. Handling of soiled linen and clothing;

ii. Storing personal care items;

iii. General cleaning to minimize the spread of pathogenic organisms;

iv. Keeping the home free from offensive odors and accumulations of dirt and garbage. 8.7550.F Supported Living Program Provider Reimbursement Requirements 1. Room and board shall not be a benefit of Supportive Living Program services.

Supportive Living Program services shall be reimbursed according to a tiered per diem rate based on Member acuity, using a methodology determined by the 3. Supportive Living Program services are subject to Post Eligibility Treatment of Income (PETI), as described in 8.7202.BB. 8.7551 Therapeutic Life Limiting Illness Support 8.7551.A Therapeutic Life Limiting Illness Support Eligibility 1. Therapeutic Life Limiting Illness Support is a covered benefit available to Members enrolled in the HCBS Children with Complex Health Needs Waiver. 8.7551.B Therapeutic Life Limiting Illness Support Definition 1. Therapeutic Life Limiting Illness Support is intended to help the Member and Family in the disease process. Support is provided to the Member to decrease emotional suffering due to health status and develop coping skills. Support is provided to the Member and/or Family Members in order to guide and help them cope with the Member’s illness and the related stress that accompanies the continuous, daily care required by a terminally ill child. 8.7551.C Therapeutic Life Limiting Illness Support Inclusions, Exclusions and 1. Support includes but is not limited to counseling, attending physician visits, providing emotional support to the family/caregiver if the child is admitted to the hospital or having stressful procedures, and connecting the Family with community resources such as funding or transportation.
Therapeutic Life Limiting Illness Support may be provided in individual or group settings.
Therapeutic Life Limiting Illness Support shall only be a benefit if it is not available under Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) coverage, Medicaid State Plan benefits, third party liability coverage or by other means.
Therapeutic Life Limiting Illness Support is limited to the Member’s assessed need up to a maximum of 98 hours per annual certification period. 8.7551.D Therapeutic Life Limiting Illness Support Provider Requirements 1. Individuals providing Therapeutic Life Limiting Illness Support shall enroll with the fiscal agent or be employed by a qualified Medicaid home health or hospice 2. Individuals providing Therapeutic Life Limiting Illness Support shall be one of the a. Licensed Clinical Social Worker (LCSW)

b. Licensed Professional Counselor (LPC)

c. Licensed Social Worker (LSW)

d. Licensed Independent Social Worker (LISW)

e. Licensed Psychologist; or 3. Non-denominational spiritual counselor, if employed by a qualified Medicaid home health or hospice Agency. 8.7552 Transition Setup 8.7552.A Transition Setup Eligibility 1. Transition Setup is a covered benefit available to Members enrolled in CFC. 8.7552.B Transition Setup Definition 1. Transition Setup care means coordination and coverage of one-time, nonrecurring expenses necessary for a Member to establish a basic household upon transitioning from a nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or Regional Center to a community living arrangement that is not operated by the State. 8.7552.C Transition Setup Inclusions 1. Transition Setup assists the Member by coordinating the purchase of items or services needed to establish a basic household and to ensure the home environment is ready for move-in with all applicable furnishings set up and operable; and 2. Transition Setup allows up to $2000 in reimbursement for the purchase of onetime, non-recurring expenses necessary for a Member to establish a basic household as they transition from an institutional setting to a community setting.

The Department may authorize additional funds above the $2,000 limit, not to exceed a total value of $2,500, when it is demonstrated as a necessary expense to ensure the health, safety, and welfare of the member. Allowable expenses a. Security deposits that are required to obtain a lease on an apartment or b. Setup fees or deposits to access basic utilities or services (telephone, internet, electricity, heat, and water).

c. Services necessary for the individual’s health and safety such as pest eradication or one-time cleaning prior to occupancy.

d. Essential household furnishings required to occupy, including furniture, window coverings, food preparation items, or bed or bath linens.

e. Expenses incurred directly from the moving, transport, provision, or assembly of household furnishings to the residence.

f. Housing application fees and fees associated with obtaining legal and/or identification documents necessary for a housing application such as a birth certificate, state ID, or criminal background check. 8.7552.C Transition Setup Inclusions 3. Transition Setup Coordination includes assistance with Transition Setup provided by a Transition Setup Coordinator to assist individuals with the logistics of setting up a new residence, such as obtaining documentation required to sign a lease, completing a lease application, securing household items, and setting up utilities.

a. Transition Setup Coordinators must be employed by a Transition Setup Coordination Provider Agency that meets the requirements outlined in 8.7400, 8.7552.F, and 8.7552.G. 8.7552.D Transition Setup Service Access and Authorization 1. To access Transition Setup, a Member must be transitioning from an institutional setting or Regional Center to a community living arrangement and participate in a needs-based Assessment through which they demonstrate a need for the service based on the following:

a. The Member demonstrates a need for the coordination and purchase of one-time, non-recurring expenses necessary for a Member to establish a basic household in the community;

b. The need demonstrates risk to the Member’s health, safety, or ability to live in the community; or c. Other services/resources to meet need are not available.

The Member ’s assessed need must be documented in the Member ’s Transition Plan and Person-Centered Support Plan. 8.7552.E Transition Setup Exclusions and Limitations 1. Transition Setup may be used to coordinate or purchase one-time, non-recurring expenses up to thirty (30) days post-transition.
Transition Setup does not substitute for services available under the Medicaid State Plan, other Waiver Services, or other resources.
Transition Setup is not available to a Member transitioning to, or residing in, a provider-owned or provider-controlled setting.
Transition Setup does not include:

a. Payment for room and board; payment for room and board.

b. Rental or mortgage expenses;

c. Ongoing food costs;

d. Regular utility charges;

e. Cable, satellite, or streaming services;

f. Appliances or items that are intended for purely diversional, recreational, or entertainment purposes (e.g. television, gaming, or video equipment);

g. Gift cards.

Transition Setup is not available for a transition to a living arrangement that does not match or exceed HUD certification criteria. 8.7552.F Transition Setup Coordination Provider Agency Requirements 1. The Transition Setup Coordination Provider Agency shall ensure all products and services delivered to the Member shall meet all applicable manufacturer specifications, state and local building codes, and Uniform Federal Accessibility Standards. 8.7552.G Transition Setup Documentation 1. The Transition Setup Coordination Provider Agency must maintain receipts for all services and/or items procured for the Member. These must be attached to the claim and noted on the Prior Authorization Request.
Transition Setup Coordination Provider Agencies must submit to the Case Management Agency the minimum documentation of the transition process, which includes:

a. A Transition Services Referral Form, b. Release of Information (confidentiality) Forms, and c. A Transition Setup Authorization Request Form.

The Transition Setup Coordination Provider Agency must furnish to the Member a receipt for any services or durable goods purchased on the Member’s behalf. 8.7552.H Transition Setup Provider Agency Reimbursement 1. Transition Setup Coordination is reimbursed according to the number of units billed, with one unit equal to 15-minutes of service. The maximum number of Transition Setup units eligible for reimbursement is 40 units per eligible Member.
Transition Setup Expenses must not exceed $2000 per eligible Member. The Department may authorize additional funds above the $2000 limit, up to $2,500, when the Member demonstrates additional needs, and if the expense(s) would ensure the Member’s health, safety and welfare.
Reimbursement shall be made only for items or services described in the Provider Care Plan with accompanying receipts. No reimbursement is allowable for items donated or otherwise obtained free of charge.
When Transition Setup is furnished to individuals returning to the community from an institutional setting through enrollment in CFC, the costs of such services are billable when the person leaves the institutional setting and is enrolled in CFC. 8.7553 Transitional Living Program 8.7553.A Transitional Living Program Eligibility 1. Transitional living Program is a covered benefit available to Members enrolled in the HCBS Brain Injury Waiver. 8.7553.B Transitional Living Program Definition 1. The Transitional living Program is a residential service designed to improve the Member's ability to live in the community by provision of 24-hour services, support and supervision. 8.7553.C Transitional Living Program Inclusions 1. All services must be documented in an approved plan of care and be prior authorized by the Department.
Program services include but are not limited to Assessment, therapeutic rehabilitation and habilitation, training and supervision of self-care, medication management, communication skills, interpersonal skills, socialization, sensory/motor skills, money management, and ability to maintain a household.
Extraordinary therapeutic needs mean, for purposes of this program, a Member who requires more than three hours per day of any combination of therapeutic disciplines. This includes, but is not limited to, physical therapy, occupational therapy, and speech therapy. 8.7553.D Transitional Living Program Exclusions and Limitations 1. The per diem rate paid to transitional living programs shall be inclusive of standard therapy and nursing charges necessary at this Level of Care. If a Member requires extraordinary therapy, additional services may be sought through outpatient services as a benefit of regular Medicaid services. The need for the Transitional Living Program service for a Member must be documented and authorized individually by the Department.
Transportation between therapeutic tasks in the community, recreational outings, and Activities of Daily Living is included in the per diem reimbursement rate and shall not be billed as separate charges.
Transportation to outpatient medical appointments is exempted from transportation restrictions noted above.
Room and board shall not be a benefit of Transitional Living Program services, set forth at Section 8.7414.
Items of personal need or comfort shall be paid out of money set aside from the Member's income and accounted for in the determination of Financial Eligibility for the Brain Injury program.
The duration of transitional living services shall not exceed 6 months without additional approval, treatment plan review and reauthorization by the 8.7553.E Transitional Living Program Provider Agency Requirements 1. Policies a. The Provider Agency shall confirm that Members must have sustained recent neurological damage (within 18 months) or have realized a significant, measurable, and documented change in neurological function within the past three months. This change in neurological function must have resulted in hospitalization.

b. The Provider Agency shall inform Members and Legally Authorized Representatives of the inherent risk associated with participation in a community-based transitional living program. Examples might include a greater likelihood of falls in community outings where curbs are present.

c. The Provider Agency shall confirm that Members need available assistance in a congregate setting for safety and supervision and require support in meeting psychosocial needs.

d. The Provider Agency shall confirm that Members require available paraprofessional nursing assistance on a 24-hour basis due to dependence in Activities of Daily Living, locomotion, or cognition.

e. Understanding that Members of transitional living programs frequently experience behavior which may be a danger to themselves or others, the Provider Agency shall ensure the program will be suitably equipped to handle such behaviors without posing a significant threat to other residents or staff. The Provider Agency shall have written agreements with other providers in the community who may provide short term Crisis intervention to provide a safe and secure environment for a Member who is experiencing severe behavioral difficulties, or who is actively homicidal or suicidal.

f. The history of behavior problems shall not be sufficient grounds for denying access to transitional living services: however, programs shall retain clinical discretion in refusing to serve Members for whom they lack adequate resources to ensure safety of program Members and staff.

g. Upon entry into the program, discharge planning shall begin with the Member and family. Transitional living programs shall work with the Member and Case Manager to develop a program of services and support which leads to the location of a permanent residence at the completion of transitional living program services.

h. Transitional living programs shall provide assurances that the services will occur in the community or in natural settings and be non-institutional in nature.

i. During daytime hours, 7:00 am to 7:00 pm, the ratio of staff to Members shall be at least 1:3 and overnight, shall be at least 2:8. The use of contract employees, except in the case of an unexpected staff shortage during documented emergencies, is not acceptable.

j. The duration of transitional living services shall not exceed six months without additional approval, treatment plan review and re-authorization by 2. Training a. At a minimum, the program director shall have an advanced degree in a health or human service-related profession plus three years of experience providing direct services to Members with a Brain Injury. A bachelor's degree with five years of experience or similar combination of education and experience shall be an acceptable substitute for a master's level education.

b. Transitional living programs shall demonstrate and document that employees providing direct care and support have the educational background, relevant experience, and/or training to meet the needs of the Member. These staff Members shall have successfully completed a training program of at least 40 hours duration.

c. Transitional living Program Provider Agencies must satisfactorily complete an introductory training course on Brain Injury and rules and regulations pertaining to transitional living centers prior to Certification of the Transitional living Program.

d. The provider, staff, and volunteers who provide direct Member care or Protective Oversight as defined at 8.7506.B.2 must be trained in first aid Universal Precautions, emergency procedures, and at least one staff per shift shall be certified as a medication aide prior to assuming responsibilities. Transitional living Program’s certified prior to the effective date of these rules shall have 60 days to satisfy this training requirement.

e. Training in the use of Universal Precautions for the control of infectious or communicable disease shall be required of all operators, staff, and volunteers. Transitional living Program’s certified prior to the effective date of these rules shall have 60 days to satisfy this training requirement.

f. Staffing of the program must include at least one individual per shift who has Certification as a medication aide prior to assuming responsibilities. 8.7553.F Transitional Living Program Provider Reimbursement Requirements 1. Room and board shall not be a benefit of Transitional living Program services.

Transitional living Program services shall be reimbursed according to a per diem rate, using a methodology determined by the Department. 8.7554 Vehicle Modifications 8.7554.A Vehicle Modifications Eligibility 1. Vehicle Modifications is a covered benefit available to Members enrolled in one a. Children’s Extensive Support Waiver b. Supported Living Services Waiver 8.7554.B Vehicle Modifications Definition 1. Vehicle Modifications means adaptations or alterations to an automobile that are:

a. The Member’s primary means of transportation.

b. To accommodate the needs of the Member, as a result of the Member’s disability and shall not be approved if the need is a typical age-related need.

c. Are necessary to enable the Member to integrate more fully into the community and to ensure the health and safety of the Member. 8.7554.C Vehicle Modifications Inclusions 1. Vehicle Modifications is authorized for Organized Health Care Delivery System 2. Upkeep and maintenance of the modifications to the vehicle are allowable 8.7554.D Vehicle Modifications Exclusions and Limitations 1. Items and services specifically excluded from reimbursement under the HCBS waivers include:

a. Adaptations or improvements to the vehicle that are not of direct medical or remedial benefit to the Member;

b. Purchase or lease of a vehicle; and c. Typical and regularly scheduled upkeep and maintenance of a vehicle. 8.7554.E Vehicle Modifications Case Management Agencies Responsibilities 1. The total cost of Home Accessibility Adaptations, Vehicle Modifications, and Assistive Technology shall not exceed 10,000 dollars over the five (5) year life of the HCBS waiver without an exception granted by the Department:

a. The Case Manager may approve Vehicle Modifications when the total cumulative cost is under $10,000 for the cost of Home Modifications, Vehicle Modifications and Assistive Technology.

b. For modifications with a cumulative total over $10,000, the Case Manager shall obtain approval by submitting a request to the Department.

i. The Case Manager shall obtain all supporting documentation according to department prescribed processes and procedures.

ii. An occupational or physical therapist (OT/PT) shall assess the Member's needs and the therapeutic value of the requested Vehicle Modification. When an OT/PT with experience in Vehicle Modification is not available, a qualified individual may be substituted, with Department approval.

iii. The Case Manager shall obtain at least two bids for the necessary work. If the Case Manager has made three attempts to obtain a written bid from a Provider Agency and the Provider Agency has not responded within thirty (30) calendar days, the Case Manager may request approval of one bid.

Requests for costs that exceed a Member’s cumulative allotment of $10,000 over the five-year life of the HCBS waiver may be approved by the Department if it:

a. Ensures the health and safety of the Member;

b. Enables the Member to function with greater independence within the community ; or c. Decreases the need for paid assistance in another HCBS waiver service on a long-term basis.

Case Management Agency approval for a higher amount shall include a thorough review of the current request as well as past expenditures to ensure cost effectiveness, prudent purchases and no unnecessary duplication. 8.7554.F Vehicle Modifications Provider Agency Reimbursement 1. The total cost of Home Accessibility Adaptations, Vehicle Modifications, and Assistive Technology shall not exceed $10,000 dollars over the five year life of the HCBS waiver without an exception granted by the Department.
Vehicle Modifications that have been completed prior to approval will not be reimbursed. 8.7555 Vision Services 8.7555.A Vision Services Eligibility 1. Vision services is available to Members enrolled in one of the following HCBS waivers:

a. Developmental Disabilities Waiver b. Supported Living Services Waiver 8.7555.B Vision Services Inclusions 1. Vision Services is authorized for Organized Health Care Delivery System 2. HCBS Developmental Disabilities (DD) Waiver; Supported Living Services (SLS)

Waiver a. Vision services include eye exams or diagnosis, glasses, contacts or other medically necessary methods used to improve specific dysfunctions of the vision system when delivered by a licensed optometrist or physician for a Member who is at least twenty-one (21) years of age.

b. Lasik and other similar types of procedures are only allowable when:

i. The procedure is necessary due to the Member’s documented specific behavioral complexities that result in other more traditional remedies being impractical or not cost effective, and ii. Prior authorized in accordance with Department procedures. 8.7556 Wellness Education Benefit 8.7556.A Wellness Education Benefit Eligibility 1. Wellness Education Benefit is a covered benefit available to Members enrolled in a) Brain Injury Waiver b) Children’s Extensive Support Waiver c) Children’s Habilitation Residential Program Waiver d) Children with Complex Health Needs Waiver e) Community Mental Health Supports Waiver f) Complementary and Integrative Health Waiver g) Developmental Disabilities Waiver h) Elderly, Blind and Disabled Waiver i) Supported Living Services Waiver 8.7556.B Wellness Education Benefit Definitions 1. Article means a written document that contains text related to health or wellness topics that a Member receives.

Article Topic means a health and wellness topic that relates to helping a Member manage health-related issues, achieve goals on their Person-Centered Support Plan, and address topics of community living.
Mail means the mechanism by which the benefit is sent to the Member through the United States Postal Service.
Plain language means friendly and clear, with a direct, conversational tone and active voice. The information is organized in logical order for the reader.

Paragraphs are one-topic and brief, and sentences are simple and short. Plain language includes using common, everyday vocabulary consistently across correspondence, with few multi-syllable words and few technical or bureaucratic words.

Service rendered means the Provider Agency has sent the Wellness Education Benefit.
Provider Agency means the entity contracted with the Department to distribute the Wellness Education Benefit.
Verified Address means an address that mail can be sent to and received by a 8. Wellness Education Benefit is individualized educational materials designed to reduce the need for a higher level of care by offering educational materials that provide members and their families with actionable tools that can be used to prevent the progression of a disability, increase community engagement, combat isolation, and improve awareness of Medicaid services. The Wellness Education Benefit helps Members and their unpaid caregivers to obtain, process, and understand information that assists with managing health-related issues, promoting community living, and achieving goals identified in their Person- Centered Support Plans. Wellness Education Benefit services include varied topics such as engaging in community activities, nutrition, adaptive exercise, balance training and fall prevention, money management, and developing social networks. 8.7556.C Wellness Education Benefit Inclusions 1. The Wellness Education Benefit shall be delivered to the Member's mailing address in a printed format.
Article topics can provide the information needed to: Navigate the Medicaid/medical system to achieve better health outcomes, successfully manage chronic conditions in order to decrease risk of nursing facility placement, effectively communicate health and wellness goals, effectively communicate with medical and social service professionals, provide unpaid caregivers with relevant information regarding best practices around support and care of the Member, achieve community living goals identified in the Person-Centered Support Plan by providing simple, actionable suggestions to help support the health and welfare of waiver Members.
Article topics shall be written in plain language.
The Wellness Education Benefit is delivered no less than once every month, with a maximum of 12 unique education materials per certification period.
Wellness Education Benefit shall be provided in a format that is accessible to the Member at the request of the Member and their support team including, but not limited to, preferred written language. For Members who cannot read standard print and would benefit from an alternative format, educational materials will be sent to Members in the requested accessible format, which may include larger print or braille. 8.7556.D Wellness Education Benefit Restrictions and Exclusions 1. Additional wellness reading materials, software, or subscriptions are excluded from the Wellness Education Benefit.
Article topics that do not address community living, Medicaid navigation, healthrelated issues, health care needs, mental health-related issues, or Person- Centered Support Plan goals shall be excluded from this benefit.
The Wellness Education Benefit does not duplicate services found in Early and Periodic Screening, Diagnostic, and Treatment. 8.7556.E Wellness Education Benefit Provider Requirements 1. Provider Agencies must be contracted with the Department to distribute the Wellness Education Benefit.
Wellness Education Benefit Provider Agency shall be responsible for the following tasks:

a. Receive and manage member data in compliance with all applicable Health Insurance Portability and Accountability Act (HIPAA) regulations and ensure client confidentiality and privacy.

b. Translate materials into select languages, as directed by the Department.

c. Both the Department and Wellness Benefit Provider Agency shall ensure that professionally certified translators and reviewers complete article translations and that translations are linguistically accurate and consistent with the formatting and technical specifications of the original document.

Translations will be reviewed for cultural appropriateness before delivery.

d. Ensure that materials are Person-Centered and are formatted in an accessible format, which may include Braille, large print, or high contrast formats.

e. Maintain records of articles sent to Members to prevent duplication of materials.

f. Conduct Member outreach to gather information on how the benefit has helped Members thrive in the community and meet the health and wellness goals.

g. Utilize information on the Member’s Person-Centered Support Plan and updated health conditions to guide the subject matter of the educational materials.

h. Identify any undeliverable Member addresses prior to each monthly mailing and manage any returned mail by sending the Department electronic, custom-formatted relevant address information. The Department will coordinate with Case Managers to update the Member’s address and send updated address to the Provider Agency.

i. Verify Member addresses data files through the United States Postal Service “National Change of Address” database and identify any addresses that are undeliverable by USPS.

i. The Department will be informed by the Wellness Education Benefit Provider Agency of the educational materials that are undeliverable or returned to sender. An attempt to deliver the following month’s service will take place using the following procedure:

The Department will notify the Members’ Case Management Agencies of any returned or undeliverable mail.
Case Management Agencies shall update addresses in accordance with Department guidance. 8.7556.F Wellness Education Benefit Provider Reimbursement Requirements 1. The Wellness Education Benefit is reimbursed based on the number of units of service provided, with one unit equal to one Article.

The Wellness Education Benefit will be delivered once every month, for twelve (12) units total in a support plan year.

a. The Case Manager may authorize up to 12 additional units per support plan year for the following:

i. Intentionally omitted ii. A Member has requested reasonable accommodation for an alternative format, such as braille.

iii. A Member requests that their representative receive a copy of the benefit to help them better utilize information provided in the benefit. Department approval is required.

The annual total units that may be authorized for the Wellness Education Benefit shall not exceed 24 units per plan year. 8.7556.G Wellness Education Benefit Case Management Agency 1. Wellness Education Benefit Introduction and Education:

a. The Case Manager shall provide Member information on the benefits of the Wellness Education Benefit, the types of articles included, and the frequency of delivery.

b. Through the person-centered planning process, the Case Manager will determine a format that is accessible to the Member including, but not limited to, preferred written language.

Case Management Agencies shall update addresses in accordance with Department guidance.
The Case Manager will work with the Member to update their Person-Centered Support Plan. Goals within a Member’s Person-Centered Support Plan may be utilized to determine specific Wellness Education Benefit materials that will support the member to meet those goals.
The Case Manager may work with the Provider Agency to ensure the educational materials are being targeted to meet any new needs the Member may have.
Disenrollment a. If a Member wishes to opt out of the service, the Case Manager shall inform the Member of the possible implications of disenrollment. If a Member disenrolls, the Case Manager must revise the Prior Authorization Request to end-date the Wellness Education Benefit.

b. The Wellness Education Benefit is recognized as an HCBS service as it relates to CCR 8.7101.35 and may be utilized to maintain waiver eligibility.

c. If services are decreased without the Member’s agreement, the Case Manager shall notify the Member of the adverse action and of appeal rights, according to Long-Term Care Waiver Program Notice of Action (LTC-803) regulations at Section 8.7206.18. 8.7557 Wraparound Services 8.7557.A Wraparound Services Eligibility 1. Wraparound Services are available as a covered benefit to Members enrolled in the HCBS Children's Habilitation Residential Program Waiver 8.7557.B Wraparound Services Description and Definition 1. Wraparound services align strategies, interventions, and supports for the Member and family, to prevent the need for out of home placement. This service may be utilized in maintaining stabilization, preventing Crisis situations, and/or de-escalation of a Crisis.

Wraparound services include Wraparound Plan and Prevention and Monitoring which are billed separately.
A Crisis may be self-identified, Family identified, and/or identified by an outside party.
Wraparound Service may be provided individually, or in conjunction with the Child and Youth Mentorship service, defined at 8.7512. 8.7557.C CHRP Wraparound Plan 1. The Wraparound Facilitator is responsible for the development of a Wraparound Plan with action steps to implement support strategies, prevent, and/or manage a future Crisis to include, but not limited to:

a. The unique strengths, abilities, preferences, desires, needs, expectations, and goals of the Member and family.

b. Environmental modifications.

c. Support needs in the Family home.

d. Respite services.

e. Strategies to prevent Crisis triggers.

f. Strategies for Predictive and/or Increased Risk Factors.

g. Learning new adaptive or life skills.

h. Behavioral or other therapeutic interventions to further stabilize the Member emotionally and behaviorally and to decrease the frequency and duration of any future behavioral Crisis.

i. Medication management and stabilization.

j. Physical health.

k. Identification of training needs and connection to training for Family Members, natural supports, and paid staff.

l. Determination of criteria to achieve stabilization in the Family home.

m. Identification of how the plan will be phased out once the Member has stabilized.

n. Contingency plan for out of home placement.

o. Wraparound Support Team may include Family caregivers, other Family Members, service providers, natural supports, professionals, and Case Managers required to implement the Wraparound Plan.

p. Dissemination of the Wraparound Plan to all individuals involved in plan implementation.

Revision of strategies shall be a continuous process by the Wraparound Support Team in collaboration with the Member, until the Member is stable and there is no longer a need for Wraparound Support Services.
On-going monitoring after completion of the Wraparound Plan may be provided if there is a need to support the Member and their Family in connecting to any additional resources needed to prevent a future Crisis. 8.7557.D Prevention and Monitoring 1. Follow-up services include monitoring to ensure that triggers to the Crisis have been addressed in order to maintain stabilization and prevent a future Crisis.
Monitoring of the Wraparound Plan shall occur at a frequency determined by the Member’s needs and include at a minimum, visits to the Member’s home, review of documentation, and coordination with other Professionals and/or Members of the Wraparound Support Team to determine progress.
Services include a review of the Member’s stability and monitoring of Increased Risk Factors that could indicate a repeat Crisis.
Revision of the Wraparound Plan shall be completed as necessary to avert a Crisis or Crisis escalation.
Services include ensuring that follow-up appointments are made and kept. 8.7557.E Wraparound Services Provider Agency Requirements 1. Individuals providing Wraparound Services shall meet the following criteria:

a. The Wraparound Plan Facilitator shall:

i. Have a Bachelor’s degree in a human behavioral science or related field of study; or ii. Have experience working with Long-Term Services and Supports (LTSS) populations, in a private or public social services Agency which may substitute for the required education on a year for year

basis 1) When using a combination of experience and education to qualify, the education shall have a strong emphasis in a human behavioral science field.

iii. Have received Certification through a Nationally Accredited Wraparound Program.

Training and Certification must encompass all of the a) Trauma informed care.

b) Youth mental health first aid.

c) Crisis support and planning.

d) Positive Behavior Supports, behavior intervention, and de-escalation techniques.

e) Cultural and linguistic competency.

f) Family and youth servicing systems.

g) Family engagement.

h) Child and adolescent development.

i) Accessing community resources and services.

j) Conflict resolution.

k) Intellectual and Developmental Disabilities.

l) Mental health topics and services.

m) Substance abuse topics and services.

n) Psychotropic medications.

o) Motivational interviewing.

p) Prevention, detection and reporting of mistreatment, abuse, neglect, and exploitation.

iv. Complete re-certification in wraparound training at least every other year or as dictated by wraparound training program. 8.7558 Workplace Assistance 8.7558.A Workplace Assistance Service Eligibility 1. Workplace Assistance is available to Members enrolled in one of the following a. Developmental Disabilities Waiver b. Supported Living Services Waiver 8.7558.B Workplace Assistance Service Definition 1. Workplace Assistance is a Supported Employment service that provides workrelated supports for Members with elevated supervision needs who, because of valid safety concerns or intensive physical needs, may need assistance from a paid caregiver that is above and beyond what could be regularly supported by the workplace supervisor, co-workers, or job coach, in order to maintain an individual job in an integrated work setting for which the Member is compensated at or above minimum wage. Training/Job Coaching, accommodations, technology, and natural supports are to be used first to maximize the Member’s independence and minimize the need for the consistent presence of a paid caregiver, through Workplace Assistance. As such, the degree to which the Member must be supported by a paid caregiver through the Workplace Assistance service, shall be based on the specific safety-related or intensive physical need(s) identified in the Person-Centered planning process for the Member at their worksite. 8.7558.C Workplace Assistance Service Inclusions 1. Workplace Assistance:

a. Is provided on an individual basis, and is primarily intended for supporting members who have Competitive Integrated Employment positions and were receiving Individual Supported Employment services, as opposed to Group Supported Employment. Workplace Assistance cannot overlap with Job Coaching.

i. In rare circumstances, one-on-one Workplace Assistance may be authorized in a group employment setting when documentation demonstrates that the regular supervision available in the group setting is insufficient to meet the member’s specific needs and all authorization criteria for Workplace Assistance are met.

b. Occurs at the Member’s place of employment, during the Member’s work hours, and when needed may also be used:

i. Immediately before or after the Member’s employment hours; or ii. during work-related events at other locations.

c. Includes but is not limited to promoting integration, furthering natural support relationships, reinforcing/modeling safety skills, assisting with behavioral support needs, redirecting, reminding to follow work-related protocols/strategies, providing hand-over-hand assistance when necessary due to physical limitation, and ensuring other identified needs are met so the Member can be integrated and successful at work;

d. May include activities beyond job-related tasks that support integration at work, such as assisting, if necessary, during breaks, lunches, occasional informal employee gatherings, and employer-sponsored events; and e. Workplace Assistance may support self-employment, including work as an independent contractor, when consistent with the parameters of Competitive Integrated Employment, as described in Section 8.7549.B.

Medicaid funds may not be used to defray business start-up or operating expenses.

Workplace Assistance is appropriate for and available to:

a. Members who require Intensive Supervision or have a documented need which warrants a Rights Modification requiring extensive supervision, such as, a court order or the Member meeting Public Safety Risk or Extreme Risk-to-Self criteria.

b. Members whose support team agrees there is justification for a paid caregiver to be present for a portion of the hours worked due to safety concerns; and those needs are beyond what could be addressed through natural supports, technology, or intermittent Job Coaching. The specific safety concerns identified by Members and their support teams may include, but are not limited to:

i. Regularly demonstrating behaviors that cause direct harm to themselves or others;

ii. Intentionally or unintentionally putting themselves in unsafe situations frequently;

iii. Often demonstrating poor safety awareness or making poor decisions related to personal safety; or iv. Require ongoing hand-over-hand support due to physical limitations that cannot be addressed through means other than a paid 8.7558.D Workplace Assistance Service Access and Authorizations 1. Prior to Workplace Assistance being authorized, including at the Person- Centered Support Plan’s annual renewal, the Member and their support team shall determine that alternatives to paid caregiver supports were fully explored, by considering the factors listed below. Documentation of these considerations shall be reflected in the Member’s Case Management record.

a. Job Coaching services have been or will be leveraged to promote the Member’s independence and minimize the need for the presence of a paid caregiver by ensuring adequate job training, advocating for appropriate accommodations, promoting natural supports, integrating technology, and using systematic instruction techniques.

b. The specific safety concern(s) to be addressed and how the Workplace Assistance staff could support the Member in addressing the safety concerns while facilitating integration and independence at work.

c. The nature of the job and work location, the Member’s longevity with the employer, the degree of continuity at the Member’s place of employment, and the likelihood of the Member putting themselves/others in harm’s way, despite training, technology, and cues from natural supports.

d. The Member’s desire to have a paid caregiver present for the identified time periods.

e. The Supported Employment provider’s informed opinion regarding the need for paid caregiver support beyond intermittent Job Coaching. This opinion shall be grounded in Employment First concepts as evidenced by:

i. The provider’s completion of a nationally recognized Supported Employment training certificate (Training Certificate) or a nationally recognized Supported Employment Certification (Certification); or ii. If the Supported Employment provider does not possess this credentialing, then the Supported Employment provider or the Case Manager may consult with:

By someone who does possess either a Training Certificate or Certification 2) Or a representative from the Department who oversees the Workplace Assistance benefit. 8.7558.E Workplace Assistance Service Exclusions and Limitations 1. A Member’s supervision level is not the sole factor which justifies the need for this service, therefore, the supervision level shall not be elevated in order to access the service. The Member’s supervision level at the worksite shall be based on actual need related to the Member at work.

Workplace Assistance services, when combined with Group Supported Employment, Day Habilitation Services and Supports, and Prevocational Services, are limited to a cumulative total of 7,112 units per support plan year.

Individual Supported Employment units are not included in this limitation. One (1) unit equals fifteen (15) minutes of service.

Workplace Assistance may not be delivered via Telehealth or remote service delivery methods. 8.7558.F Workplace Assistance Service Provider Agency Requirements 1. Workplace Assistance staff shall consistently seek to promote the Member’s independence and integration at work. Where possible, efforts shall be made to reduce or eliminate the need for Workplace Assistance services over time, and the efforts and progress shall be documented by the provider.
The training for Workplace Assistance staff shall:

a. Include fundamentals of Employment First principles with emphasis on promoting independence and inclusion; and b. Provide insight regarding a paid caregiver’s role at a Member’s place of employment such that the Workplace Assistance staff’s presence does not hinder the Member’s interaction with co-workers, customers, and other community Members. 8.7559 Youth Day Service 8.7559.A Youth Day Services Eligibility 1. Youth Day Service is a covered benefit available to Members enrolled in the HCBS Children’s Extensive Support Waiver. 8.7559.B Youth Day Services Definition 1. Youth Day Service is the care and supervision of Members ages 12 through 17 while the primary caregiver works, volunteers, or seeks employment. 8.7559.C Youth Day Services Inclusions 1. Youth Day Service may be provided in the residence of the Member, the Youth Day Service Provide Agency, or in the community.

Youth Day Service shall be provided according to an individual or group rate as defined below:

a. Individual: the Member receives Youth Day Services with a staff ratio of 1:1, billed at 15-minute unit. There are no other youth in the setting also receiving Youth Day Service, Respite or third-party supervision.

b. Group: the Member receives supervision in a group setting with other individuals who may or may not have a disability. Reimbursement is limited to the Member. 8.7559.D Youth Day Services Exclusions and Limitations 1. This service is limited to Members ages 12 through 17.

This service may not substitute for or supplant special education and related services included in a Member’s Individualized Education Plan (IEP) developed under Part B of the Individuals with Disabilities Education Act, 20 U.S.C. § 1400 (2011). This includes after school care provided through any education system and funded through any education system for any student.
This service may not be used to cover any portion of the cost of camp.
This service is limited to 10 hours per calendar day and 90 days per certification period The Department may approve a higher amount based on a need due to the Member’s disability or unique family circumstances. 8.7560 State Funded Supported Living Services (State-SLS) Program 1. The State Funded Supported Living Services (State-SLS) program is funded through an allocation from the Colorado General Assembly. The State-SLS program is designed to provide services to individuals with an intellectual or Developmental Disability to remain in their community. The State-SLS program shall not supplant Home and Community-Based Services for those who are currently eligible. 8.7560.A State-SLS Definitions 1. Corrective Action Plan means a written plan, which includes the detailed description of actions to be taken to correct non-compliance with State-SLS requirements, regulations, and direction from the Department, and includes the date by which each action shall be completed and the individuals responsible for implementing the action.
Community Resource means services and supports that a Member may receive from a variety of programs and funding sources beyond Natural Supports or Medicaid. This may include, but is not limited to, services provided through private insurance, non-profit services and other government programs.
Natural Supports means an informal relationship that provides assistance and occurs in the Member's everyday life including, but not limited to, community supports and relationships with Family Members, friends, co-workers, neighbors and acquaintances 4. Performance and Quality Review means a review conducted by the Department or its Contractor at any time to include a review of required Case Management services performed by the Case Management Agency to ensure quality and compliance with all statutory and regulatory requirements 5. State Fiscal Year means a 12-month period beginning on July 1 of each year and ending June 30 of the following calendar year. 8.7560.B State-SLS Administration 1. The Case Management Agency (CMA) shall administer the State Supported Living Services (State-SLS) program according to all applicable statutory, regulatory and contractual requirements, and Department policies and guidelines.

a. The Case Management Agency is responsible for providing Case Management to all individuals enrolled in the State-SLS program.

b. The Case Management Agency shall have written procedures related to the administration, Case Management, service provision, and waiting list for the State-SLS program.

c. All records must be maintained in accordance with Section 8.7405.

d. The Case Management Agency shall maintain a waiting list of eligible individuals for whom Department funding is unavailable in accordance with Section 8.7560.G.

e. The Case Management Agency shall develop procedures for determining how and which individuals on the waiting list will be enrolled into the State- SLS program that comply with all applicable statutory, regulatory and contractual requirements including Section 8.7560.G.

f. Any decision to modify, reduce or deny services or supports set forth in the State-SLS program, without the Individual’s or Legally Authorized Representative’s agreement, are subject to the requirements in Section 8.7202.S.

Member Eligibility a. General Eligibility requirements i. Individuals must be a resident of Colorado;

ii. Be eighteen (18) years of age or older; and iii. Be determined to have an intellectual or Developmental Disability pursuant to the procedures set forth in Section 8.7202.D.

b. Eligibility for the State-SLS program does not guarantee the availability of services under this program.

General Provisions a. The availability of services offered through the State-SLS program may not be consistent throughout the State of Colorado or between Case Management Agencies.

b. An individual enrolled in the State-SLS program shall access all benefits available under the Medicaid State Plan, HCBS Waiver Community First Choice or EPSDT, if available, prior to accessing services under the State- SLS program. Services through the State-SLS program may not duplicate services provided through the State Plan and the Member must utilize State Plan services before accessing services through the State-SLS program when available to the Member.

c. Evidence of attempts to utilize all other public benefits and available and accessible community resources must be documented in the State-SLS individualized Support Plan by the Case Manager, prior to accessing State-SLS services or funds.

d. The State-SLS program shall be subject to annual appropriations by the Colorado General Assembly.

e. These regulations shall not be construed to prohibit or limit services and supports available to persons with Intellectual and Developmental Disabilities that are authorized by other state or federal laws.

f. When an individual is enrolled only in the State-SLS program the Case Manager shall authorize a Provider Agency to deliver the services, when g. The Case Manager may authorize services from multiple State-SLS service categories at once, unless otherwise stated.

h. Unless otherwise specified, State-SLS services may be utilized in combination with other community resources and/or Medicaid services.

State-SLS services shall not be duplicative of other resources or HCBS services, and all other available and accessible resources shall be utilized before State-SLS services.

i. The Member shall be evaluated at least annually for eligibility for HCBS Medicaid Waivers and other available Medicaid funded supports. The Case Manager shall document the results of the assessment in the State SLS individualized Support Plan.

Performance and Quality Review a. The Department shall conduct a Performance and Quality Review of the State-SLS program to ensure that the Case Management Agency is in compliance with all statutory and regulatory requirements.

b. A Case Management Agency found to be out of compliance shall be required to develop a Corrective Action Plan, upon written notification from the Department. A Corrective Action Plan must be submitted to the Department within 10 business days of the date of the written request from the Department. A Corrective Action Plan shall include, but is not limited to:

i. A detailed description of the actions to be taken to remedy the deficiencies noted on the Performance and Quality Review, including any supporting documentation;

ii. A detailed timeframe for completing the actions to be taken;

iii. The employee(s) responsible for implementing the actions; and iv. The estimated date of completion.

c. The Case Management Agency shall notify the Department in writing, within 3 business days if it will not be able to present the Corrective Action Plan by the due date. The Case Management Agency shall explain the reason for the delay and the Department may grant an extension, in writing, of the deadline for the submission of the Corrective Action Plan.

i. Upon receipt of the proposed Corrective Action Plan, the Department will notify the Case Management Agency in writing whether the Corrective Action Plan has been accepted, modified, or rejected.

ii. In the event that the Corrective Action Plan is rejected, the Case Management Agency shall re-write the Corrective Action Plan and resubmit along with the requested documentation to the Department for review within five (5) business days.

iii. The Case Management Agency shall begin implementing the Corrective Action Plan upon acceptance by the Department.

iv. If the Corrective Action Plan is not implemented within the timeframe specified therein, funds may be withheld or suspended. 8.7560.C State-SLS Inclusions and Covered Services 1. Services for individuals waiting for HCBS waiver enrollment.

a. Eligible Members may receive the following state general funded services:

i. All HCBS Waiver Services identified as available to Members enrolled in the SLS waiver as identified throughout section 8.7500 et seq.

ii. Service limitations in the HCBS SLS waiver and set forth in section 8.7500 et seq. apply to the State-SLS program.

iii. The following additional services are also available to members who are not eligible for or do not meet the level of care for Community First Choice as defined in Section 8.7600 and include:

a) Electronic Monitoring as defined at Section 8.7520, et seq.

b) Homemaker as defined at Section 8.7527, et seq.

c) Personal Care as defined at Section 8.7538, et seq.

d) Remote Supports as defined at Section 8.7544, et seq.

iv. Service limitations and service rules found in Community First Choice in Section 8.7600, et seq. apply to the State-SLS program.

v. Participant Directed services including CDASS and IHSS are not allowed under State-SLS.

vi. The Case Management Agency may authorize the services identified in the State-SLS Individual Support Plan while the Member is awaiting HCBS waiver enrollment.

Services for Individuals Experiencing Emergency Situations or Temporary Hardships a. State-SLS may be utilized to provide the following emergency or temporary services to individuals who have been determined to meet the criteria for an Intellectual / Developmental Disability as specified in Section 8.7202.D, in situations where temporary assistance can alleviate the need for a higher Level of Care. These services cannot be duplicative and shall not be accessed if available through other sources. In order to access State-SLS, an Individual Support Plan must be completed.

i. Payment of utilities:

Paying gas/electric bills and/or water/sewer bills:

a) Documentation must be maintained by the Case Management Agency that all alternative programs, community support, and natural supports were utilized before any State-SLS funds were authorized.

ii. Services with acquiring emergency food, at a retail grocery store when there are no other community resources available 1) Documentation must be maintained by the Case Management Agency demonstrating the reason why State- SLS funds were utilized over other sources of emergency food. This may include but is not limited to:

a) Other emergency food programs are not available.

b) Home delivered meals have unexpectedly stopped.

iii. Pest infestation abatement:

Documentation must be maintained by the Case Manager showing that infestation abatement is not covered under the Member’s residential agreement or lease.
Documentation that the pest abatement professional is licensed in the state of Colorado, must be maintained by the Case Management Agency and provided to the Department upon request.
Pest infestation abatement shall not be authorized if the Member resides in a provider owned and/or controlled property.
Documentation showing proof of payment must be maintained by the Case Management Agency administering the State-SLS program.

b. Service Limitations i. Support for utilities shall not exceed $1,000.00 in a State Fiscal Year.

ii. Support for pest infestation abatement shall not exceed $2,000.00 in a State Fiscal Year.

Supports for pest infestation abatement shall not cover more than one infestation event in a State Fiscal Year; and 2) Multiple treatments per event may be authorized, if determined necessary by a licensed pest abatement professional.

iii. Emergency food support shall not exceed $400.00 in a State Fiscal Year.

Services to Support Independence in the Community.

a. State-SLS may be utilized to provide an individual found eligible for or enrolled in an HCBS Medicaid waiver, with a one-time payment or acquisition of needed household items, in the event the Member is moving into a residence as defined in Section 8.7101.I.2.e..

i. State-SLS funds may be utilized for payment or acquisition of:

Initial housing costs including but not limited to a one-time initial set up for pantry items and/or kitchen supplies and/or furniture purchase.

ii. Individuals enrolled in the HCBS-DD waiver residing in a Group Residential Services and Supports (GRSS) or Individual Residential Services and Supports - Host Home (IRSS-HH) setting are not eligible for this Support.

b. State-SLS funds may support someone to have greater independence when they are moving into their own home, by paying for housing application fees.

c. The Case Management Agency shall maintain receipts or paid invoices for purchases authorized in this section. Receipts or paid invoices must contain at a minimum, the following information: business name, item(s) purchased, item(s) cost, date paid, and description of items purchased.

Documentation must be made available to the Department upon request.

All items must be purchased from an established retailer that has a valid business license.

d. Service limitations i. The one-time furniture purchase shall not exceed $300.00.

ii. The one-time initial pantry set up shall not exceed $100.00.

iii. The one-time purchase of kitchen supplies shall not exceed $200.00.

iv. The payment of housing application fees are limited to five (5) in a State Fiscal Year.

On-going State-SLS Support.

a. State-SLS funds may be authorized by the Case Management Agency for individuals who have been determined to meet the DD Determination requirements, but do not meet the requirements to be enrolled in HCBS- SLS Waiver Section 8.7101.I.

i. All HCBS Waiver Services identified as available to Members enrolled in the SLS waiver as identified throughout Section 8.7500, et seq.

ii. Service limitations and service rules found in the HCBS-SLS eligible Waiver Services in Section 8.7500, et seq. apply to the State-SLS program.

iii. The following additional services are also available to members who are not eligible for or do not meet the level of care for Community First Choice as defined in Section 8.7600 and include:

a) Electronic Monitoring as defined at Section 8.7520, et seq.

b) Homemaker as defined at Section 8.7527, et seq.

c) Personal Care as defined at Section 8.7538, et seq.

d) Remote Supports as defined at Section 8.7544, et seq.

v. Service limitations and service rules found in Community First Choice in Section 8.7600, et seq. apply to the State-SLS program.

v. Participant Directed services including CDASS and IHSS are not allowed under State-SLS.

vi. A Provider Agency is authorized to provide State-SLS services; and b. When an individual is enrolled in an HCBS waiver, State-SLS services may be utilized in combination with other community resources and/or Medicaid services. State-SLS services shall not be duplicative of other resources or HCBS services, and all other available and accessible resources shall be utilized before State-SLS services.

i. Individuals enrolled in HCBS SLS and HCBS DD shall not use State SLS for ongoing services but may use State SLS for emergency services or temporary hardships only.

ii. Only a Provider Agency can provide these services.

c. Service Limitation i. Total authorization limit for the plan year shall be determined by the Department and be communicated annually on the State-SLS Program rate schedule. 8.7560.D State-SLS Individual Support Plan 1. State-SLS Members are required to have a State SLS Individual Support Plan that is signed and authorized by the CMA Case Manager and the Member, or their Legally Authorized Representative.

The State-SLS Individual Support Plan shall be developed through an in-person meeting that includes, at least, the individual seeking services and the Case Manager. Upon Department approval, contact may be completed by the Case Manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted only when a public health emergency or natural disaster has been formally declared by state or federal authorities.
If a Member seeks additional services or identifies a change in need, the State- SLS Individual Support Plan shall be reviewed and updated by the Case Manager prior to any change in authorized services.
The State-SLS Individual Support Plan shall be effective for no more than one year and reviewed quarterly with the Member or on a more frequent basis if a change in need occurs.

a. Any changes to the provision of the services identified in the State-SLS Individual Support Plan are subject to available funds within the defined service area.

b. Any decision to modify, reduce or deny services set forth in the State-SLS Individual Support Plan, without the Member’s consent is subject to the Dispute Resolution Process found in Section 8.7202.S.

The State-SLS Individual Support Plan and all supporting documentation will be maintained by the Case Manager and will be made available to the Department upon request.
The State-SLS Individual Support Plan shall include the following:

a. The services authorized, the Member’s identified needs and how the services will address the needs.

b. The scope, frequency, duration, and cost of each service.

c. Other community resources being utilized.

d. Documentation demonstrating why the individual enrolled in State-SLS is not eligible or enrolled in a HCBS Medicaid waiver or documentation showing which HCBS waiver the individual is enrolled in;

e. Documentation demonstrating if other public or community resources have been utilized and why State-SLS funds are being utilized instead of or in combination with other resources.

f. Total cost of the services being authorized.

g. Information to support authorization of services for Individuals Experiencing Temporary Hardships, including:

i. A description of the hardship.

ii. The reason for the hardship.

iii. The length of time the support will be authorized, including the date of the onset of the hardship and the date it is expected to end.

iv. Total amount needed to support the individual and what other community resources are contributing.

v. A plan to reasonably ensure the hardship is temporary.

vi. A plan to reasonably ensure that dependence on State-SLS funds will be temporary.

vii. The dates of when the long-term solution will be in place and when the temporary hardship is expected to end.

viii. Documentation demonstrating how utilizing State-SLS funds will lead to the Member gaining more independence in the community or maintaining their independence in the community 8.7560.E State-SLS Case Management Services 1. Administration a. The Case Management Agency shall comply with all requirements set forth in Section 8.7200, et seq.

Case Management Duties:

a. The Case Manager shall coordinate, authorize, and monitor services based on the approved State-SLS Individual Support Plan.

i. The Case Manager shall have, based on the Member’s preference, an in person, virtual, or telephone contact once per quarter with b. The Case Manager shall assist Members to gain access to other resources for which they are eligible and to ensure Members secure longterm support as efficiently as possible.

c. The Case Manager shall provide all State-SLS documentation upon the request from the Department.

d. Referrals to the State-SLS program shall be made through the Case Management Agency in the geographic defined service area the Member or Applicant resides in. 8.7560.F State-SLS Transferring Services Between Case Management Agencies 1. When an individual enrolled in, or on the waiting list for, the State-SLS program moves to another Case Management Agency’s defined service area, and wishes to transfer their State-SLS, the following procedure shall be followed:

a. The originating Case Management Agency will contact the receiving Case Management Agency to inform them of the individual’s desire to transfer.

b. The originating Case Management Agency will send the State-SLS Individual Support Plan to the receiving Case Management Agency, where the receiving Case Management Agency will determine if appropriate State-SLS funding is available or if the individual will need to be placed on a waiting list. The receiving Case Management Agency’s decision of service availability will be communicated in the following way:

i. The receiving Case Management Agency will notify the individual seeking transfer of its decision by the individual’s preferred method, no later than 10 business days from the date of the request; and ii. The receiving Case Management Agency will notify the originating Case Management Agency of its decision by U.S. Mail, phone call or email of its decision no later than 10 business days from the date of the request.

c. The decision shall clearly state the outcome of the decision including:

i. The basis of the decision; and ii. The contact information of the assigned Case Manager or waiting list manager.

d. The originating Case Management Agency shall contact the individual requesting the transfer no more than five days from the date the decision was received to:

i. Ensure the individual understands the decision; and ii. Support the individual in making a final decision about the transfer.

e. If the transfer is approved, there shall be a transfer meeting in-person when possible, or by phone if geographic location or time does not permit, within 15 business days of when the notification of service determination is sent out by the receiving Case Management Agency. The transfer meeting must include but is not limited to the transferring individual and the receiving Case Manager. Any additional attendees must be approved by the transferring individual.

f. The receiving Case Management Agency must ensure that:

i. the transferring individual meets their primary contact of the receiving Case Management Agency.

ii. The individual is informed of the date when services will be transferred, when services will be available, and the length of time the services will be available.

g. The receiving Case Manager shall have an in-person face to face meeting with the Member to review and update the State-SLS Individual Support Plan, prior to the services being authorized. Upon Department approval, contact may be completed by the Case Manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the Case Manager or Member (e.g. natural disaster, pandemic, etc.). 8.7560.G State-SLS Waiting List Protocol 1. Persons determined eligible to receive services under the State SLS program, shall be eligible for placement on a waiting list for services when state funding is unavailable.

Waiting lists for persons eligible for the State SLS program shall be administered by the Case Management Agency, uniformly administered throughout the State and in accordance with these rules and the Department’s procedures.
Persons determined eligible shall be placed on the waiting list for services in the Case Management Agency service area of residency.

a. The date used to establish a person's placement on a waiting list shall be:

i. The date on which an individual is determined eligible for the State- SLS program through the DD Determination and the identification of need.

As funding becomes available in the State SLS program in a defined service area, persons shall be considered for services in order of placement on the local Case Management Agency’s waiting list.
Individuals with no other State or Medicaid funded services or supports will be given priority for enrollment including individuals who lose Medicaid eligibility and lose Medicaid Waiver Services.
Exceptions to these requirements shall be limited to:

a. Emergency situations or temporary hardships where the health, safety, and welfare of the person or others is greatly endangered, and the emergency cannot be resolved in another way. Emergencies are defined as follows:

i. Homeless: the person will imminently lose their housing as evidenced by an eviction notice; whose primary residence during the night is a public or private facility that provides temporary living accommodations; any other unstable or non-permanent situation; is discharging from prison or jail; or is in the hospital and does not have a stable housing situation to go upon discharge.

ii. Abusive or Neglectful Situation: the person is experiencing ongoing physical, sexual, or emotional abuse or neglect in their present living situation and his/her health, safety or well-being are in serious jeopardy.

iii. Danger to Others: the person's behavior or psychiatric condition is such that others in the home are at risk of being hurt by them.

Sufficient supervision cannot be provided by the current caretaker to ensure the safety of persons in the community.

iv. Danger to Self: a person's medical, psychiatric, or behavioral challenges are such that they are seriously injuring/harming themself or is an imminent danger of doing so.

v. Loss or Incapacitation of Primary Caregiver: a person’s primary caregiver is no longer in the person’s primary residence to provide care; the primary caregiver is experiencing a chronic, long-term, or life-threatening physical or psychiatric condition that significantly limits the ability to provide care; the primary caregiver is age 65 years or older and continuing to provide care poses an imminent risk to the health and welfare of the person or primary caregiver; or, regardless of age and based on the recommendation of a professional, the primary caregiver cannot provide sufficient supervision to ensure the person’s health and welfare.

Documentation demonstrating how the individual meets the emergency criteria shall be kept on file at the Case Management Agency and made available to the 8.7560.H State-SLS Case Management Agency and Provider Agency 1. A Provider Agency must submit all claims, payment requests, and/or invoices to the Case Management Agency for payment within thirty (30) days of the date of service, except for Services and Supports rendered in June, the last month of the State Fiscal Year. All claims, payment requests, and/or invoices for services rendered in June must be submitted by the date specified by the Case Management Agency to ensure payment.
Case Management Agency must submit all claims, payment requests, and/or invoices in the format and timeframe established by the Department.
Case Management Agency and Provider Agency claims, payment requests, or invoices for reimbursement shall be made only when the following conditions are met:

a. Services are provided by a qualified Provider Agency.

b. Services are authorized and delivered in accordance with the frequency, amount, scope and duration of the service as identified in the Member’s State-SLS Individual Support Plan;

c. Required documentation of the specific service is maintained and sufficient to support that the service is delivered as identified in the State- SLS Individual Support Plan and in accordance with the service definition;

d. All Case Management Activities must be documented and maintained by 4. Case Management Agency and Provider Agencies shall maintain records in accordance with Sections 8.130.2 and 8.7405.

Case Management Agency and Provider Agency reimbursement shall be subject to review by the Department and may be completed after the payment has been made to the Case Management Agency and Provider Agency.
Case Management Agencies and Provider Agencies are subject to all program integrity requirements in accordance with Section 8.076.
The reimbursement for this service shall be established in the Department’s published fee schedule.
Except where otherwise noted, Provider Agency reimbursement shall be based on a statewide fee schedule. State developed fee schedule rates are the same for both public and private provider agencies and the fee schedule and any annual/periodic adjustments to the fee schedule are published in the provider bulletin and can be accessed through the Department’s fiscal agent’s website.

a. State-SLS rates shall be set and published in the provider bulletin annually each State Fiscal Year. 8.7561 Family Support Services Program (FSSP) 8.7561.A FSSP Administration 1. The Case Management Agency (CMA) shall administer the Family Support Services Program (FSSP), subject to available appropriations and according to the rules, regulations, policies and guidelines of the Department, local Family Support Council (FSC) and Case Management Agency.

The Case Management Agency shall ensure that the FSSP is implemented within its defined service area.
The Case Management Agency shall designate one (1) person as the contact for the overall implementation and coordination of the FSSP.
Referrals to the FSSP shall be made through the Case Management Agency pursuant to Section 8.7202.B.
Nothing in these rules and regulations shall be construed as to prohibit or limit services and supports available to a Member with an Intellectual and Developmental Disability or Developmental Delay and their families which are authorized by other state or federal laws.
The Case Management Agency, in cooperation with the local FSC, shall ensure that the FSSP is publicized within the designated service area.
The Case Management Agency shall develop written policies and procedures for the implementation and ongoing operation of the FSSP, which must be kept on file and made available to the Department or the public, upon request. 8.7561.B FSSP Family Support Council (FSC)
The Case Management Agency shall assist its defined service area to establish and maintain an FSC pursuant to Section 25.5-10-304, C.R.S.
The Case Management Agency shall establish an FSC roster that includes the names of Members, type of membership and identifies the chairperson. The roster shall be available to the Department or the public, upon request.
Composition of the FSC:

a. The majority of the members and the chairperson of each FSC shall be Family Members of an individual with an Intellectual and Developmental Disabilities or Developmental Delay.

b. New members of the FSC shall be recruited from the service area. New members shall be approved by the current FSC and the governing body of c. The members of the FSC shall receive written notice of their appointment.

d. The Case Management Agency shall ensure an orientation and necessary training regarding the duties and responsibilities of the FSC is available for all council members. The training and orientation shall be documented with a record of the date of the training, who provided the training, training topic, and names of attendees.

e. The size of the FSC shall be sufficient to meet the intent and functions of the council, but no fewer than five (5) persons, unless approved by the f. Each FSC shall establish the criteria for tenure of members, selection of new members, the structure of the council and, in conjunction with the Case Management Agency, a process for addressing disputes or disagreements between the FSC and the Case Management Agency.

Such processes shall be documented in writing. Processes may include a request for mediation assistance from the Department.

The FSC duties include providing guidance and assistance to the Case Management Agency on the following:

a. Overall implementation of the FSSP;

b. Development of the written annual FSSP report for the defined service area, as defined at Section 8.7561.K;

c. Development of written procedures describing how families are prioritized for FSSP funding;

d. Development of written policy defining how an emergency fund is established, funded and implemented. The policy must include a definition of a short-term Crisis or emergency and the maximum amount of funds a Family may receive per event and/or year;

e. Provide recommendations on defining the “other” service category within the parameters as defined in this part;

f. Monitor the implementation of the overall services provided in the defined service area; and g. Provide recommendations on how to assist families who are transitioning out of the FSSP. 8.7561.C FSSP Member Eligibility 1. Any individual with an Intellectual and Developmental Disability or Developmental Delay, as determined pursuant to Section 25.5-10-211, C.R.S., living with their Family is eligible for the FSSP. Living with a Family means that the individual's place of residence is with that family.

a. If an individual does not reside in the primary residence because of transition into or out of the home for more than 6 months, that individual is no longer eligible for FSSP.

b. The Case Management Agency, in cooperation with the local FSC, shall determine what constitutes a transition.

The Family and eligible individual shall reside in the State of Colorado.
Eligibility for the FSSP does not guarantee the availability of services under this 8.7561.D FSSP Direct Services and Inclusions 1. Services and supports available under the FSSP may be purchased from any provider that is able to meet the individual needs of the family.
All services must be needed as a result of the individual’s Intellectual and Developmental Disability or Developmental Delay and shall not be approved if the need is a typical age-related need. Correlation between the need and the disability must be documented in the Family Support Plan (FSP).
All services must be provided in the most cost-effective manner, meaning the least expensive manner to meet the need.
All services shall be authorized pursuant to the FSP.
Services provided to the Family through the FSSP shall not supplant third party funding sources available to the Family including, but not limited to, public funding, insurance, or trust funds.
Case Management Agencies shall not charge a separate fee for assisting individuals to access services identified on the FSP.
FSSP funds shall not be used for any donation to religious, political, or otherwise causes, or activities prohibited by law.
Included Direct Services:

a. Assistive technology is equipment or upgrades to equipment, which are necessary for the individual with an Intellectual and Developmental Disability or Developmental Delay to communicate through expressive and receptive communication, move through or manipulate his or her environment, control his or her environment, or remain safe in the family home. Assistive technology includes non-Adaptive Equipment that meets disability-specific needs identified in the Family Support Plan.

b. Environmental engineering is a home or vehicle modification needed due to the individual’s disability and is not a regular maintenance or modification needed by all owners. Modifications to the home or vehicle must be:

i. Necessary due to the individual’s Intellectual and Developmental Disability or Developmental Delay;

ii. Needed due to health and safety; or iii. To allow the individual to attain more independence;

iv. Modifications must be completed in a cost-effective manner. Costeffective manner means the least expensive manner to meet the identified need. Home modifications are to be limited to the common areas of the home the individual with an Intellectual and Developmental Disability frequents, the individual’s bedroom, and one bathroom. Other bedrooms and bathrooms shall not be modified. All devices and adaptations must be provided in accordance with applicable state or local building codes and/or applicable standards of manufacturing, design, and installation.

Only homes or vehicles occupied and owned by the Family where the eligible individual resides may be modified. Minor modifications may be made to rental units with the permission of the landlord. Rental modifications must be made in a way that the modification can be moved with the eligible individual during a change in residence.

c. Medical and dental items prescribed by a medical professional licensed and qualified to prescribe such items and are needed to maintain or attain physical health. Medical, dental, and vision services, exams and procedures are available when not covered by another source.

i. Over the counter medications and vitamins are excluded, except as indicated at Section 8.800.4.D, when prescribed by a medical professional licensed and qualified to write such prescriptions.

d. Other: Services in this category must be identified in the FSP, are specific to the family, and are limited to:

i. A consultant and/or advocate to assist a Family with accessing services outside of the Case Management Agency.

ii. Recreational needs of the individual with an Intellectual and Developmental Disability or Developmental Delay when the need of recreation is above and beyond the typical need due to the disability or delay. The cost of family recreation passes shall the cost of one family pass per fiscal year and shall be limited to use only at community recreation centers, except in communities where community recreation centers do not exist and in cases where the use of an alternative recreation facility is justified by a need related to the disability or delay, and the activity and/or facility is recommended by a licensed or certified professional qualified to make the recommendation. In such circumstances, the Case Management Agencies shall document the professional recommendation and demonstrate that the chosen facility is the least expensive option to meet the family’s needs.

The following items are specifically excluded under the FSSP and shall not be eligible for coverage:

a) Entrance fees for:

i) Zoos;

ii) Museums;

iii) Movie theaters, performance theaters, concerts, other entertainment venues; and iv) Professional and minor league sporting events.

b) Outdoors play structures; and c) Batteries for recreational items.

iii. Specialized services as identified by the FSC and Case Management Agency included in their written policy and are available to any Family receiving ongoing FSSP assistance in the service area.

e. Parent and sibling support, which may include special resource materials or publications, cost of care for siblings, or behavioral services or counseling.

f. Professional services are services which require licensure or certification to treat a human condition other than medical, dental or vision, and is provided to the individual with an Intellectual and Developmental Disability or Developmental Delay. Professional services must be provided by qualified, certified and/or licensed personnel in accordance with the standards and practices of the industry. Professional services may include related support items, equipment, or activities which are recommended as

part of the therapy with supporting documentation from the treating professional. Insurance expenses directly incurred by the individual with an Intellectual and Developmental Disability or Developmental Delay are included.

g. Program expenses are services provided by the Case Management Agency for the benefit of multiple families; and are funded through the direct service line. Program expenses include:

i. Maintenance, operation, or enhancement of a resource library that consists of an inventory of goods and equipment used to meet the needs of individuals with an Intellectual and Developmental Disability or Developmental Delay on a temporary basis;

ii. Costs associated with participation with other community agencies in the development, maintenance, and operation of projects, supports or services that benefit individuals with an Intellectual and Developmental Disability or Developmental Delay;

ii. Development or coordination of a training event for families;

iv. Costs of an event sponsored by the Case Management Agency for all eligible individuals and their families to meet other families to provide socialization and an opportunity to build a network of support; or v. Development and coordination of group respite.

vi. The FSC in conjunction with the Case Management Agency shall determine the maximum amount of direct services to be used for program expenses.

h. Respite is the temporary care of an individual with an Intellectual and Developmental Disability that provides relief to the primary caregiver.

i. Transportation is the direct cost to the Family that is higher than costs typically incurred by other families because of specialty medical appointments or therapies. Specialty medical appointments or therapies are defined as appointments needed due to the individual’s Intellectual and Developmental Disability or Developmental Delay. The direct cost is the cost of transportation, lodging, food expense, and long-distance telephone calls to arrange for or coordinate medical services which are not covered by other sources. 8.7561.E FSSP Waiting List 1. The Case Management Agency shall maintain an accurate and up-to-date waiting list of eligible individuals for whom FSSP funding is unavailable in the current fiscal year.

In cooperation with the local FSC, the Case Management Agency shall develop written procedures for determining how and which individuals on the waiting list will be enrolled into the FSSP.
Individuals receiving ongoing FSSP funding shall not be listed on the waiting list for the program.
Individuals determined to be prioritized for FSSP funding shall be served prior to individuals determined at a lower level of prioritization.
The Case Management Agency must inform eligible families of the program and waiting list procedures and offer Assessment and enrollment onto either the waiting list or the program, based on the Assessment and available appropriations.
Any individual on the waiting list for FSSP may receive emergency funding through the Case Management Agency through the FSSP, if the needs meet the parameters set by the FSC and the Case Management Agency.
Waiting lists shall not exist for any Case Management Agency that does not expend all FSSP direct service funds. 8.7561.F FSSP Prioritization for Family Support Services (FSSP) Funding 1. Case Management Agencies must ensure that families with the highest assessed needs shall be prioritized for FSSP state funding.
Case Management Agencies, in conjunction with the FSC, will develop written procedures that describe how families shall be prioritized and notified of the prioritization process.
The Assessment process shall be applied equally and consistently to all families who are assessed.
Case Management Agencies must distribute the prioritization process to families in their defined service area at the time the Family requests FSSP funding, when the individual is placed on the waiting list, or upon request.
The Case Management Agency must notify families in writing of the results of the 6. All families, both on the waiting list and receiving FSSP services, shall be assessed for level of need on an annual basis or earlier if the family’s circumstances change.
The Assessment must contain the following components:

a. The qualifying individual’s disability and overall care need, which includes:

i. The type of disability or condition and the need and complexity of medical or personal care for the individual;

ii. The need for, frequency of, and amount of direct assistance required to care for the individual; and iii. The types of services needed that are above and beyond what is typically needed for any individual.

b. The qualifying individual’s behavioral concerns, including how behaviors disrupt or impact the family’s daily life, the level of supervision required to keep the individual and others safe, and the services and frequency required to help with the behaviors.

c. The Family composition, which considers obligations and limitations of the Parent(s), the number of siblings, disabilities of other family members living in the home, and the level of stability of the family, such as pending divorce or age and disability of Parents.

d. The family’s access to support networks, which includes the level of isolation or lack of support networks for the family, such as not having extended family nearby, living in rural areas or availability of providers.

e. The family’s access to resources such as family income, insurance coverage, HCBS waivers, and/or other private or public benefits. 8.7561.G FSSP Case Management Responsibilities 1. Case management is the coordination of services provided for individuals with an Intellectual and Developmental Disability (IDD) or Developmental Delay that consists of facilitating enrollment, assessing needs, locating, coordinating, and monitoring needed FSSP funded services, such as medical, social, education, and other services to ensure non-duplication of services, and monitor the effective and efficient provision of services across multiple funding sources.

At minimum, the Case Manager is responsible for:

a. Determining initial and ongoing eligibility for the FSSP;

b. Development, application assistance, and annual re-evaluation of the Family Support Plan (FSP); and c. Ensuring service delivery in accordance with the FSP.

Family Support Plan Requirements a. Families enrolled into the FSSP shall have an individualized FSP which meets the requirements of an Individualized Plan, as defined in Sections 25.5-10-202 and 25.5-10-211, C.R.S., and includes the following information:

i. The name of the eligible individual;

ii. The names of Family Members living in the household;

iii. The date the FSP was developed or revised;

iv. The prioritized needs requiring support as identified by the family;

v. The specific type of service or support, how it relates to the Family need and the individual’s disability or Developmental Delay, and period which is being committed to in the FSP, including, when applicable, the maximum amount of funds which can be spent for each service or support without amending the FSP;

vi. Documentation regarding cost-effectiveness of a service or support, which can include quotes, bids, or product comparisons but must include the reason for selecting a less cost-effective service or support, when applicable;

vii. A description of the desired results, including who is responsible for completion;

viii. The projected timelines for obtaining the service or support and, as appropriate, the frequency;

ix. A statement of agreement with the plan;

x. Signatures, which may include digital signatures of a family representative and an authorized Case Management Agency representative;

xi. The level of need;

xii. The length of time the funds are available; and xiii. A description of how payment for the services or supports will be made.

b. The FSP shall integrate with other service plans affecting the Family and avoid, where possible, any unnecessary duplication of services and supports.

c. The FSP shall be reviewed at least annually or on a more frequent basis if the plan is no longer reflective of the family's needs.

i. Any changes to the provision of services and supports identified in the FSP are subject to available funds within the defined service area.

ii. Any decision to modify, reduce or deny services or supports set forth in the FSP, without the family's agreement, are subject to the requirements in Section 8.7201.D.

Emergency Fund a. Each Case Management Agency shall establish an emergency fund that may be accessed by any individual eligible for the FSSP when needed due to an unexpected event that has a significant impact on the individual or family’s health or safety and impacts the family’s daily activities.

b. Any individual with an Intellectual and Developmental Disability (IDD) or Developmental Delay determined by the Case Management Agency and living with Family shall be eligible to receive emergency funds regardless of the enrollment status of the family.

c. The Case Management Agency in conjunction with the Family Support Council shall develop written policies and procedures regarding the Emergency Fund. At a minimum the policies and procedures must:

i. Define the purpose of the emergency fund;

ii. Define an unexpected event and significant impact;

iii. Describe the process for accessing emergency funds;

iv. Describe how funding determinations are made;

v. Give a timeline of the determination of the request;

vi. Define the maximum funding amount per Family or per event; and vii. Describe how families will be notified of the decision in writing. 8.7561.H FSSP Billing and Payment Procedures 1. The Case Management Agency shall develop and implement policies, procedures, and practices for maintaining documentation for the FSSP and reporting information in the format and timeframe established by the Department.

Families shall maintain and provide either receipts or invoices to the Case Management Agency documenting how funds provided to the Family through the FSSP were expended. The Case Management Agency shall maintain supporting documentation capable of substantiating all expenditures and reimbursements made to providers and/or families, which shall be made available to the a. When the Case Management Agency purchases services or items directly for families, the Case Management Agency shall maintain receipts or invoices from the service provider and documentation demonstrating that the provider was paid by the Case Management Agency. Receipts or invoices must contain, at a minimum, Member and/or Family name, provider name, first and/or last date of service, item(s) or service(s) purchased, item(s) or service(s) cost, amount due or paid.

b. When the Case Management Agency reimburses families for services or items, the Case Management Agency shall ensure the Family provides the Case Management Agency with receipts or invoices prior to reimbursement. The Case Management Agency shall maintain receipts or invoices from the families, and documentation demonstrating that the Family was reimbursed by the Case Management Agency. The Case Management Agency must ensure all receipts or invoices provided by the families contain, at a minimum, Member and/or Family name, provider name, first and/or last date of service, item(s) or service(s) purchased, item(s) or service(s) cost, amount paid.

c. When the Case Management Agency provides funding to the families for the purchase of services or items in advance, the Case Management Agency shall notify the families that they are required to submit invoices or receipts to the Case Management Agency of all purchases made prior to the close of the State Fiscal Year. The Case Management Agency must ensure that all receipts or invoices are collected and maintained from the family, as well as documentation demonstrating that the Family received funding from the Case Management Agency. The Case Management Agency must ensure all receipts or invoices provided by the families contain, at a minimum, Member and/or Family name, provider name, first and/or last date of service, item(s) or service(s) purchased, item(s) or service(s) cost, amount paid.

The Case Management Agency shall submit to the Department, on a form and frequency prescribed by the Department, information which outlines individual Family use of the FSSP.
The Case Management Agency shall report only FSSP expenditure data in the format and timeframe as designated by the Department. 8.7561.I FSSP Program Evaluation 1. The Case Management Agency, in cooperation with the local Family Support Council, shall be responsible for evaluating the effectiveness of the FSSP within its defined service area on an annual basis.
The evaluation may be based upon a Family satisfaction survey and shall address the following areas:

a. Effectiveness of outreach/public awareness including:

i. The demographics of participants in comparison to demographics of the service area; and ii. How well the program integrates with other community resources.

b. Satisfaction and program responsiveness to include:

i. Ease of access to the program;

ii. Timeliness of services;

iii. Effectiveness of services;

iv. Availability of services;

v. Responsiveness to Family concerns;

vi. Overall Family satisfaction with services; and vii. Recommendations.

c. Effective coordination and utilization of funds to include:

i. Other local services and supports utilized in conjunction with the FSSP; and ii. Efficiency of required documentation for receipt of the FSSP.

d. The Case Management Agency, and participating families as requested, shall cooperate with the Department regarding statewide evaluation and quality assurance activities, which includes, but is not limited to providing the following information:

i. The maximum amount any one Family may receive through the FSSP during the fiscal year; and ii. The total number of families to be served during the year. 8.7561.J FSSP Performance and Quality Review 1. The Department shall conduct a Performance and Quality Review of the FSSP to ensure that it complies with the requirements set forth in these rules.

A Case Management Agency found to be out of compliance with these rules through the results of the Performance and Quality Review, shall be required to develop a Corrective Action Plan, upon written notification from the Department.

A Corrective Action Plan must be submitted to the Department within ten (10) business days of the receipt of the written request from the Department. A Corrective Action Plan shall include, but not limited to:

a. A detailed description of the action to be taken, including any supporting documentation;

b. A detailed time frame specifying the actions to be taken;

c. Employee(s) responsible for implementing the actions; and d. The implementation timeframes and a date for completion.

The Case Management Agency shall notify the Department in writing, within three (3) business days if it will not be able to present the Corrective Action Plan by the due date. The Agency shall explain the rationale for the delay and the Department may grant an extension, in writing, of the deadline for the Agency’s compliance.

a. Upon receipt of the Corrective Action Plan, the Department will accept, modify or reject the proposed Corrective Action Plan. Modifications and rejections shall be accompanied by a written explanation.

b. In the event that the Corrective Action Plan is rejected, the Agency shall re-write the Corrective Action Plan and resubmit along with the requested documentation to the Department for review within five (5) business days.

c. The Agency shall implement the Corrective Action Plan upon acceptance by the Department.

d. If corrections are not made within the requested timeline and quality specified by the Department, funds may be withheld or suspended. 8.7561.K FSSP Annual Report 1. Each Case Management Agency shall submit an annual FSSP report to the Department by October 1 of each year. The report will contain two sections.

a. The first section must describe how the Case Management Agency plans to spend the FSSP funds in the current fiscal year and will include:

i. Description of the outreach/public awareness efforts for the coming year;

ii. Description of anticipated special projects or activities under the Program Expense service category; and iii. Goals with measurable outcomes for any changes to the FSSP.

b. The second section of the annual report will describe how the FSSP funds were spent in the previous year and must contain:

i. The program evaluation outcomes for the previous year as described in this section;

ii. The total amount of funds expended by service category;

iii. The total number of families served, and the total number of families placed on the waiting list;

iv. Detailed information for the Program Expense service category to 1) The total number of families that utilized services under the Program Expense category;

The specific services provided; resource library, special projects, training events, social events, or group respite;
How these services enhanced the lives of families in the community and the total number of families who participated in each project; and 4) The report shall include the total number of staff, total of staff cost, and other costs associated with the Program Expense service category.

v. A description of how the annual FSSP report was distributed to eligible families; and vi. The signature of Family Support Council (FSC) members, the FSSP Coordinator, and the Case Management Agency Executive Director. 8.7562 HCBS Telehealth Delivery 1. Telehealth means the broad use of technologies to provide services and supports through HCBS waivers when the Member is in a different location from the 8.7562.A HCBS Telehealth Inclusions 1. HCBS Telehealth may be used to deliver support through the following authorized HCBS Waiver Services:

a. Adult Day Services; defined at Section 8.7505;

b. Behavioral Management and Education; defined at Section 8.7508;

c. Behavioral Therapies - Behavioral Consultation; defined in Section d. Behavioral Therapies - Behavioral Counseling, Group, defined in Section e. Behavioral Therapies - Behavioral Counseling, Individual, defined in

Section 8.7509;

f. Behavioral Therapies - Behavioral Plan Assessment; defined in Section g. Bereavement Counseling; defined at Section 8.7511;

h. Child and Youth Mentorship; defined at Section 8.7512;

i. Community Connector; defined at Section 8.7514;

j. Counseling Services, Family; defined at Section 8.7516;

k. Counseling Services, Group; set forth at Section 8.7516;

l. Counseling Services, Individual; set forth at Section 8.7516;

m. Day Habilitation; described at Section 8.7517;

n. Expressive Therapy - Art and Play Therapy, Group; defined at Section o. Expressive Therapy - Art and Play Therapy, Individual; defined at Section p. Expressive Therapy - Music Therapy, Group; defined at Section 8.7521;

q. Expressive Therapy - Music Therapy, Individual; defined at Section r. Independent Living Skills Training; defined at Section 8.7529;

s. Mentorship; defined at Section 8.7533;

t. Movement Therapy; defined in Section 8.7534;

u. Palliative/Supportive Care; defined at Section 8.7536;

v. Substance Use Counseling, Family; defined at Section 8.7548;

w. Substance Use Counseling, Individual; defined at Section 8.7548;

x. Supported Employment - Job Coaching, Individual, defined in Section 8.7549;

y. Supported Employment - Job Development, Levels 1-6, Individual, defined at Section 8.7549;

z. Life Skills Training; described at Section 8.7530;

aa. Peer Mentorship; defined at Section 8.7537;

bb. Therapeutic Life Limiting Illness Support, Family; defined at Section 8.7551;

cc. Therapeutic Life Limiting Illness Support, Group; defined at Section 8.7551;

dd. Therapeutic Life Limiting Illness Support, Individual; defined at Section 8.7551; and ee. Wraparound Services - Wraparound Plan and Prevention and Monitoring; defined at Section 8.7557.

HCBS Telehealth may only be used to deliver consultation for the following services:

a. Adaptive Therapeutic Recreational Fees and Equipment, described at

Section 8.7504;

b. Assistive Technology; defined in Section 8.7507 c. Home Accessibility Modifications and Adaptations; defined in Section 8.7525 and d. Vehicle Modifications, defined in Section 8.7554.

e. Providers shall follow all billing policies and procedures as outlined in the Department’s current waiver billing manuals and rates/fees schedules and may not bill separately for consultation. 8.7562.B HCBS Telehealth Exclusions and Limitations 1. HCBS Telehealth is subject to the limitations of the respective service it supports as referenced in this rule at Section 8.7562.A.

HCBS Telehealth is not a duplication of Health First Colorado Telehealth or Telemedicine services.
HCBS Telehealth is not permitted to be used for any service not listed in this rule at Section 8.7562.A. 8.7562.C HCBS Telehealth Provider Agency Requirements 1. Providers that choose to use HCBS Telehealth shall develop and make available a written HCBS Telehealth Policy which at a minimum shall include the following:

a. The Member may refuse telehealth delivery at any time without affecting the Member’s right to any future services and without risking the loss or withdrawal of any service to which the Member would otherwise be entitled;

b. All required and applicable confidentiality protections that apply to the services;

c. The Member shall have access to all collected information resulting from the services utilized as required by state law;

d. How utilization of HCBS Telehealth will be made available to those Members who require assistance with accessibility, translation, or have limited visual and/or auditory capabilities;

e. A contingency plan for service delivery if technology options fail; and, f. Provider Agencies shall maintain a copy of the HCBS Telehealth Policy signed by the Member in their records.

Provider Agencies shall ensure the use of HCBS Telehealth is the choice of the Member. The HCBS Provider Agency shall maintain a consent form for the use of HCBS Telehealth in the Member’s record.
Provider Agency shall complete a provider-developed evaluation of the Member and caregiver prior to using HCBS Telehealth services that identifies the Member’s ability to participate and outlines any accommodations needed while utilizing HCBS Telehealth.
Providers must comply with all HIPAA and confidentiality procedures. HCBS Providers Agencies must be able to use a technology solution that allows realtime interaction with the Member which may include audio, visual and/or tactile technologies.
Provider Agencies shall not use HCBS Telehealth to address a Member’s emergency needs.
Providers Agencies shall use a HIPAA compliant technology solution meeting all privacy requirements. 8.7562.D HCBS Telehealth Reimbursement 1. HCBS Telehealth does not include reimbursement for the purchase or installation of Telehealth equipment or technologies.
HCBS Waiver service providers utilizing Telehealth shall follow all billing policies and procedures as outlined in the Department’s current waiver billing manuals and rates/fees schedules. This includes the prohibition on collecting copayments or charging Members for missing set times for services. 8.7600 Community First Choice 8.7600.A Community First Choice (CFC) Program 1. The Community First Choice Program is funded through an appropriation from the Colorado General Assembly and the Federal government. The CFC program is designed to provide select Home and Community-Based Services and Supports to eligible members on the State Plan.
Legal authority as defined in 8.7000.A. 8.7601 General CFC Provisions 1. CFC must be provided to individuals on a statewide basis and in a manner that provides services and supports in the most integrated setting appropriate to meet individuals’ needs, and without regard for the individual’s age, type or nature of disability, severity of disability, or the form of home and community-based services and supports that the individual requires to lead an independent life.
Individuals receiving services through CFC will not be precluded from receiving other home and community-based or long-term care services and supports through other Medicaid state plan, waiver, grant or demonstration authorities, as long as there is no duplication of services.
For the duration of the first year of CFC implementation, Case Managers shall assess current HCBS waiver members for CFC eligibility and services at the time of Continued Stay Review. Case Managers may assess current HCBS waiver members prior to the scheduled Continued Stay Review as warranted by a documented change in the member’s needs, diagnosis, or condition. 8.7602 CFC Member Rights and Responsibilities 1. CFC must adhere to all requirements in Home and Community-Based Services Member Rights and Responsibilities as defined in 8.7001 et seq. 8.7603 CFC Definitions 1. Activities of Daily Living is as defined at Section 8.7100.A.1.
Assessment is as defined at Section 8.7200.B.1 3. Case Management is as defined at Section 8.7100.A.7.
Case Management Agency (CMA) is as defined at Section 8.7100.A.8.
Member, for purposes of this Section 8.7600, et seq. means an individual who has met CFC eligibility requirements and has been offered and agreed to receive CFC Services.
Community First Choice (CFC) is as defined at Section 8.7001.A.1-A.
Continued Stay Review is as defined at Section 8.7100.A.14.
Institution is as defined at Section 8.7100.A.39.
Level of Care (LOC) is as defined at Section 8.7100.A.43.
Level of Care Assessment is as defined at Section 8.7100.A.44.
Long-Term Services and Supports (LTSS) is as defined at Section 8.7100.A.47.
Medicaid Eligible is as defined at Section 8.7100.A.48.
Reassessment is as defined at Section 8.7100.A.55.
Referral is as defined at Section 8.7100.A.56. 8.7604 CFC Member Eligibility 1. Individuals of all ages shall be eligible for CFC if they meet Level of Care and financial eligibility criteria.

a. CFC is available to individuals who, absent the provision of home and community-based attendant services and supports provided under CFC, would require the level of care furnished in a:

i. Nursing Facility;

ii. Intermediate Care Facility;

iii. In Patient Psychiatric Facility for Individuals under 21; or iv. Hospital b. Financial Eligibility Criteria: To be eligible for the CFC Benefit, an individual shall meet one of the following eligibility groups:

i. Members shall meet Medicaid Assistance eligibility criteria as stated at Section 8.100 and be enrolled in a Medicaid eligibility group that includes nursing facility services.

CFC does not qualify as a Health First Colorado eligibility group.

ii. Members eligible for, and enrolled in, an HCBS Waiver as defined in 8.7000, will be eligible for CFC.

Level of Care determination process a. Individuals shall be referred to the Case Management Agency for an initial Long-Term Services and Supports (LTSS) eligibility determination. The LTSS Level of Care (LOC) eligibility determination screen as defined in 8.401 is used to determine an individual's need for institutional Level of Care.

b. The state-prescribed Assessment instrument as defined in 8.401 shall measure six defined Activities of Daily Living (ADLs) and the need for supervision for behavioral, executive or cognitive dysfunction. ADLs include bathing, dressing, toileting, mobility, transferring, and eating.

c. Level of Care Assessments and Reassessments shall be performed by Case Management Agencies and utilize the same instrument in determining the Level of Care for all LTSS programs.

d. The individual must require Long-Term Services and Supports to remain in their own home, in the family residence, or in the community.

e. To utilize CFC Services, the individual must choose to receive services in their home or community.

f. The Case Management Agency shall certify CFC eligibility only for those individuals determined by a Level of Care Assessment to require the Level of Care available in an Institution according to Section 8.401.

g. For the initial Level of Care Screen, verified Medical Documentation of the individual's diagnoses or health conditions and prescribed medications shall be provided as outlined in 8.7100.D.

Institutional Status a. Members who are residents of Institutions are not eligible for CFC Services while residing in such Institutions.

b. A Member enrolled in CFC and who is admitted to a hospital may not receive CFC Services while residing in the hospital.

i. Providers shall not be reimbursed for CFC Services provided while the member is in a hospital.

c. A Member enrolled in CFC and who is admitted to a nursing facility or ICF- IID may not receive CFC Services while in the nursing facility or Intermediate Care Facilities.

Maintenance of CFC Eligibility a. Reevaluation of the Member to verify Medicaid, financial, and program eligibility is required within twelve months following any previous Assessment. The Continued Stay Review will follow the same procedures set forth at Section 8.401.11-.17(H).
Termination a. The Department shall discontinue a member’s enrollment in the CFC benefit when one of the following occurs:

i. The Member no longer meets the CFC Benefit Level of Care and/or Financial eligibility criteria, ii. The member dies, iii. The member is admitted for a long-term stay beyond one month in an Institution, or iv. The member voluntarily withdraws from the CFC program. 8.7605 CFC Case Management Agency Requirements 1. Case Management Agencies must adhere to all Home and Community-based Services requirements as defined at Section 8.7200, et seq. 8.7606 CFC Provider Requirements 1. CFC providers must adhere to all Home and Community-Based Services Provider Agency Requirements as defined at 8.7400, et seq. 8.7607 CFC Covered Services 1. CFC includes the following Home and Community-Based Services as defined at

Section 8.7500, et seq. Services include:

a. CFC Direct Care Services:

i. Health Maintenance Activities as described at Section 8.7523, ii. Homemaker as described at Section 8.7527, iii. Personal Care as described at Section 8.7538, b. Electronic Monitoring as described at Section 8.7520.

c. Home Delivered Meals as described at Section 8.7526, d. Remote Supports as described at Section 8.7544, and e. Transition Setup as described at Section 8.7552. 8.7607.A CFC Direct Care Services Exception Request 1. CFC Direct Care Services Exception Request Definitions a. Case Management Supervisor or Alternative Qualified Professional Review means the required first-level review from a Case Management Supervisor or Alternative Qualified Professional to authorize service hours above the Age-Appropriate Task Standards for Children, the Task Standards for Adults, 7 hours per week of the Protective Oversight task in Personal Care, and the Annual CFC Service Soft Caps when indicated by the Direct Care Services Calculator (DCSC).

i. Case Management Agencies shall develop an internal process for the Supervisor or Alternative Qualified Professional Review which includes deadlines to ensure exceedance requiring a CFC Direct Care Services Department Review Request meets the applicable deadlines.

b. CFC Direct Care Services Department Review Request means the required process for service authorizations above 7 hours per week of the Protective Oversight Task in Personal Care and/or the Annual CFC Service Soft Caps, as defined at Sections 8.7502.LL, 8.7515.E, 8.7528.E, 8.7538.D, 8.7527.D, and 8.7523.D, for Homemaker, Personal Care, and/or Health Maintenance Activities.

c. The CFC Direct Care Services Exception Request means a formal request submitted by a Case Manager, with required supporting documentation, seeking a Case Management Supervisor or Alternative Qualified Professional Review or a CFC Direct Care Services Department Review to authorize CFC Direct Care Services in excess of established limits, including applicable maximum Task Standards and service caps. Case Managers must follow the guidelines described in Section 8.7607.A.2 and all additional operational guidance from the Department. Case Management Supervisor or Alternative Qualified Professionals must follow the guidelines described in Section 8.7607.A.3 and all additional operational guidance from the Department. The Department must follow the requirements described in Section 8.7607.A.4.

d. For the purposes of the CFC Direct Care Services Exception Request, Case Management Supervisor means a Case Management Supervisor that meets the qualifications described in Section 8.7203.A.6 and performs all other supervisory requirements described in Section 8.7204.

e. For the purposes of the CFC Direct Care Services Exception Request, Alternative Qualified Professional means an alternative professional that is contracted by the Case Management Agency and is qualified to provide a review within the scope of their license, such as a Registered Nurse or other credentialed professional.

CFC Direct Care Services Exception Request Case Manager Responsibilities a. Case Managers shall submit for a Case Management Supervisor or Alternative Qualified Professional Review and, if applicable, a CFC Direct Care Services Department Review Request if the Member meets the criteria described in this section and Department operational guidance to exceed the Age-Appropriate Task Standards for Children, the Task Standards for Adults, 7 hours per week of the Protective Oversight Task in Personal Care, and the Annual CFC Service Soft Caps. The Case Manager makes the final determination on submitting a Case Management Supervisor or Alternative Qualified Professional Review b. Case Managers shall seek a Case Management Supervisor or Alternative Qualified Professional Review and obtain approval from a Case Management Supervisor or Alternative Qualified Professional prior to:

i. Authorizing hours above the Age-Appropriate Task Standards for Children;

ii. Authorizing hours above the Task Standards for Adults;

iii. Submitting a CFC Direct Care Services Department Review Request to exceed 7 hours per week of Protective Oversight Task in Personal Care; and/or iv. Submitting a CFC Direct Care Services Department Review Request to exceed Annual CFC Service Soft Caps.

c. If the total exceedance of the Age-Appropriate Task Standards for Children or Task Standards for Adults is greater than the Annual CFC Service Soft Caps, a CFC Direct Care Services Department Review Request is required.

i. Case Managers shall submit a CFC Direct Care Services Department Review Request to the Department at least 30 calendar days prior to the service start date after obtaining approval from a Case Management Supervisor or Alternative Qualified Professional. Urgent requests can be submitted when there has been a sudden or unexpected change to the Member’s needs and there is an immediate risk to the Member’s health and safety. Approval from a Case Management Supervisor or Alternative Qualified Professional Review is required prior to submitting an urgent request.

ii. In each CFC Direct Care Services Department Review Request, the Case Manager must include Member-specific documentation, including Assessment findings and service plan details, that demonstrate service appropriateness and compliance with applicable policy.

iii. In each CFC Direct Care Services Department Review Request, the Case Manager must clearly describe the Member’s needs, the reason standard limits are insufficient, and how the requested exception supports the Member’s health, safety, and communitybased living.

iv. Case Managers are responsible for responding to requests for additional information within the 7 calendar days. If additional information is not provided to the Department, the Department will issue an outcome based on the information that was initially provided.

d. Case Managers shall ensure compliance with all Member noticing requirements, as described at 8.7202.R, and issue a Notice of Action for any adverse action taken as a result of the CFC Direct Care Services Exception Request.

e. Case Managers must involve Members in the CFC Direct Care Services Department Review Request by reviewing materials with the Member prior to submitting a CFC Direct Care Services Department Review Request and by providing copies of submitted information, requests for additional information, and CFC Direct Care Services Department Review Request outcomes at the Member’s request.

CFC Direct Care Services Exception Request Case Management Supervisor or Alternative Qualified Professional Responsibilities a. The Case Management Supervisor or Alternative Qualified Professional shall conduct a Case Management Supervisor or Alternative Qualified Professional Review for any request to exceed the Age-Appropriate Task Standards for Children or Task Standards for Adults.

b. A Case Management Supervisor or Alternative Qualified Professional must approve a Case Management Supervisor or Alternative Qualified Professional Review for any request for service hours that exceed the Annual CFC Service Soft Caps or a request to exceed more than 7 hours per week of the Protective Oversight Task in Personal Care prior to a Case Manager submitting CFC Direct Care Services Department Review Request. If the Case Management Supervisor or Alternative Qualified Professional Review is denied, the Case Manager shall not submit a CFC Direct Care Services Department Review Request.

c. Case Management Supervisors or Alternative Qualified Professionals shall approve first-level review requests to exceed the Annual CFC Service Soft Caps and requests to exceed the Age-Appropriate Task Standards for Children, and Task Standards for Adults if the record demonstrates all of i. The care need is documented in the LOC assessment, PCSP, and supporting records;

ii. The request constitutes Extraordinary Care, when applicable;

iii. The request is age-appropriate or exceeds Parental or Legal Guardian of a Minor Responsibility, when applicable;

iv. The request is not duplicative of other covered supports; and v. The requested additional hours are necessary to ensure health and welfare and support safe community living, including avoiding unnecessary or increased risk of institutionalization.

d. If the Case Management Supervisors or Alternative Qualified Professional Review results in a partial approval or denial, the Case Management Supervisors or Alternative Qualified Professional shall state that Members were only partially approved or denied because certain criteria were not fully satisfied.

e. Supervisors or Alternative Qualified Professionals must document approval/denial in the DCSC and shall sign the DCSC. The completed DCSC and required supporting documentation shall be retained in the Member’s record.

CFC Direct Care Services Exception Request Department Responsibilities a. The Department will provide an initial response to the Case Manager regarding the CFC Direct Care Services Department Review Request within 14 calendar days.

i. If additional information is needed for the Department to process the CFC Direct Care Services Department Review Request, a request for additional information will be provided to the submitting Case Manager. If additional information is not provided to the Department within 7 calendar days, the Department will issue an outcome based on the information that was initially provided.

b. The Department will review the submitted CFC Direct Care Services Department Review Request. The Department shall approve additional hours on a case-by-case basis when a demonstrated need is documented and justified by the Member’s case manager and the request meets the review criteria set forth in this section. Any denial or partial approval must include written findings that identify the specific criterion or criteria not met and the evidence relied upon.

c. The CFC Direct Care Services Department Review Request will be reviewed for:

i. Whether the service hours requested are duplicative and/or meet the definition of Extraordinary Care;

ii. The reason Age-Appropriate Task Standards for Children, Task Standards for Adults, and/or Annual CFC Service Soft Caps are insufficient based on the Members assessed need;

iii. How the CFC Direct Care Services Department Review Request maintains the Member’s health and safety and promotes sustainable community-based living; and iv. Age-appropriateness and for duplication of Parental or Legal Guardian of a Minor Responsibility for requests for children.

d. The Department shall approve additional hours on a case-by-case basis when a demonstrated need is documented and justified by the Member's Case Manager and sufficiently meets the review criteria described in

Section 8.7607.A.3.b.

e. The Department shall issue a determination letter for each CFC Direct Care Services Department Review Request unless the CFC Direct Care Services Department Review Request is withdrawn by the Case Manager.

Each determination letter shall include:

i. The type of exception that was requested;

ii. The amount requested by the Case Manager;

iii. The approved, partially approved, or denied service hours;

iv. The Member’s approved DCSC-calculated totals by service category and any relevant threshold;

v. A summary of the documentation reviewed, including the PCSP and supporting justification; and vi. The regulatory citation(s) to support the decision.

f. If the Case Management Supervisors or Alternative Qualified Professional Review results in a partial approval or denial, the Case Management Supervisors or Alternative Qualified Professional shall state that Members were only partially approved or denied because certain criteria were not fully satisfied.

g. The CFC Direct Care Services Department Review Request process shall be implemented in a uniform manner applied equally to Members statewide, but outcomes shall be based on individual assessed needs and h. The Department may delegate the review of CFC Direct Care Services Department Review Request to a third-party vendor. Any third-party vendor shall be subject to the same requirements applicable to the Department as outlined in this section. 8.7608 CFC Service Delivery Models 1. CFC members may utilize a Provider Agency defined at 8.7001.A.12-B. to receive Personal Care and Homemaker.

CFC members may utilize one of the following self-directed service delivery models to receive Personal Care, Homemaker, and/or Health Maintenance Activities:

a. Consumer Directed Attendant Support Services defined at 8.7515., or b. In-Home Support Services defined at 8.7528.

CFC members cannot utilize Consumer Directed Attendant Support Services and In-Home Support Services/Provider Agency services simultaneously. In-Home Support and Services can be used in conjunction with Provider Agency services, as long as there is no duplication.

Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]..

10 CCR 2505-10 8.8000 MEDICAL ASSISTANCE - SECTION 8.8000 Rural Provider Access and Affordability Stimulus Grant Program {#sec-10-ccr-2505-10-8.8000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.8000}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

MEDICAL ASSISTANCE - SECTION 8.8000 Rural Provider Access and Affordability Stimulus Grant Program 10 CCR 2505-10 8.8000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ 8.8000 Rural Provider Access and Affordability Stimulus Grant Program 8.8000.A PURPOSE AND LEGAL BASIS 1. Pursuant to C.R.S. § 25.5-1-207, the Rural Provider Access and Affordability Stimulus Grant Program provides grants to qualified providers to improve health care affordability and access to health care services in rural communities and to drive financial sustainability for rural hospitals and clinics.

8.8000.B DEFINITIONS

Advisory Committee means the rural provider access and affordability advisory committee as defined in section 25.5-1-207 (3), C.R.S.
Department means the Colorado Department of Health Care Policy and Financing.
Health Care Access Project means a project that expands access to health care in Rural Communities including but not limited to:

a. Extending hours for access to primary care or behavioral health services, b. Investing in dual track emergency department management, c. Expanding access to Telemedicine including remote monitoring support, d. Providing new or replacement Hospital beds, e. Expanding access to long term care and recovery care in skilled nursing facilities, and f. Creating or expanding sites that provide surgical care, chemotherapy, imaging, and advanced imagining including computerized tomography scans.

Health Care Affordability Project means a project that modernizes the information technology infrastructure of Qualified Rural Providers including but not limited to:

a. Creating a shared analytics platform and care coordination platforms among Qualified Rural Providers, and b. Enabling technologies, including telehealth and e-consult systems, that allow Qualified Rural Providers to communicate, share clinical information, and consult electronically to manage patient care.

Hospital means a hospital licensed or certified pursuant to section 25-1.5-103 (1)(a), C.R.S. or an affiliate owned or controlled as defined in section 25.5-4-402.8 (1)(b), C.R.S., by the hospital.
Qualified Rural Provider means a Hospital located in a Rural Community in Colorado that has a lower net patient revenue or fund balance compared with other Rural Hospitals.
Rural Community means a county with a population of fewer than fifty thousand residents; or a municipality with a population of fewer than twenty-five thousand residents if the municipality is not contiguous to a municipality with a population of twenty-five thousand or more residents.
Rural Stimulus Grant means funding received from the rural provider access and affordability grant program established in section 25.5.1-207, C.R.S.
Telemedicine means the delivery of medical services as defined at section 12-240-104 (6), C.R.S.

8.8000.C GRANT AWARD PROCEDURES

Rural Stimulus Grants will be awarded through an application process.

a. A request for grant application form shall be issued by the Department and posted for public access on the Department’s website at https://hcpf.colorado.gov/research-data at least 30 days prior to the application due date.

b. A Qualified Rural Provider may submit applications for more than one project or may submit a joint application with another Qualified Rural Provider.

The application will include:

a. Project overview.

b. Proposed budget including:

i. Total funds requested not to exceed $650,000 per project per applicant, ii. Itemized direct expenses, iii. Indirect expenses limited to federal Negotiated Indirect Costs Rate Agreement (NICRA) or de minimis rate of 10 percent if the applicant does not have an NICRA, iv. If applicable, documentation of quotes or estimates for construction, equipment, or other expenditures, and v. If applicable other sources of funding that will be utilized to complete the proposed project.

c. Project timeline to commence no earlier than July 1, 2023 and to conclude no later than December 31, 2026.

d. Description of Qualified Rural Provider’s diversity, equity, and inclusion strategy and how diverse community needs are met by the project.

e. Demonstration of financial need.

i. Qualified Rural Providers in the bottom 40% of net patient revenues for the threeyear average of 2016, 2017, and 2018 or the bottom 6% fund balance for 2019 as determined by the Department’s review of CMS 2552-10 Medicare Cost Reports are considered to meet the financial health requirement.

ii. Other Qualified Rural Providers may submit additional financial supporting information to support their financial need.

a. For capital investment projects, facility or equipment age.

b. Impact to health care affordability or access to care.

i. Statement of need outlying underlying problem the funding will address.

ii. Description of how the project’s goals and objectives will be sustained after the Rural Stimulus Grant funds have been expended.

iii. Description of how the project will increase access to specialty care, if applicable.

iv. Description of how project will improve care coordination, if applicable.

v. Description of partner engagement, if applicable.

The Advisory Committee will review Rural Stimulus Grant applications and recommend Rural Stimulus Grant awards to the Department’s executive director based on the following criteria:

a. Budget and financial need.

b. Partner collaboration, support, or engagement.

c. Completeness of response.

d. Ability to execute and complete project.

e. Reasonableness of timeline.

f. Diversity, equity and inclusion and how diverse communities will be impacted by the project.

g. County Medicare and Medicaid caseload percentage of population.

h. Statement of need.

i. Sustainability of project.

j. Impact to health care affordability or access to care.

The Department’s executive director or his or her designee shall make the final Rural Stimulus Grant awards to Qualified Rural Providers.

a. The total funding for Rural Stimulus Grants is limited to no more than $9.6 million with no more than $4.8 million for Health Care Access Projects and no more than $4.8 million for Health Care Affordability Projects.

b. The Department may change Rural Stimulus Grant amounts depending on the final number of Rural Stimulus Grants awarded, the availability of Rural Stimulus Grant funds, or the goals stated in the Rural Stimulus Grant application.

c. Rural Stimulus Grant applicants may request reconsideration of Rural Stimulus Grant awards within 5 business days of award notification in writing to the Department’s executive director. The executive director will respond to the request for reconsideration within 10 business days of receipt.

d. The Department will execute a grant agreement with each Rural Stimulus Grant recipient.

The Department will disburse Rural Stimulus Grant funds no earlier than July 1, 2023 and no later than July 1, 2024. Any money not disbursed by July 1, 2024 will revert to the Economic Recovery and Relief Cash Fund created pursuant section 24-75-228 (2)(a), C.R.S.
Rural Stimulus Grant recipients will expend Rural Stimulus Grant funds by the timeline in their grant agreement and no later than December 31, 2026. Any Rural Stimulus Grant funds not expended by Rural Stimulus Grant recipients by December 31, 2026 will be recovered by the Department to be returned to the U.S. Department of the Treasury.

8.8000.D PERMISSIBLE USES OF GRANT AWARDS

Rural Stimulus Grant funds must be used for Health Care Affordability Projects or Health Care Access Projects to improve health care affordability and access in Rural Communities.
Rural Stimulus Grant funds may not be deposited into a pension fund and may not be used to service debt, satisfy a judgment or settlement, or contribute to a “rainy day” fund.

8.8000.E REPORTING REQUIREMENTS FOR GRANT RECIPIENTS

Recipients of Rural Stimulus Grant funds for capital expenditures must submit a written justification as set forth in 31 Code of Federal Regulations 35.6 (b)(4) to the Department.
For the duration of the grant agreement, Rural Stimulus Grant recipients must submit a quarterly report to the Department no later than the 10th day of the month following the end of each quarter including but not limited to a brief narrative and itemized expenditure and performance metric data.
Rural Stimulus Grant recipients will submit a final report to the Department within 30 calendar days following the end of the grant agreement including an overall narrative and itemization of all expenditures and performance metric data for the total Rural Stimulus Grant award.

8.8000.F RECORD RETENTION AND ACCESS

Rural Stimulus Grant recipients must maintain records of expenditures for a minimum of five years after funds have been expended or returned to the Department, whichever is later.
Rural Stimulus Grant recipients must allow the Department and state and federal auditors access to records related to the expenditure of Rural Stimulus Grant funds. 8.8500 Rural Sustainability Payments 1. A Sustainability Payment of $100,000 per Critical Access Hospital and $20,000 per Rural Health Center will be issued March 1, 2024 and each subsequent year on August 1st annually for all qualified rural providers participating in the state’s Rural Connectivity Program.

a. Critical Access Hospitals (CAH) are Centers for Medicare and Medicaid Services (CMS)designated hospitals with <25 beds which are >35 miles from the nearest hospital.

b. Rural Health Clinics (RHC) are Centers for Medicare and Medicaid Services (CMS)designated primary care clinics that operate in rural counties.

i. According to the Centers for Medicare and Medicaid Services (CMS), RHCs are clinics that are located in areas designated by the Bureau of the Census as rural and by the Secretary of the Department of Health and Human Services (DHHS) or the State as medically underserved. An RHC is a clinic that is located in a rural area designated as a shortage area, is not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases, and meets all other requirements of 42 C.F.R. 447.371.

At minimum, to qualify this payment or a partial payment, a participating rural provider must be connected to one of the state’s Health Information Exchanges (HIEs) and the Community Analytics Platform (CAP) established by the Office of eHealth Innovation.

a. The participating rural provider must have a signed agreement with one of the Colorado Health Information Exchanges (HIEs) so the participating rural provider can view medical records contained within the HIE.

b. The participating rural provider must have a signed agreement with the vendor managing the Community Analytics Platform (CAP) so the participating rural provider is accessing the CAP and authorizing the vendor managing the CAP to capture data on its behalf.

To continue receiving the full amount each year, providers will make continuous efforts to maintain or increase their level of connectivity between the provider and one of the state’s HIEs and the CAP.

a. Each year the Office of eHealth Innovation, and the Department will present the criteria for a participating provider to receive a payment or partial payment to the eHealth Commission.

b. The eHealth Commission will approve any changes to the criteria. The eHealth Commission will provide a public forum for any changes to the criteria.

Following the criteria approved by the eHealth Commission, the Office of eHealth Innovation, and the Department will review all participating rural providers to determine the payment or partial payment.

a. A participating rural provider will be notified if they are qualified to receive a payment or partial payment.

b. If a participating provider is not qualified to receive a payment or will receive only a partial payment, the notification will explain the criteria that the participating rural provider did not fulfill. _________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

10 CCR 2505-10 MED 11E MEDICAL ASSISTANCE - FORM MED-11E [Repealed eff. 06/30/2014] {#sec-10-ccr-2505-10-med-11e omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 MED 11E}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

Medical Services Board MEDICAL ASSISTANCE - FORM MED-11E - Repealed eff. 06/30/2014 10 CCR 2505-10 _MED-11E [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ FORM MED 11E Repealed, effective June 30, 2014. _________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]

2505 Office of Public and Private Initiatives [Rules repealed eff. 05/15/2013]

10 CCR 2505-2 HEALTH CARE COVERAGE COOPERATIVES - [Repealed eff. 05/15/2013] {#sec-10-ccr-2505-2 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-2}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

Office of Public and Private Initiatives HEALTH CARE COVERAGE COOPERATIVES 10 CCR 2505-2 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ This rule was repealed, effective May 15, 2013 _________________________________________________________________________ Editor’s Notes

History Entire rule repealed eff. 05/15/2013.

2505 Executive Director of Health Care Policy and Financing

10 CCR 2505-5 Executive Director of Health Care Policy and Financing Rules {#sec-10-ccr-2505-5 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-5}

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

EXECUTIVE DIRECTOR OF HEALTH CARE POLICY AND FINANCING RULES

10 CCR 2505-5 [Editor’s Notes follow the text of the rules at the end of this CCR Document.]

1.010 FINANCE AND ACCOUNTING

The incorporation by reference (as indicated within) throughout section 1.010 excludes later amendments to, or editions of, the referenced materials. Pursuant to C.R.S. § 24- 4- 103(12.5) the State Department maintains copies of this incorporated text in its entirety available for public inspection during regular business hours, at: Colorado Department of Health Care Policy and Financing, 303 E. 17th Ave Denver, CO 80203.

Certified copies of incorporated materials are provided at cost upon request.

Incorporated materials are found in the following sections: 1.010.1, 1.010.3(4), 1.010.12(3)(a), 1.010.14(1), 1.010.14(2), 1.010.14(4), 1.010.14(4)(a), 1.010.14(4)(a)(i), 1.010.14(4)(b), 1.010.14(4)(c), 1.010.14(4)(d), 1.010.1 Definitions Please be advised that the definitions set forth in 1.010.1 also apply to 1.020.

The following definitions are used in this rule manual, unless the context otherwise requires. 2 C.F.R. Part 200, the Office of Management and Budget (OMB) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, also known as Uniform Guidance, is the federal uniform administrative requirements, cost principles, and audit requirements for federal awards such as Medical Assistance and was officially adopted by the US Department of Health and Human Services on September 27, 2024. 2 C.F.R. Part 200 (2025) is hereby incorporated by reference.

Accounts Receivable are recoveries that may be due the County Department of Social/Human Services for, but not limited, to the following: Overpayment of a benefit or benefits, Ineligibility for a benefit or benefits, Fee for service provided, Overpayment to a Vender of goods, Provider of service, or Employee.

Allowable Medical Assistance Expenditures are those which the Colorado Department of Health Care Policy and Financing deems are allowed or required.

Applicable Credits refer to those receipts or reductions of Medical Assistance expenditure-type transactions that offset or reduce expense items as Direct or Indirect Costs. Examples of such transactions are: Purchase discounts, rebates or allowances, recoveries or indemnities on losses, insurance refunds or rebates, adjustments of overpayments, or erroneous charges. To the extent that such credits accrue to or are received by the County Department of Social/Human Services and relate to allowable costs, they shall be credited to the Colorado Department of Health Care Policy and Financing and/or the appropriate federal award as a reduction of Medical Assistance expenditures.

Applicant is any individual who has applied for benefits under the Programs of Medical Assistance administered or supervised by the Colorado Department of Health Care Policy and Financing, in accordance with the provisions of C.R.S.§ 25.5-4-103.

Appointing Authority is the person with the direct authority and responsibility for appointment of employment, disciplinary action, promotion of, and or discharge of employment, over another person.

Appropriation means the authorization by ordinance or resolution of a spending limit for Medical Assistance expenditures and obligations for specific purposes, in accordance with the provisions of C.R.S. § 29-1-102.

Approving Authority is the person with direct authority and responsibility for reviewing and approving of another's activities or requests for payment of expenses.

Arms-length Bargaining means both parties to a Contract have relatively equal powers of negotiation upon entering into the Contract. Neither party has a disproportionate amount of power to strong-arm the other party.

Business Process Standard is a structured guideline that defines minimum requirements for how core activities must be carried out to address/promote consistency in the timely and accurate delivery of benefits and quality customer service to Coloradans within the County Department’s role in determining or renewing Medical Assistance coverage. Business Process Standards will be developed in collaboration between the State Department and County Departments and must account for the varying sizes of County Departments.

Capital Medical Assistance Expenditure shall be the cost of the asset including the cost to put it in place. Capital Medical Assistance Expenditure for equipment means the net invoice price of the equipment, including the cost of any modifications, attachments, accessories, or auxiliary apparatus necessary to make it usable for the purpose for which it is acquired. Ancillary charges, such as duty, freight, and installation may be included in, or excluded from, capital Medical Assistance expenditure cost in accordance with the County Department of Social/Human Services' accounting policies.

Capitalized Equipment is tangible personal property that has an acquisition cost of more than $5,000.00, which is not a permanent part of a building and does not lose its identity through incorporation into a more complex unit.

Capital Lease transfers to the lessee substantially all of the benefits and risks related to ownership of the property. The lessee records the leased property as an asset and establishes a liability for the lease obligation.

Cash means the cash account(s) of the County Department, all petty cash accounts and any other cash accounts maintained.

Cash Reconciliation means the treasurer/bank balance shall be agreed to the general ledger cash balance using an outstanding warrant list and possibly other identifiable reconciling items.

Chart of Accounts is a numbered list of accounts that gives order and consistency to a bookkeeping system. Common terminology and classifications shall be used consistently throughout the budget, the accounts, and the financial reports of the fund.

Colorado Benefits Management System (CBMS) is the computer system that determines an Applicant’s eligibility for Medical Assistance (Medicaid eligibility determination system).

Colorado Department of Local Affairs means the agency to which the Board of County Commissioners submits the annual County Department of Social/Human Service budget.

Colorado Government Human Services Financial Officer’s Association (CGHSFOA) improves the practice of governmental finance and accounting and develops closer relationships and understanding among those concerned with public human service finance in Colorado.

Colorado Human Services Directors Association (CHSDA) is a nonprofit association representing the County Department of Social/Human Services directors from across the state of Colorado.

Commercial Lodging is a hotel, motel, resort or public inn as defined in C.C.R § 101-1:

Rule 5-1.2.14 or a bed and breakfast as defined in C.R.S. § 39-1-102.

Commitment Vouchers as defined by State of Colorado Fiscal Rules, 1 C.C.R § 101- 1:Rule 3-1 (2024), which is hereby incorporated by reference, include any approved form of purchase order, Contract, travel authorization, advice of employment, grant contract, license agreement, parking license agreement and other written authorization for disbursements which satisfy the requirements in a document providing the following:

A description of goods or services being purchased or other reasons for the disbursement of funds;
The amount to be paid;
The obligation is being charged to the appropriate account; and 4. That procurement requirements have been satisfied.

Contract means a mutually binding legal relationship obligating the seller to furnish the supplies or services and the buyer to pay for them. It includes all types of commitments that obligate the government to a Medical Assistance expenditure of appropriated funds and that, except as otherwise authorized, are in writing.

Contractor is an entity that receives a Contract, as defined in 2 C.F.R. § 200.1, which is hereby incorporated by reference. A Contractor provides goods and services within normal business operations, operates in a competitive environment, and provides goods and services that are ancillary to the operation of the federal program.

Corrective Action means action taken by an auditee that corrects identified deficiencies.

Cost Allocation Plan is a systematic and rational allocation of all administrative costs and a narrative description of the procedures that will be used in identifying, measuring and allocating all administrative costs to the benefiting programs and activities.

Cost Objective is a program, grant, organizational subdivision, function, Contract or other activity for which costs are being accumulated.

Cost Pool is an aggregation of costs for subsequent allocation to another cost pool or a cost objective.

Costs are expenses incurred, either directly or indirectly. Costs include such items as labor, material, supplies, rent or building charges, operating expenses, and administrative expenses that might properly be assigned to a project or program. It does not include transfers to a general fund or similar fund.

County Board of Social/Human Services or County Board means the county’s Board of County Commissioners, county board of social or human services or district board of social or human services except in the case of the City and County of Denver or the City and County of Broomfield, this means the city and county board with responsibility for Medical Assistance and related activities.

County Department of Social/Human Services or County Department means the county department of social or human services or district department of social or human services, except in the case of the City and County of Denver or the City and County of Broomfield, this means the department or agency responsible for Medical Assistance and related activities.

County Department Director means the director of the County Department of Social/Human Services or district department of social/human services.

County means a County or a city and County.

County Financial Management System (CFMS) means the financial system of record to report all county Medical Assistance expenditures to the State Department.

Data refers to all books, papers, maps, photographs, or other documentary materials regardless of physical form. Data may be in hard copy form, microfiche, electronic, or other form.

Deferred Revenue means a revenue collected but not yet earned.

Direct Costs are those Costs that can be specifically and readily identified with a program, grant, function, contract, or other activity.

Disability - According to federal Regulations, a person is considered to have a Disability if s/he: 1) has a physical, communication, or mental impairment which substantially limits one or more major life activities; 2) has a record of such an impairment, or 3) is regarded as having such an impairment. Such impairments may include, but are not limited to, blindness, deafness, paraplegia, contagious diseases, etc.

Disbursement is any decrease in fund resources.

Double-entry Accounting is a method of accounting that recognizes the duality of a transaction. Any change in one account also causes a change in another account.

Eligibility and Enrollment Collaboration Agreement (“Collaboration Agreement”): A formal agreement between a County Department and an external entity to facilitate eligibility and enrollment utilizing existing processes and resources.

Eligibility and Enrollment Cost Sharing Agreement (“Cost Sharing Agreement”: A formal agreement between a County Department and an external entity to facilitate eligibility and enrollment leveraging cost sharing procedures that allow the external entity to pay the state and county share of Costs to facilitate potential onsite placement of County Department personnel. Equipment shall be an article of non-expendable, tangible personal property having a cost, which equals the lesser of the capitalization level established by the County Department of Social/Human Services for financial statement purposes, or $10,000.00.

Executive Director means the Executive Director of the Colorado Department of Health Care Policy and Financing.

Expenditure, which are Medical Assistance expenditures, represented by a decrease in fund resources other than through inter-fund transfer.

Federal Award means federal financial assistance and federal cost-reimbursement Contracts that non- federal entities receive directly from federal awarding agencies or indirectly from pass-through entities.

Federal Financial Assistance means assistance that non-federal entities receive or administer in the form of grants, loans, loan guarantees, property (including donated surplus property), cooperative agreements, interest subsidies, insurance, food commodities, direct appropriations, and other assistance, but does not include amounts received as reimbursement for services rendered to individuals as:

Medicare payments (payments to a non-federal entity for providing patient care services to Medicare eligible individuals), and 2. Medicaid payments (payments to a Subrecipient for providing patient care services to Medicaid eligible individuals) unless a state requires the funds to be treated as federal awards expended because reimbursement is on a cost-reimbursement basis.

Fiscal Year for a County Department of Social/Human Services is the period covered by the County Department appropriations for social/human services funds and shall be the calendar year, which coincides with the County Department fiscal year. The fiscal year covered by the Colorado Department of Health Care Policy and Financing appropriations and allocations to the counties shall be July through June. The fiscal year covered by the federal grants in aid shall be October through September. Federal projects may cover fiscal years other than the federal fiscal year and will be specified in the terms of the project.

Fund is an accounting entity which owns assets and incurs liabilities. This means the social/human services fund in each County Department must be accounted for separately from any other funds in the County Department. The assets, including Cash, must be identified as assets of this fund.

General Ledger is a book or computer database that contains a full set of accounts. It should be in balance at all times with aggregate debits equaling aggregate credits.

Generally Accepted Accounting Principles (GAAP) are uniform minimum standards of and guidelines to financial accounting and reporting. Adherence to GAAP assures that financial reports of all state and local governments–regardless of jurisdictional legal provisions and customs–contain the same types of financial statements and disclosures, for the same categories and types of funds and activities, based on the appropriate measurement and classification criteria as amended by . Governmental Accounting Standards Board (GASB) 34.

Indirect Costs relate to a cost incurred that cannot be specifically and readily identified with a cost objective and therefore must be allocated on some basis of imputed benefit.

Indirect Costs are more commonly known as the Costs of administration.

Internal Control is a process affected by an entity's board of directors, management, and other personnel that is designed to provide reasonable assurance regarding the achievement of objectives in the following categories: a) reliability of financial reporting, b) effectiveness and efficiency of operations, and c) compliance with applicable laws and Regulations.

The above definition reflects certain fundamental concepts as stated in the US Government Accountability Office Standards for Internal Controls in the Federal Government (the “Green book”) revised September 2022:

Internal controls are a process. It is a means to an end, not an end in itself. People affect internal controls. It is not policy manuals and forms, but people at every level of an organization.
Internal control can be expected to provide only reasonable, not absolute assurance, to an entity's management and board.
Internal Control comprises five interrelated components:

a. Control Environment: The people - their individual attributes, including integrity, ethical values and competence - and the environment in which they operate. They are the engine that drives the entity and the foundation on which everything rests.

b. Risk Assessment: Mechanisms that identify, analyze, and manage related business and operating risks.

c. Control Activities: Control policies and procedures must be established and implemented to help ensure that the actions identified by management as necessary to address risks and obtain the specified goals are effectively carried out. Policies and procedures should be reviewed on a periodic basis by management.

d. Information and Communication: Surrounding these activities are information and communication systems. These enable the County Department of Social/Human Services to capture and exchange the information needed to conduct, manage and control their operations.

e. Monitoring: The entire process must be monitored and modifications made as necessary. In this way, the system can react dynamically, changing as conditions warrant.

Inventory means a physical identification and count and/or to provide a list of items.

Management Decision Letter means the evaluation by the federal awarding agency, State Department or pass-through entity of the audit and/or review findings and corrective action plan and the issuance of a written decision as to what Corrective Action is necessary.

Medical Assistance is defined in C.R.S. § 25.5-1-103.

Medical Services Board means the state board authorized to act in accordance with the provisions of C.R.S. § 25.5-1-301.

Member is a generic term for an individual or group of individuals who receives any assistance from the County Department of Social/Human Services whether it is in the form of cash, non-cash or services.

Nursing Facility is a state-certified institution that provides 24-hour medical and nursing care, rehabilitation, and other health-related services.

Partisan refers to any election in which any one of the candidates for office is nominated or elected representing a political party whose candidates for presidential election received votes at the last preceding election at which presidential electors were selected.

Pass-through Entity (PTE) is a non-federal entity that provides a Subaward to one or more Subrecipients to carry out part of a federal Program. The State Department is the PTE for the Medical Assistance Program.

Payroll means a list of Medical Assistance expenditures and/or disbursements that are similar in nature or object of expenditure. An employee Payroll listing wages, with the amounts due to each employee, is an example of a Payroll. A listing of Old Age Pension benefits payable to eligible OAP members is another type of Payroll. Such lists become vouchers when certified and approved.

Personal Property is property such as machinery, Equipment, or furniture that is not real property.

Post-audit is the examination and verification of Medical Assistance expenditures after reimbursement with state and/or federal funds.

Procurement Card, also known as a p-card or credit card, is a simplified purchasing process which allows employees to quickly and efficiently purchase without involving the accounts payable process.

Program is a generic term for any “social services”, “assistance payments,” “ payments under the Colorado Medical Assistance Act,” or a specific function or activity.

Random Moment Sampling is the federally approved cost allocation method that documents the efforts expended in support of programs in order to receive reimbursement for the Medical Assistance expenditures.

Real Property is land and generally anything erected on, growing on, or attached to land, for instance, a building.

Reasonable Timeline is as much time as reasonable, and within the sole discretion of the State Department, given the context of the request being made to the County Recipient means any individual or group of individuals who is receiving or has received benefits from Programs of Medical Assistance administered or supervised by the Colorado Department of Health Care Policy and Financing, in accordance with the provisions of C.R.S. § 25.5-4-103 (21).

Regulation is a Rule or order issued by an executive authority or regulatory agency of a government and having the force of law.

Reimbursable Medical Assistance Expenditures are supported in whole or in part by state general fund, federal (Pass Through) or a combination of state and federal money.

Rule is an agency statement of general applicability and future effect implementing, interpreting, or declaring law or policy or setting forth the procedure or practice requirements of any agency. Rule includes Regulation.

Signature includes both physical signatures and electronic signatures, which means an electronic sound, symbol, or process attached to or logically associated with a record and executed or adopted by a person with the intent to sign the record, as set forth in C.R.S. § 24-71-101. In any written communication in which a signature is required or used, any party to the communication may affix a signature by use of an electronic signature that complies with the requirements of C.R.S. § 24-71.3-101.

Social/Human Services Fund is a fiscal and accounting entity with a self-balancing set of accounts recording Cash and other financial resources, together with all related liabilities and residual equities or balances, and changes therein, which are segregated for the purpose of carrying on specific activities or attaining certain objectives in accordance with special regulations, restrictions, or limitations.

State Department means the Colorado Department of Health Care Policy and Financing.

Subaward is an award provided by the pass-through entity to a Subrecipient for the

purpose of carrying out a portion of the federal award and creates a federal financial assistance relationship with a Subrecipient, as set forth in 2 C.F.R. § 200.331, which is hereby incorporated by reference.

Subrecipient means a non-federal entity that expends federal awards received from a pass-through entity to carry out a federal Program, but does not include an individual that is a beneficiary of such a Program. A Subrecipient may also be a Recipient of other federal awards directly from a federal awarding agency. Guidance on distinguishing between a Subrecipient and a Contractor is provided in 2 C.F.R. § 200.331. County Departments of Social/Human Services are Subrecipients for the Medical Assistance Program.

Training Function is a meeting, conference, or other function which is held to enhance staff knowledge or to educate customers of the county that are affected by the county department operations or regulations.

Transportation is travel by commercial airline, railroad, bus, taxicab, county-owned, or personally-owned automobile or any other means of conveyance.

Vendor generically means a dealer, distributor, merchant, or other seller providing goods or services that are required for the conduct of a federal Program. These goods or services may be for an organization's own use or for the use of beneficiaries of the federal Program. Additional guidance on distinguishing between a Subrecipient and a Vendor is provided in in 2 C.F.R. § 200.331 1.010.2 Purpose and Scope These Rules are the fiscal Rules for County Departments concerning Medical Assistance and the administration of that assistance including but not limited to fiscal internal controls, financial reporting, accounting and auditing.

The Colorado Department of Health Care Policy and Financing’s Finance and Accounting Manual consists entirely of Executive Director Rules as allowed by C.R.S. § 25.5-1-108. 1.010.3 Board of County Commissioners 1. Board of County Commissioners Responsible for Appropriating up to Twenty Percent Share As per C.R.S. § 25.5-4-206 and C.R.S. § 26-1-122(1)(a), the Board of County Commissioners for each county shall annually appropriate as provided by law the funds necessary to defray up to the county twenty percent share of the overall cost of Medical Assistance administration and related activities delivered in the county, including the Costs allocated to the administration of each, and shall include in the tax levy the funds appropriated for that purpose. Such appropriation shall be based upon the County Department budget prepared by the County Department Director.

Board of County Commissioners Responsible for Availability of up to Twenty Percent Share Additional funds shall be made available by the Board of County Commissioners if the county funds so appropriated prove insufficient to defray up to the county twenty percent share of actual costs for Medical Assistance administration.
Approval of the County Department Budget The Board of County Commissioners approves the final County Department budget for administration of Medical Assistance eligibility determination and the administration of the County Department.
Distribution of the Budget No later than thirty days following the beginning of the calendar year, the Board of County Commissioners shall file the budget adopted pursuant to C.R.S. § 29- 1- 108, including the budget message, with the Colorado Department of Local Affairs, as set forth in C.R.S. § 29-1-113.
Liability Insurance The Board of County Commissioners shall purchase insurance for its officers, employees and agents that protects them against any liability for injuries or damages resulting from their negligence or other tortious conduct during the course of their service or employment. The Board of County Commissioners can, in writing, assume the risk and the financial responsibility of a reasonable deductible.
Surety Bond or Insurance A surety bond shall be purchased for the County Department Director and other County Department employees, who receive, disburse, handle or have access to currency, checks, money orders, and warrants. The bond shall be in favor of the County Department and be the greater of $10,000 or 15% of the maximum value of Cash and or cash-like items the County Department Director and employees have access to during a year. In lieu of a surety bond, crime insurance coverage may be purchased. This can also be satisfied with liability insurance purchased through the Colorado Counties Casualty and Property Pool. The Board of County Commissioners can, in writing, assume the risk and the financial responsibility of a reasonable deductible. This bonding requirement applies to any contractual employees having the same responsibilities.
Sign All Warrants One member of the County Board shall have their Signature on all social/human services warrants. In the case of a Signature there shall be detailed written procedures that set forth accounting and fiscal internal controls surrounding the application of the Signature.
Approve All Medical Assistance Expenditures Pursuant to C.R.S. § 30-11-107(b), the County Board shall review and approve all Medical Assistance expenses of the County.
Federal Compliance on Pass Through Funds and Establishment of Contract/Agreement Policies and Procedures The County Board is responsible for establishing policies and procedures regarding entering into Contracts, grants, block grants, and other agreements binding on the county, and complying with applicable federal and state Program laws and Regulations even though the funds were passed through the State Department. Per C.R.S. § 30-11-107(1)(aa), the County Board may delegate its power to enter into such Contracts and agreements where amounts specified comply with limits and requirements set forth in such policies and procedures.
Financial Statements and Reporting The County Board is ultimately responsible for appointing a designee for the preparation, content, completion and/or distribution of materially correct financial statements of the social/human services fund. Pursuant to C.R.S. § 30-11-121, such person shall serve at the pleasure of the County Board.

a. Financial Reports Follow Generally Accepted Governmental Accounting Principles Each monthly reporting period shall be regarded as an integral part of the fiscal year. Revenues shall be allocated to monthly reporting periods in accordance with generally accepted governmental accounting principles.

Medical Assistance expenditures, such as salaries and operating expenditures, shall be allocated to interim periods in which they were incurred. Arbitrary assignment to a monthly period shall not be allowed.

b. Financial Reports Come from the General Ledger The county general ledger and supporting systems to the general ledger shall be the system used to record the county financial information and the system from which standard reports shall be prepared and forwarded to the County Board of Social/Human Services.

Responsibility for Fiscal Medical Assistance Record Retention The County Board shall retain all necessary and complete fiscal Medical Assistance records retained for audit purposes and ensure that adequate prior years' Medical Assistance expenditure documents are maintained for use in the budgeting process. Fiscal Medical Assistance Records include but are not limited to general ledger, accounting source documents, personnel and Payroll records, time sheets, and canceled checks.

a. Three years of financial records from the date of the submission of the final financial report will be retained for other federally funded Programs.

Exceptions to the records retention requirement:

i. If litigation or audit began prior to when the three-year period expires, records are retained until resolution or final action is taken.

ii. State Department notifies the County Board in writing to extend the retention period.

iii. Records are transferred to the federal agency.

Responsibilities for County-wide Functions/Reporting The County Board shall ensure that countywide functions and/or reporting responsibilities normally administered by a department other than social/human department services are fulfilled. . 1.010.4 Financial and Budgetary Responsibilities of the County Department Director 1. Responsibility for Accounting and Fiscal Internal Control The County Department Director is responsible for organizing staff functions to assure adequate control and safeguards for all Cash, fixed assets and negotiable items (checks and money orders) handled by, stored in or used in the County Department and establish appropriate fiscal internal controls and separation of duties.

a. Fiscal Internal Control Activities Fiscal internal control activities include, but are not limited to, reviews by the County Department Director or high level financial staff member of actual performance, controls over information processing, physical controls over vulnerable assets, , segregation of duties, proper execution of transactions, accurate and timely recording of transactions, and access restrictions to and accountability for resources and records.

Budgetary Responsibility a. Budget Preparation As part of the county budget, the County Department Director shall prepare a County Department budget and submit this to the County Board for approval.

b. Annual Budgets The County Department Director shall be responsible for estimating future needs of the County Department as accurately as possible, utilizing all available data.

c. Spending Within Budgeted Appropriations The County Department Director shall be responsible for assuring that Medical Assistance expenditures do not exceed appropriations and for controlling the county fund balance at all times. If the County Department Director anticipates overspending, this should be communicated to the State Department prior to the over expenditure for Medical Assistance occurs.

d. Budget Revisions The County Department Director shall be responsible for initiating requests to the County Board for changes in the County Department budget.

e. Delegation of County Department Director Fiscal Responsibilities The County Department Director can delegate fiscal responsibilities to a County designee so long as the County Department Director is ultimately responsible for those delegated functions and the County Department maintains written documentation of the delegation. 1.010.5 County Treasurer 1. County Treasurer Shall Act As Custodian Pursuant to C.R.S. § 26-1-123, the County Treasurer shall be the treasurer and custodian of the social/human services fund and shall disburse money from the fund only upon distinct County Department warrants drawn by the person duly appointed by the County Board.

Bank Accounts External to County Treasurer’s Office To prevent unauthorized closures and access, bank accounts external to the County Treasurer’s Office, which contain County match dollars intended for federal and state reimbursement, are not permitted.
County Treasurer's Reports The County Treasurer, or county entity acting as the County Treasurer, shall prepare a monthly report to the County Department Director and the County Board, which indicates a beginning balance of Cash, the amount of monies deposited into the social/human services fund each month, the warrants redeemed by the treasurer or designated redemption entity each month, and an ending Cash balance. Alternate forms of tracking the monthly amounts of Cash through a redemption entity are also accepted. One example of this is the use of a zero balance account(s) where the balance of this account(s) at any point in time is the amount of unredeemed warrants.
No County Treasurer's Fee for Social/Human Services Fund The County Treasurer, or county entity acting as the County Treasurer, shall not collect any fee for the collection or deposit of any monies into the county social/human services fund. 1.010.6 Chart of Accounts A chart of account system shall reflect the order of the Statement of Net Assets/Balance Sheet and Statement of Activity/Statement of Revenues and Expenditures accounts.

The structure shall start with the accounts that go into current assets, the first section of the balance sheet, and end with the last category of expenses in the income statement. 1.010.7. General Ledger 1. Double-Entry General Ledger Each county social/human services fund shall maintain a double-entry general ledger system that is the basis for the accounting system and for financial reporting. The general ledger shall be the location in which all of the active accounts are collected.

General Ledger in Balance The general ledger shall be in balance at all times, with aggregate debits equaling aggregate credits. 3 Qualified Staff to Maintain and Utilize the County t Accounting System Only county staff experienced in bookkeeping and accounting shall maintain and utilize the County Department accounting system for the county social/human services fund.
Subsidiary Journals Subsidiary journals shall be maintained to support the general ledger.
Postings Are to Be Current The accounting system shall be kept current. Each month's Medical Assistance transactions shall be recorded to the general ledger as soon as possible after all information is received concerning receipts, expenditures, disbursements, actual revenue, and deferred revenue, for a month.
Budgetary Accounts The budget amounts for each calendar year shall be entered in the county general ledger or budget system used by the county. The amounts noted shall reflect the final budget as approved by the Board of County Commissioners or other governing body with authority to approve the budget. If the budget is subsequently revised, the amounts by program shall be posted to the appropriation and estimated revenue accounts. 1.010.8. Financial Statement Reporting 1. Prepare in Accordance with Generally Accepted Accounting Principles (GAAP) issued by the Governmental Accounting Standard Board (GASB)

Financial statements shall be prepared in accordance with generally accepted accounting principles for government entities.

Reflect All Financial Activities Financial statements shall reflect all of the financial activities of the County 3. Additional Financial Reports Additional reports to fully disclose the operations of the County Department shall be tailored to meet the County Department’s needs and enhance the ability to make timely and accurate decisions. Reports shall include but are not limited to such items as: comparison of budget to actual for programs or organizational units; efficiencies and economies in operations; and the results of specific programs and activities, as reflected in accomplishments, benefits, and effectiveness; and compliance with grant requirements and administrative policies. 1.010.9. Accounting and Fiscal Internal Controls 1. Personnel Responsible for Accounting and Fiscal Internal Controls The County Board, the County Department Director, County Department managers and supervisors, and employees are all responsible for the accounting and fiscal internal control processes within and surrounding the County Department.

a. Signature Authority The County Department shall identify those persons authorized to sign or approve specific documents for another person. The County Department Director shall approve of such listings that shall contain the name(s) and of those persons delegated Signature authority.

b. Personnel There shall be personnel of quality, integrity, and experience commensurate with their assigned responsibilities.

c. Access to Assets There shall be restrictions permitting access to assets only by authorized persons in the performance of their assigned duties.

Written Plan of Accounting and Fiscal Internal Controls The county is responsible for establishing and maintaining a documented accounting and fiscal internal controls plan that shall be on file at the County Department. This plan shall reflect the current operations of the County Department and shall provide for but not be limited to the following:

a. Accounting and Fiscal Internal Controls Procedures There shall be adequate authorization and procedures to provide effective accounting control over assets, liabilities, revenues, and expenditures.

b. Continuous Review of the Accounting and Fiscal Internal Controls Plan.

There shall be an effective process of internal review and adjustment for changes in operating conditions.

c. Purchasing or Procurement Cards (P-Cards)

If the County Department utilizes a p-card program, tthe County Department Director is responsible for establishing and maintaining written department-specific p-card program policies and procedures that include, but are not limited to, purchasing approvals, accounting controls, cardholder compliance and training for employees participating in the pcard program.

Separation of Duties There shall be fiscal internal control procedures that include the appropriate separation of duties such as, but not limited to the following:

a. Separation of Duties for the Receipt and Recording of Cash The same employee shall not receive Cash, record the receipt, deposit the funds, and make journal and/or ledger entries for Cash.

b. Separation of Duties for the Receipt of Negotiable Items and the Control of Negotiable Items The same employee shall not receive negotiable items, dispense these items and control the repository and the inventory of them.

c. Separation of Duties, Ordering and Paying for Goods and Services The same employee shall not order, receive, and process payment for goods and/or services. Orders for goods and/or services are to be approved in writing by the County Department Director prior to placing such orders. There shall be written approval from the County Department Director prior to payment being made for goods and services received.

Effectiveness and Efficiency of Operations There shall be an appropriate balance between accounting and fiscal internal controls, and the effectiveness and efficiency of operations.
Reliable Financial Reporting There shall be systems in place for the accurate and timely compilation of financial reports.
Compliance with Applicable Laws and Regulations There shall be a review process to ensure compliance with the many and varied laws, Rules and Regulations that are included with the administration of federal grants.
Official Receipts a. Consecutively Numbered Receipt Book County Departments shall maintain manual or automated receipt books with receipts numbered consecutively. Manual receipt books shall be prenumbered.

b. Mail Listing of All Negotiable Items There shall be a listing at the point the mail is opened for all negotiable items. This mail listing shall be prepared by the person opening the mail and by someone other than the bookkeeper/accountant.

c. Restrictively Endorsed Negotiable Items Each County Department shall have a restrictive endorsement stamp and each negotiable item shall be immediately stamped with a restrictive endorsement at the point the mail is opened.

d. Separation of Duties for Mail List Preparation and Receipt Writing The preparation of the mail and the writing of receipts, whether automated or manual, shall be performed by different people. If possible, the monies shall be sent to another person for preparation of the deposit.

Deposit of All Cash All Cash or negotiable items made payable to the County Department shall be deposited directly into the social/human services fund.

a. Daily Deposit of All Cash Totaling $500 or More Monies shall be deposited daily unless the total amount received is less than $500.00. Once the cumulative amount of monies received equals $500 or more, it shall be deposited no later than the next business day.

Sufficient security shall be provided to secure Cash and negotiable items against theft or loss.

b. Cash Receipts Shall Equal Cash Deposits The Cash receipt total shall be the same as the amount deposited.

c. Reconcile the Mail List to the Receipts to the Deposits At least at the end of each month, the mail listing and the listing of receipts shall be reconciled with the amount deposited and any differences shall be noted and reconciled.

d. Identification of Cash Receipts At a minimum, Cash receipts shall include information to distinguish Colorado Department of Health Care Policy and Financing remittances, county revenues, plus receipts from individuals, Vendors, and other sources.

e. Maintain a Cash Receipts Journal The county shall record the monies received for deposit into the social/human services fund on a Cash receipts journal. The Cash receipts journal shall record the receipt transactions for a calendar month.

f. Receipt of Negotiable Items Not Made Payable to the County Department If the county must accept negotiable items made payable to others, the county shall initiate a procedure to record the county receipt of the negotiable item, the amount of the negotiable item, the sender, the payee, the reason the transaction must be handled in this way, and the date the negotiable item was forwarded to the payee. All available methods to eliminate or minimize these transactions shall be undertaken by the county.

Reconciliation of County Information with Statewide Financial Automated Systems a. The county reimbursement or billing will be based on the information that is transmitted by the statewide- automated tracking systems to the CFMS.

The County Departments shall reconcile their own information with the Medical Assistance expenditures, reimbursements, and billing information documented in the statewide automated tracking systems and the State financial reporting system.

b. Correct Coding of Information The county shall correctly code all information reported to CFMS. These codes determine whether the Medical Assistance expenditure falls within budgetary allocations, disregards budgetary maximums or is a special project.

i. Reimbursable and Non-Reimbursable Costs Some Costs have a reimbursable portion and a non-reimbursable portion. The county shall split and appropriately code these Costs for reporting in the CFMS.

c. Reporting of Refunds All refunds collected for previously reimbursed Medical Assistance expenditures shall be reported in the CFMS. This reporting shall follow the procedures of the statewide automated tracking systems and/or the financial reporting systems.

d. Over-collections If the County Department collects more money from a payer than the amount established as due, a County Department warrant shall be issued to the payer to repay this over-collection within 30 business days of determining the over-collection. 1.010.10. Balance Sheet Accounts 1. Social/Human Services Fund A fund to be known as the social/human services fund shall be established and maintained in each of the counties of the State of Colorado.

a. Separate from Other Funds The social/human services fund in each county shall be accounted for separately from any other funds in the county so that the cash balance in the social/human services fund can be determined at all times.

b. Special Revenue Fund The social/human services fund shall be maintained as a special revenue fund and used to account for the proceeds of specific revenue sources that are legally restricted to Medical Assistance expenditures for specified purposes.

c. Includes All Medical Assistance The social/human services fund shall include all money appropriated by the Board of County Commissioners for the County Department’s administration of Medical Assistance eligibility and enrollment and related purposes.

d. Includes All Colorado Department of Health Care Policy and Financing and Federal Funds The social/human services fund shall include all money allotted, allocated, or apportioned to the county by the State Department. These funds are granted by the State of Colorado and by the federal government for Medical Assistance eligibility and enrollment and related purposes and paid to the county by the State Department.

e. Composition of the Social/Human Services Fund The fund consists of:

i. Assets, ii. Liabilities, iii. Approved budget, and iv. Fund balance (surplus or deficit of local revenues, both current and prior year).

Cash and Warrants a. Cash Reconciliation(s)

i. Performed within 30 business Days All Cash accounts are to be reconciled within 30 business days following the current month-end.

ii. Warrants Redeemed List A redeemed warrant listing(s) shall be retained or alternative procedures should be in place to reconcile the Cash balance of the social/human services fund. The reconciliation of the fund shall be based on warrants written and warrants outstanding along with other reconciling items to agree the book balance of the Cash in the account with the actual Cash balance of the social/human services fund.

iii. Retain Redeemed Warrants The redeemed warrants shall be retained, filed in numerical sequence or by date redeemed, and available for audit. A facsimile listing of redeemed warrants provided by the financial institution shall be acceptable.

b. Date of Warrant Issue The date of issue on a warrant must be on or before the date of mailing.

i. Delivery On the established pay date, all member and Vendor warrants shall be mailed to the last known address of the payee. Member and Vendor warrants shall only be hand delivered to payees if the County Department has the appropriate Internal Controls in place.

Employee compensation or employee travel reimbursement may be hand delivered with appropriate Internal Control surrounding the delivery.

c. Warrant Redemption Period of 180 calendar Days Each warrant drawn on and issued from the social/human services fund shall bear a notation clearly printed in a prominent position upon its face, stating that the warrant is void after a predetermined number of days, for example: “Void after 180 calendar days from issue date.”

i. Exception to Rule County Departments shall not have the option of using a time period longer than 180 calendar days for canceling warrants but may use a shorter period of time for cancellation of the warrants.

ii. Canceling Warrants Any warrants outstanding after the specified time period shall be canceled in accordance with the county internal control procedures or by resolution of the County Board at their next County Board meeting with the stipulation that should such warrant be presented for payment, a new warrant shall be issued.

iii. Stale Dated Warrants A stop-payment order will be issued to the County Treasurer or county redemption entity at the time the warrant cancellation resolution is passed.

d. Forged Warrants i. County Procedure Disposition of the forged warrant shall follow whatever steps are available at the county level to recover the amount of the forged warrant.

ii. Non-Reimbursable The Medical Assistance expenditure as a result of a forged warrant is non-reimbursable. If the amount is collected (from the forger or through return through the banking system) the refund is not reported through the CFMS. 1.010.11. Accounts Receivable 1. Establish Accounts Receivable The County Department shall establish recoveries due from Members for all fiscal and administrative areas in a manner consistent with 10 C.C.R § 2505-5 1.020.

Interest Payment on Delinquent Accounts Receivables a. Statutory Interest If permitted by Program Rules, a delinquent receivable not already assigned an interest rate may be assessed interest at the statutory rate as set by C.R.S. § 5-12-102.

b. Interest begins after payment becomes due or from the date of mutual settlement Interest of eight percent per annum compounded annually can be collected for all monies after they become due, or money due on mutual settlement of accounts from the date of such settlement and on money due on account from the date when the same became due.

c. Interest Stated Separately Interest liability incurred shall be presented on each billing statement as a separate amount from the original amount due.

Monthly Billing for Accounts Receivable The billing shall be supported by the details of the amount owed, prepared by the County Department referencing the delinquent receivable, the number of days of interest to be paid if applicable, and the interest rate if applicable.
Aging Accounts Receivable Each month every account receivable shall be aged in increments of 1-30 calendar days past due, 31-60 calendar days past due, 61-90 calendar days past due, and 91 or more calendar days past due.

a. Referral of Accounts Receivable to a Collection Agency When a county has exhausted its collection resources on a claim, the claim shall be referred to a collection agency and written off.

Accounts Receivable Recorded in the General Ledger The total amount of recoveries due shall be recorded in the county's general ledger accounting system. The account will be adjusted at a minimum each quarter reflecting additional amounts due and collections received.
Accounts Receivable, Subsidiary Journal The county shall maintain detailed subsidiary journals and the total of the subsidiary journals must equal the amount(s) recorded in the general ledger accounting system for accounts receivable. 1.010.12. Fixed Assets 1. Inventory The County Department shall be responsible for a physical inventory, at least every two years, of property, both real and personal, belonging to the County Department. An inventory shall be required only with respect to items of property having an original cost that equals or exceeds $10,000.00. For control purposes a County Department may establish an amount less than $10,000.00.

a. To maintain the federal identity of a capital asset, the County must properly track and account for the asset, ensuring it is clearly identified as a federal asset, and adhering to federal Regulations for its use and disposal. 2 C.F.R. Part 200 Subpart D Property Standards is hereby incorporated by reference and outlines insurance coverage and property standards for real property and Equipment acquired or improved with federal funds. For example, the County may have a central property management database whereby county staff conduct a physical inventory, at least every two years; however, the County Department Director is responsible for accounting for assets funded by the Medical Assistance Program.

Property Records Each County Department shall maintain detailed property records disclosing the:

a. Serial number or another identification number b. Date acquired, c. Cost of the fixed asset or value at the time of donation, d. Specific Program fund or Cost Pool used to acquire the fixed asset, e. Any alterations made to the fixed asset, and f. The physical location of the fixed asset.

Useful Life, Use and Disposal a. Useful Life The fixed asset acquired must be used by, and in, the County Department for the useful life of the asset. Useful life will be the same as defined by the Internal Revenue Service for straight-line depreciation for that class of asset as discussed in the Internal Revenue Manual 1.35.6, Property and Equipment Accounting (2024), which is hereby incorporated by reference.

b. Use for the County Department The County Department must use the fixed asset for the program for which it was acquired and for as long as needed. The County Department must not encumber the fixed asset without prior approval of the State Department..

c. Discontinuance of Asset or Program If fixed assets were purchased for a Program that has been discontinued or the asset is no longer needed, the County Department must follow disposition instructions from the State Department which will consist of retaining, selling, or transferring the title after compensating the State Department for the amount owed to the U.S. Department of Health and Human Services. This federal agency is entitled to an amount calculated by multiplying the percentage of the federal portion towards the original purchase by the current market value or proceeds from the sale/transfer.

The State Department will advise the County on where the credit should be posted. If the State Department fails to provide requested disposition instructions within 120 days, fixed assets with a current fair value in excess of $10,000 per unit may be retained or sold by the County 4. Recorded in the General Ledger The total dollar amount of fixed assets shall be recorded in the general ledger and shall be supported by and agree to the detailed property records that disclose the funding source of the assets.

Donated Fixed Assets Fixed assets donated to a County Department shall be recorded at the fair market value on the date of the gift and treated as purchased Equipment for inventory and accounting purposes.
Leased Fixed Assets With No Intent to Purchase The fixed asset so acquired must be used by, and in, the County Department for the term of the lease.

a. Interest Interest is allowable per the restrictions found in this rule manual, section 1.010.11.3.

b. Allowable Cost in a Sale and Leaseback Costs under sale and leaseback arrangements are allowable only up to the amount that would be allowed had the County Department continued to own the fixed asset.

c. Limit on Amount of Reimbursement Fixed assets rented by the county with no intent to purchase are reimbursable only up to the amount of the annual depreciation had the county purchased the asset.

Capital Lease of Fixed Assets Costs under leases, are allowable only up to the amount that would be allowed had the county purchased the fixed asset on the date the lease agreement was executed. This amount would include expenses such as depreciation or use allowance, maintenance, and insurance.

a. No County shall enter into any financed purchase of an asset whose duration, including all optional renewal terms, exceeds the weighted average useful life of assets being financed, as set forth in C.R.S. 29-1-103(3)(e)(I). 1.010.13. Revenue 1. County Tax Revenue The county government, through the budget process, determines the amount of county tax revenue that will be deposited into the social/human services fund during a calendar year.

a. Apportioned Taxes County tax revenue apportioned to the social/human services fund includes but is not limited to:

i. Levy on assessed valuation of property, and ii. Specific ownership taxes.

b. Deposits are Revenues The county shall record the actual deposits made each month to the social/human services fund from information furnished by the County Treasurer. No calculation of earned revenue from county sources is necessary month by month.

Miscellaneous Revenue a. Revenue from Social/Human Services Costs All revenue received by a county or County Department, as a result of part or all of the costs being borne by a social/human services Program, shall be deposited into the social/human services fund.

b. Donations and Gifts Unrestricted bequests, gifts or donations to the County Department are used as local revenue. If a restricted donation to the county is invested and the income from the investment is not restricted, such income is a source of local revenues.

State and/or Federal Revenue and Payables a. Monthly Posting to the General Ledger Accounting entries to record the County Department calculation of the monthly earned revenues and electronic benefit authorization payables shall be posted monthly to the county general ledger. 1.010.14 Medical Assistance Expenditures and Allowable versus Unallowable Costs A Medical Assistance expenditure must benefit the Program for which it is incurred, meaning that any cost charged to Medical Assistance must be directly related to those that are necessary for achieving the specific goals and objectives of the federal Program, essentially ensuring that funds are used only for activities that are in accordance with Program guidelines and the 2 C.F.R. Part 200 Cost Principles.
Costs are allowable if they are reasonable, necessary, and allocable to Medical Assistance, as set forth in 2 C.F.R. § 200.403, which is hereby incorporated by reference, and if they comply with funding statute and State Department requirements.

b. Medical Assistance Expenditures Shall Be Necessary and Reasonable Medical Assistance Expenditures shall be necessary and reasonable for proper and efficient performance and administration. A cost is reasonable if, in its nature and amount, it meets all the following criteria c Medical Assistance Expenditures Shall Be Compared to Market Prices for Reasonableness i. Medical Assistance Expenditures shall be compared to the market prices for comparable goods or services as a test for reasonableness.

ii. Medical Assistance Expenditures Shall Be Ordinary and Necessary Medical Assistance Expenditures shall be of a type generally recognized as ordinary and necessary for the operation of the governmental unit or the performance of the federal award.

iii. Medical Assistance Expenditures Shall Meet Standards Such as Sound Business Practices and Arms-Length Bargaining Medical Assistance Expenditures shall have restraints or requirements imposed by such factors as: sound business practices; arms-length bargaining; federal, State and other laws and Regulations; and, terms and conditions of the State and/or federal award.

iv. Medical Assistance Expenditures Shall Be the Same as Would Be Incurred by a Prudent Person Medical Assistance Expenditures shall not exceed that which would be incurred by a prudent person under the circumstances prevailing at the time the decision was made to incur the cost. A prudent person is one who considers their responsibilities to the governmental unit, its employees, the public at large, and the federal government.

d. Medical Assistance Expenditures Shall Be Allocable Medical Assistance Expenditures that are allocable must benefit the federal Program to which they are being charged.

i. Relative Benefits Received A Cost is allocable to a particular cost objective if the goods or services involved shall be chargeable or assignable to such cost objective in accordance with the relative benefits received.

ii. Cost Shifting to Fund Deficiencies Any cost allocable to a particular federal award or cost objective shall not be charged to other federal awards to overcome fund deficiencies or to avoid restrictions imposed by law or terms of the federal awards, or for other reasons. However, this prohibition shall not preclude shifting costs that are allowable under federal and State laws for two or more awards in accordance with existing Program agreements.

Examples of Allowable versus Unallowable Costs Per 2 C.F.R. Part 200 and each of the subsections of 2 C.F.R. Part 200 listed below, all of which are hereby incorporated by reference, the following list represents examples of allowable and unallowable costs; however, it is not meant to be comprehensive. These are intended to cover the most common types of costs incurred. Omission of a particular item does not indicate that it is allowable or unallowable.

a. Allowable costs are direct. The cost results in a direct benefit to Medical Assistance. The cost can be easily and accurately traced to Medical Assistance. Some Indirect Costs are also allowed.

i. Advertising, as described in 2 C.F.R. § 200.421, which includes the recruitment of personnel, e.g. help wanted ads.

ii. Compensation for personal services, as described in 2 C.F.R. § 200.430, which includes remuneration for enrollment and eligibility duties justified in a job description. The County Department must update job descriptions and use daily logs (100% time reporting) to specifically justify enrollment and eligibility work. Routine fiscal and budget activities do not fall under the compensation for personal services for enrollment and eligibility services.

iii. Compensation for fringe benefits, as described in 2 C.F.R. § 200.431, which includes fringe benefits for enrollment and eligibility workers that are reasonable and are required by law, an entityemployee agreement, or an established policy of the County iv. Conferences, as described in 2 C.F.R. § 200.432, which means an event to disseminate technical information to the County Department. Allowable Costs include rental of facilities, speakers’ fees, attendance fees, cost of meals and refreshments, and local transportation.

v. Defense and prosecution of criminal and civil proceedings, claims, and appeals, as described in 2 C.F.R. § 200.435, which includes the service costs that bear a direct relationship to a judicial or administrative proceeding, provided by counsel, accountants, counsel, accountants, consultants, or others engaged to assist the County Department before, during, or after the commencement of that proceeding.

vi. Employee health and welfare costs, as described in 2 C.F.R. § 200.437, which includes Costs incurred in accordance with the County Department’s written policies for improving employee health.

vii. Depreciation, as described in 2 C.F.R. § 200.436, which can be claimed as an indirect cost on items with a unit cost of $10,000 or more. Assets may be depreciated or claimed as cost sharing but not both. Depreciation may be calculated on the non-federal share of the asset. Depreciation is not allowed on assets that have outlived their depreciable lives.

viii. Maintenance and repair, as described in 2 C.F.R. § 200.452, which includes utilities, insurance, security, necessary maintenance, janitorial services, repair, or upkeep of buildings and Equipment which neither add to the permanent value of property nor appreciably prolong its intended life but keep it in an efficient operating condition.

ix. Materials and supplies, including costs of computing devices, as described in 2 C.F.R. § 200.453, that are necessary for the performance of the Medical Assistance Program. Withdrawals from general stores or stockrooms must be charged to the federal Program based on their actual net cost, using a consistent inventory valuation method in accordance with GAAP.

x. Memberships, as described in 2 C.F.R. § 200.454, which includes memberships in business, technical, or professional organizations such as CGHSFOA and CHSDA.

xi. Member participation, as described in 2 C.F.R. § 200.456, means support for Member participation in or attendance at Medical Assistance activities, such as Member engagements, conferences, or surveys facilitated by the County Department, and includes stipends, travel allowances, registration fees, temporary dependent care, and per diem paid directly to or on behalf of Members whose perspectives or input are sought as part of the federal Program.

These costs must be documented in the County Department’s written policies and procedures and treated consistently across all federal awards.

xii. Security, as described in 2 C.F.R. § 200.457, which includes the protection and security of facilities, personnel, and work products.

xiii. Publication and printing, as described in 2 C.F.R. § 200.461, which includes electronic and print media.

xiv. Telecommunication and video surveillance, as described in 2 C.F.R. § 200.471, which includes phones, internet, video surveillance and cloud servers, except for the prohibitions outlined under the procurement section at 1.010.15.

b. Unallowable Costs An unallowable cost is an expense that cannot be charged to or reimbursed by the federal grant, regardless of whether they are reasonable or necessary. Costs must be directly related to the Medical Assistance Program activities and not be mixed with other, unrelated expenses.

i. Direct funding provided by the County Department to the Applicant or Member; this includes any Costs that are billable as claims through the State Department claims payment system. Examples include gift cards or payments provided for Member needs such as diapers, gasoline, car repairs, meals/snacks, entertainment activities such as books/toys, rent, cell phone, medical equipment, etc.

ii. Alcoholic beverages, as described in 2 C.F.R .§ 200.423.

iii. Single Audits, as described in 2 C.F.R. § 200.425, that fall under the $1,000,000 threshold of federal expenditures.

iv. Bad debts, as described in 2 C.F.R. § 200.426, which are debts determined to be uncollectible.

v. Contributions and donations, as described in 2 C.F.R. § 200.434, which includes cash, property, and services from the County Department to other entities.

vi. Entertainment and prizes, as described in 2 C.F.R. § 200.438, which includes amusement, social activities, gifts, or challenges.

vii. Equipment and other capital Expenditures as Indirect Costs, as described in 2 C.F.R. § 200.439(b)(7).

viii. Fines, penalties, damages and other settlements, as described in 2 C.F.R. § 200.441, which includes legal judgments and settlements against the County Department.

ix. Fundraising and investment management, as described in 2 C.F.R § 200.442, which includes solicitation of gifts and bequests and similar expenses to raise capital or obtain contributions.

x. Goods or services for personal use of County Department employees, as described in 2 C.F.R. § 200.445, regardless of whether the cost is reported as taxable income to the employees.

xi. Recruiting costs, as described in 2 C.F.R. § 200.463, which includes special emoluments, fringe benefits, and salary allowances incurred to attract professional personnel that do not meet the test of reasonableness.

xii. Scholarships, student aid costs, and tuition, as described in 2 C.F.R. § 200.466, where the purpose of the federal award is not to provide training to participants and the federal agency has not approved the cost.

xiii. Selling and marketing costs, as described in 2 C.F.R. § 200.467, which includes the selling and marketing of any Medical Assistance products or services.

xiii. Travel insurance paid by the traveler is not allowable for 3. Proper Classification of Federal Match Enhanced and Non-Enhanced Activities The Patient Protection and Affordable Care Act Care made additional funds available for specific activities related to Medical Assistance eligibility processing and determination activities. Those specific identified administrative activities relate to eligibility, enrollment, and supporting functions including customer service and other required functions that support eligibility and enrollment. These activities are referred to as “enhanced” which means a higher federal reimbursement is provided. The table below describes the percentage of federal, state, and local share of expenses that qualify for the enhanced reimbursement.

a. Enhanced Activities The following non-exhaustive list of Medical Assistance activities that can be categorized as enhanced are reimbursable at the enhanced rate are listed below.

Expense Total Federal State Local Enhanced 100% 75% 15% 10% i. Enrollment and eligibility work performed in CBMS and supported by job descriptions that accurately reflect the work being done.

ii. Call center staff providing activities related to eligibility determination or on-going case maintenance and supported by job descriptions that accurately reflect the work being done.

iii. IT staff setting up or maintaining workstations for enrollment and eligibility workers. Managing access and management of CBMS is a State Department function.

iv. Interpreters who perform enrollment and eligibility support activities such as interpreting for Members in the enrollment and eligibility process for applications, recertifications, and case maintenance.

This is supported by job descriptions or contractual agreements that accurately reflect the work being done.

v. Supervisory or leadership responsibilities directly related to enrollment and eligibility processes such as intake, acceptance, eligibility determinations, on-going Cash maintenance, and customer services activities related to enrollment and eligibility activities.

vi. Operating expenses such as cleaning, repairs and maintenance, telephone, travel, ADP equipment (printers, copiers, scanners), office space, and office supplies consumed by enrollment and eligibility workers, and those individuals that support or supervise this work. Office space must be calculated on actual space occupied by enrollment and eligibility staff and not be allocated based on an FTE percentage.

b. Non-enhanced Activities All other Medical Assistance eligibility and enrollment activities that cannot be categorized as enhanced as outlined above are reimbursable at the non-enhanced rate. The following non-enhanced activities that cannot be categorized as enhanced are outlined below and are reimbursable at the non-enhanced rate. See the following table for the percentage of federal, state, and local share of expenses that qualify at the non-enhanced reimbursable rate.

Expense Total Federal State Local Non- Enhanced 100% 50% 30% 20% i. Call center staff functions related to benefits, general beneficiary education, and plan choice, which are not functions delegated to the County Department.

ii. Program integrity; once a case is determined eligible, the enrollment and eligibility portion are complete; therefore, this covers quality review, audit, and fraud activities.

iii. Staff development and training.

iv. Human resources and routine fiscal activities of accounting, finance, and budget staff activity or other staff, unless these employees complete enrollment and eligibility case activities or inquiries.

v. Attorneys or legal staff involved in the enrollment and eligibility discussion or decision but not involved with CBMS.

vi. Transportation is a post-eligibility activity which covers travel. For additional guidance, see section 1.010.17 on travel.

viii. Security and shredding services are not directly related to enrollment and eligibility.

ix. Repairs and maintenance on the County computer network and other equipment such as firewall monitoring, electronic fax system, text messaging service, telephone system, etc.

x. Equipment and other capital Medical Assistance expenditures are unallowable as Indirect Costs as set forth in 2 C.F.R. § 200.439, which is hereby incorporated by reference.

xi. Outreach activities that relate to eligibility and enrollment, including personnel costs.

Prior Written Approval Prior written approval for the Medical Assistance Program means obtaining explicit, documented permission from the State Department before undertaking certain actions or incurring specific costs. This ensures that expenditures align with the federal Program Regulations, preventing potential disallowances or disputes.

To avoid disallowance, a County Department must seek prior written approval from the State Department for the following non-exhaustive list of activities in accordance with 2 C.F.R. § 200.407, which is hereby incorporated by reference.

Additional costs may also require prior written approval.

a. Cost Sharing Acceptable contributions are verifiable in the County Departments records, are not included in any other federal Program, are necessary and reasonable to achieve objectives, are allowable under the 2 C.F.R .Part 200 cost principles, and are not paid directly or indirectly under another federal Program, as set forth in 2 C.F.R. § 200.306, which is hereby i. Depreciation on assets is permitted so long as the property is not counted toward meeting cost share requirements, as set forth in 2 C.F.R. § 200.436, which is hereby incorporated by reference.

b. Program Income Per 2 C.F.R. § 200.307, which is hereby incorporated by reference, gross income earned by the County Department is directly generated as a result of the federal award. Program income must be expended prior to applying federal funds.

c. Equipment and other capital Medical Assistance expenditures Assets consisting of general-purpose Equipment with a unit cost of $10,000 or more, and capital improvements that materially increase their value or useful life, as set forth in 2 C.F.R. § 200.439, which is hereby d. Fundraising costs Fundraising for the purpose of meeting the Medical Assistance Program objectives, as set forth in 2 C.F.R. § 200.442, which is hereby 5. Factors Affecting Allowability of Costs To be allowable for reimbursement under federal awards, 2 C.F.R. § 200.403 which is hereby incorporated by reference, Medical Assistance expenditures reported in the CFMS shall meet the following general criteria:

a. Medical Assistance Expenditures Shall Have Consistent Treatment A cost shall not be assigned to a federal award as a direct cost if any other cost incurred for the same purpose in like circumstances has been allocated to the federal award as an indirect cost.

b. Medical Assistance Expenditures Shall Comply With GAAP Medical Assistance Expenditures must, except as otherwise required by 2 C.F.R. Part 200, which is hereby incorporated by reference, be determined in accordance with GAAP.

c. No Provision for Profit Reimbursable Medical Assistance expenditures shall be based on actual cost with no provision for profit or increment above cost.

d. Medical Assistance Expenditures Shall Be Based on Actual Costs Reimbursable Medical Assistance expenditures shall be an actual cost and not a cost based on an average, allocated, anticipated or budgeted cost.

e. Medical Assistance Expenditures Shall Not Be Prohibited Reimbursable Medical Assistance expenditures shall not be those prohibited under federal, State, or local laws, Rules, and Regulations.

f. Medical Assistance Expenditure Policies, Regulations, and Procedures Shall Be Applied Uniformly Reimbursable Medical Assistance expenditures shall be consistent with policies, regulations, and procedures that apply uniformly to State and federal awards and other activities of the county.

g. Medical Assistance Expenditures Shall Only Be Used Once as a Match Medical Assistance expenditures shall not be included as a cost or used to meet cost sharing or matching requirements of any other federal award in either the current or a prior period, except as specifically provided by federal law or Regulation.

h. Medical Assistance Expenditures Shall Be Net of Applicable Credits i. Net of All Credits Medical Assistance expenditures shall be claimed net of all credits, including but not limited to, volume and cash discounts, refunds, rental income, trade-ins, scrap sales, rebates or allowances, recoveries or indemnities on losses, insurance refunds, adjustments of overpayments, and erroneous charges.

Documentation of Medical Assistance Expenditures To be allowable for reimbursement under federal awards, Medical Assistance expenditures reported in CFMS shall meet the following criteria:

a. Documentation to Support Medical Assistance Expenditures The authorization to purchase, documentation of the receipt of the goods or services, the Vendor's invoice, and a signed commitment voucher or signed approval to pay for each disbursement are documents supporting Medical Assistance expenditures and must be retained and available for audit purposes.

i. Prior Authorization Medical Assistance expenditures shall have County Department e prior authorization evidenced by a signed requisition, purchase order, or similar form of prior authorization, as set forth in 2 C.F.R. § 200.318, which is hereby incorporated by reference.

ii. Receiving Reports Medical Assistance expenditures shall be documented by evidence of the receipt of goods or services such as a receiving report or other supporting documentation signed by an employee authorized to receive the goods or services. A receiving report or other supporting documentation shall include actual quantities received, any unsatisfactory condition, and compliance with specifications, prior to a voucher being processed for payment and shall be attached to the voucher packet.

iii. Verification of Vendor's Invoice The Vendor's invoice must be verified by checking for proper purchase authorization, notation of receipt of goods/services, correct addition, and extensions. The invoice should be approved either in hard copy or electronically by the person verifying its accuracy. Any discounts for prompt payment or volume purchase shall be reported as a credit or reduction of Medical Assistance expenditures.

iv. Commitment Vouchers No disbursement of funds shall be made unless the county approval process has been followed.

Employee Salary and Benefits To be allowable for reimbursement under federal awards, employee salary and benefits reported in the CFMS shall meet the following criteria:

a. Documentation of Employee Salary and Benefits The County Department Director and/or County Board will document employee salary, benefits, and withholdings on Payroll records. County Department Medical Assistance Expenditure payroll allowances shall be supported on timesheets separate from other county personnel costs.

These Payrolls must be available for audit and retained as per Colorado Office of State Archives requirements set forth in C.R.S. § 24-80-102 i, Documentation of Employee Salary and Benefits County Departments shall have records documenting all personnel actions including, but not limited to, appointments and separations, employee salary level, transfers, demotions, funding changes, pay increases, promotions, terminations, title changes, attendance and leave records, longevity or other circumstances affecting employee compensation.

ii. Controls Over Employee Salary and Benefits Adequate controls shall be maintained to initiate changes in salary due to promotion, longevity or other circumstances affecting employee compensation.

b. Employee Wage Assignments County Department employee wages are subject to execution, levy, attachment, garnishment, or other legal processes.

c. Leave Records All County Departments shall maintain records of all leave both accrued and taken.

Reimbursements for Employee Training a. Training Purpose Training Functions shall be held to achieve program objectives, develop employees, enhance employee's job performance, and shall be limited to reasonable and actual Costs.

b. Training Attendance The attendance of employees at Training Functions shall include only those individuals related to the purpose of the function.

c. Training Functions Shall Be Documented d. Training Functions shall have a written agenda, study materials, and be led by an identified presenter. 1.010.15. Procurement 1. The County or the County Department must develop, maintain and use documented procedures for procurement transactions using Medical Assistance dollars or other federal funds.

Bid System A County Department that purchases in excess of $100,000 shall use a formal advertising and bidding process to provide, to the maximum extent practicable, open and free competition. Per C.F.R. § 200.319(a), which is hereby incorporated by reference, all County Department procurement transactions under the federal award must be conducted in a manner that provides full and open competition. If a County Department is unable to use this process, written justification shall be available from the County Department giving the facts related to the purchase and the inability to advertise and seek bids.
Federal Funding Accountability and Transparency Act of 2006 (FFATA)

Requirements Regardless of procurement method, a County Department that receives funds directly from a federal entity and purchases from the same vendor goods and/or services in excess of $30,000.00 is subject to the FFATA requirements.

a. First-Tier Recipient of Federal Funds A County Department that receives Medical Assistance funds only is not subject to the FFATA requirements because in this instance, the State Department is the prime Recipient (first-tier) of the Medical Assistance funds and as such bears the FFATA responsibility. When the County Department receives federal dollars in excess of the Medical Assistance funds, the County Department bears the FFATA responsibility.

Suspension and Debarment Federal funds cannot be awarded to a Contractor that has been suspended or debarred.

a. Exclusions Extract on SAM.gov The County Department must verify procurement eligibility of a Contractor by reviewing the Exclusions Extract at https://sam.gov/content/exclusions.

Prohibition of Telecommunications and Video Surveillance Services or Equipment Due to national security, a County Department is prohibited from procuring equipment, services, or systems produced by Hytera Communications Corporation, Hangzhou Hikvision Digital Technology Company or Dahua Technology Company or their subsidiaries or affiliates. 1.010.16. Contracts The County Departments shall adhere to all county guidelines for Contract processes and procedures. In the absence of county procedures, the County Department shall follow State Contract process and procedures pursuant to 1 C.C.R. § 101 through 1 C.C.R. § 109 (2025), which are hereby incorporated by reference.

To be allowable for reimbursement under federal awards, Medical Assistance expenditures for Contracts reported in the CFMS shall meet the following criteria:

Contract Intent Each County Department shall be responsible for assuring that the Contracts they initiate are within the intent of the funding source and that the Contract is necessary and is the most economical and efficient means for accomplishing the identified tasks.
Subrecipient versus Contractor Determination Each County Department shall be responsible for determining the substance of the agreement as required by 2 C.F.R. § 200.331, which is hereby incorporated by reference, between the county and its Vendors. County Departments must have a documented process for the determination of a Subrecipient versus Contractor. County Departments must maintain documentation of the determination as part of the agreement. When the result of the determination is a Subrecipient:

a. The County Department must have a written monitoring process for oversight of its Subrecipients. This process must include a risk assessment of each Subrecipient.

b. The risk assessment is not part of the selection process but must be done at the outset of the Subaward and at least annually thereafter.

c. Counties must follow information and documentation requirements required by 2 C.F.R. § 200.332, which is hereby incorporated by 3. Interagency Contracts Formal agreements between two agencies, sometimes referred to as “Interagency Agreements,” “ Memoranda of Understanding,” or “Memoranda of Agreement” are to be treated as if they are Contracts.

Contracts Legality The County Department shall be responsible for assuring that all constitutional, statutory, regulatory, and grant requirements have been met prior to signing a Contract.
Protection of Interests A County Department shall negotiate and process a Contract when protecting the interest of the county can only be accomplished by using a Contract. When questions arise in this area, the county legal representative should be contacted for assistance.
Advance Payments/Retainers Contracts and other commitment vouchers shall not provide for advance payment for goods and/or services unless it is an established industry standard or unless the party to the Contract provides a benefit to the county at least equal to the cost and risk of the advance payment. Any advance payment made on a Contract shall require the written approval of the chairman of the County Board, or an authorized delegate.
No Personal Benefit The county signatories of a Contract shall have no personal or beneficial interest whatsoever in the goods or services described in the contract.
Contracts at a Minimum Shall:

a. Be in Writing All Contracts at a minimum shall be prepared in writing.

b. Specifically Identify the Parties to the Contract All Contracts at a minimum shall specifically identify the parties to the Contract.

c. Contain a County Fiscal Year Restriction All Contracts shall contain a fiscal year restriction such as:

“This contract is subject to and contingent upon the continuing availability of budgeted county funds for the purposes hereof.”

d. Contain a Restriction Regarding the Availability of State and/or Federal Funds Contracts shall contain a restrictive clause involving State and or federal funds such as:

“This contract is subject to and contingent upon the continuing availability of State and or federal funds for the purposes hereof.”

e. All Contracts Shall Contain Provisions for:

i. Statement of Work;

ii. Payment terms, including maximum dollar amount;

iii. Performance period (Contract beginning and end dates); and iv. General terms and conditions.

f. Request Payment at Least Monthly Contractors shall bill for goods or services at least monthly. Goods or services performed must be identified in detail. Contracts shall specify that all parties to the Contract shall maintain, for audit purposes, documentation to support Medical Assistance expenditures claimed under the Contract. Payments made should be coded to account categories that identify the type of expense being paid.

g. Define Breach of Contract The county shall define breach of Contract and include available remedies in the Contract.

Contract Review a. Contract Monitoring The County shall have a monitoring system to assure that Medical Assistance expenditures claimed are within the terms of the Contract.

b. Review for Availability of Funds Before the execution of a Contract, the County Department Director or a delegate shall review the Contract for completeness and to ensure that funds are available to cover the Contract liability; written evidence of the director’s or delegate’s review shall be maintained with the Contract.

c. Review for Compliance Before execution of a Contract, the County Department Director or delegate shall categorize the Contract according to risk using the State Controller’s “Review and Approval of State Contracts” criteria or criteria established by written policy of the County Department Director. The County Department legal representative shall review all high risk Contracts to include compliance with:

i. The federal and the State constitution, ii. Federal and State laws, iii. Federal and State Rules and Regulations, iv. Executive orders, and v. The authority of the County Department of Social/Human Services to enter into the Contract.

The County Department shall maintain written documentation of the risk analysis of the Contract as well as a copy of the results of the written legal review in the Contract file.

d. Delegation of the Contracting Authority Under certain circumstances the County Department Director may delegate, in writing, authority to execute Contracts. Delegation of the County Department Director's Signature authority does not eliminate the requirement that all Contracts have a risk analysis and, if required, legal review, or exempt any County Department from securing the required approval from the chairman of the County Board.

Contract Signature Approval a. Signature Authority The chairman of the County Board or a designee shall sign all Contracts on behalf of the County Department. Delegated authority shall be in writing and maintained for audit purposes.

b. Signatures It shall be the responsibility of the contracting county to obtain Signatures of all parties to the Contract and to retain at least one Contract that contains the Signatures of all of the contracting parties.

Required for Personal Services Contracts shall be required when a County Department purchases personal services that are provided in a relationship other than that of employee-employer.

Personal service Contracts include maintenance and service agreements, including but not limited to, legal services, management services, extensions of County Department staff, other public or private agencies, automated data processing services, and training by other than the Colorado Department of Health Care Policy and Financing, Colorado Department of Human Services, or another County Department staff.

a. Contract Provision for Personal Services in excess of $100,000 To be included as a reimbursable expense from the State Department, personal services Contracts over $100,000 shall include all of the following Contract requirements:

i. Performance measures and standards developed specifically for the Contract by the administering County;

ii. Accountability standards requiring regular Vendor reports on achievement of the specified performance measures and standards;

iii. Payment provisions allowing the County to withhold payment until successful completion of all or specified parts of the Contract and requiring prompt payment upon successful completion;

iv. Monitoring requirements specifying how the County and the Vendor will evaluate each other’s performance, including progress reports, site visits, inspections, and reviews of performance data; and v. Processes for resolving disputes between the County and the Vendor.

Required for Lease/Rent A County Department shall negotiate and process a Contract when leasing buildings, or other office or meeting space.
Compliance with Laws Existing laws, Rules and Regulations cannot be overridden by terms in a Contract or a memorandum of understanding. 1.010.17. Travel The County Department shall adhere to all county guidelines for travel policies and reimbursement procedures. In the absence of county policies and procedures, County Departments shall follow 2 C.F.R. § 200.475(d), which is hereby incorporated by 1. To be allowable for reimbursement under federal awards, Medical Assistance travel expenditures reported in the CFMS shall meet the following criteria:

a. General All costs for travel related to Medical Assistance eligibility and enrollment activity shall be pre-approved by the County Department Director.

Appropriate supporting documentation shall be maintained prior to travel.

b. Travel Policies Shall Be Consistent Throughout the County The travel policies for County Department employee reimbursement for lodging, meals, and Transportation shall be consistent with those policies in the county’s other departments, offices, and divisions.

c. Travel Expense as Part of Another Fee If travel expenses (meals, lodging, Transportation, etc.) are included in conference fees, registration fees, or are otherwise furnished at no additional cost to the traveler, no reimbursement shall be made for these items. If, however, a meal included in a commercial transportation ticket is not adequate, and the traveler incurs an additional meal expense, reimbursement may be claimed at the authorized rate for that meal.

d. Travel Reimbursement for Only County Business Lodging, meals, and other reimbursable travel expenses shall only be reimbursed for the period of time necessary for the traveler to accomplish the County Department business.

e. Limited Time for Reimbursement Reimbursement for travel and related expenses is available for the current month (month being paid) and two preceding months.

Transportation Transportation costs charged to the State are costs incurred by employees who are in travel status on official business.

a. Reimbursement for the Most Economical and Efficient Means Available Transportation shall be completed using the most economical and efficient means available that will satisfactorily accomplish the County Department business.

b. Documentation of Trip Sufficient documentation of the purpose and the cost of the trip shall be included with the travel expense form. If the purpose of the travel is not solely for business purposes, the individual involved shall make a reasonable allocation of the expenses and the travel reimbursement request shall contain sufficient documentation to indicate the allocation made and the basis for the allocation.

c. Mileage Rate Reimbursement of vehicle transportation shall not be greater than the standard mileage rate for business established by the US Internal Revenue Service. This mileage rate is to cover all ownership and operating costs of the vehicle. The County Department shall adhere to all county guidelines for mileage reimbursement..

d. Transportation Does Not Include Employee's Spouse or Other Non- County Employee Reimbursable costs shall not include the cost of an employee's spouse or other non-County Department employee(s) accompanying the employee on a business trip.

e. Only One Reimbursement per Vehicle When two or more people travel together in the same personally owned and operated automobile, only the employee responsible for the automobile shall be allowed mileage reimbursement.

Lodging a. Lodging Receipt Receipts for lodging shall be obtained and submitted with the travel expense form. The actual lodging receipt is required. Charge slips are not sufficient.

b. Travel Reimbursement at Reasonable Accommodations Employees pre-authorized to travel shall be reimbursed the actual cost of reasonable accommodations. Employees may be required to use approved or designated lodging facilities in certain areas to assist in controlling travel cost. Reimbursement shall be limited to the cost of commercial lodging.

Meals a. Meal Per Diem Employees pre-authorized to travel shall be reimbursed for the cost of meals, including tax, tip and other incidental expenses at a rate not higher than the per diem rates set under 5 U.S.C. § 5701-11 (2025) (Travel and Subsistence Expenses; Mileage Allowances).
Reimbursable Items In addition to lodging, meals, and Transportation, the following actual expenses incurred as a necessary part of approved travel may be reimbursed.

a. Travel Tips Reasonable tips paid by the traveler for bellhops, porters, maids, and ground transportation are reimbursable up to the daily incidental per diem.

Tips paid in conjunction with meals are included in the meal per diem and cannot be claimed separately.

b. Commercial Vehicle Commercial Transportation expenses paid by the traveler are reimbursable. A receipt shall be required for each individual ride in a commercial vehicle, if over $25.00.

c. Travel Campsite Fees Campsite fees paid by the traveler for a commercial campground or a State or national park are reimbursable. A receipt shall be required if over $25.00.

d. Parking Fees Parking fees paid by the traveler are reimbursable. A receipt shall be required for any single fee over $25.00.

e. Travel Registration Fees Registration fees paid by the traveler are reimbursable. A receipt is required for all registration fees paid.

f. Rental Car Cost Rental car costs paid by the traveler are reimbursable. A receipt is required for all Medical Assistance rental car expenditures.

g. Communications Charges Telephone, fax, and other similar charges paid by the traveler for official County Department business are reimbursable. A receipt shall be required for any single charge over $25.00. Personal phone calls are included in the incidental per diem rate; they cannot be claimed separately.

h. Toll Road Charges Toll road charges paid by the traveler are reimbursable when the travel is for official County Department business and when the travel is preapproved.

Travel Approval and Expense Form a. Approval The County Department Director shall approve according to the travel expense process. This Signature shall certify a review and approval of all travel expense items. Receipts for lodging, parking and other miscellaneous claims shall be attached to the County Department copy of the travel expense form. This travel expense form and all receipts shall be retained. Approval of this travel expense form shall be shown by the employee’s supervisor’s Signature. The employee requesting reimbursement shall sign the travel expense form to certify that all expenses listed are for approved County Department purposes.

b. Travel Expense Form The County Department prescribed travel expense form shall be used for claiming all travel expenses for which an employee, volunteer, or County Board member requests reimbursement. A properly completed and approved travel expense form shall support all payments for travel expenses.

c. Travel Advances At the discretion of and in compliance with County Department policies and procedures, employees may request a Cash advance to conduct business for the County Department. The amount of the travel advance shall be no larger than the total per diem allowance for the planned trip.

The County Department-prescribed request for Travel Advance form or alternate form containing the same information shall be used for requesting an advance. The form should require the signed approval of the employee’s supervisor and the County Department Director.

Travel Coding and Reimbursement Travel Coding Travel shall be reported under the same program and function coding as the employee's salary and benefits. If the travel expense is reported under a coding other than the coding for the employee's salary and benefits, sufficient explanation and/or documentation to support this alternate coding shall be attached to the travel expense form. 1.010.18. Office Space 1. To be allowable for reimbursement under federal awards, Medical Assistance expenditures for office space reported in the CFMS shall meet the following criteria:

a. Allocation of Office Space Costs The reimbursement for office space is a part of each program's administrative allocation and allowable only to the extent of each program's administrative allocation. The allocation of the total office space costs to each program is to be based on square foot used or other reasonable and documented method.

b. Sharing Office Space If a building is shared with another agency, the County Department cost shall not exceed the prorated share of the total building costs based on square feet used.

c. Substantiating Space Costs Prior to building or contracting for another building, or changing the current Contract, the County shall obtain and retain documentation that office space costs incurred are equal to or less than the cost of comparable commercial leases in the area.

Allowable Costs for County Owned Office Space a. Allowable Capital Costs for Owned Office Space The allowable cost for county-owned office space is based on a usage allowance of two percent per year of the capitalized cost of the building or an amount based on a reasonable depreciation schedule that is approved by the State Department Approving Authority b. Medical Assistance Expenditure of the Social/Human Service Fund The full amount of the usage allowance or depreciation for office space shall be an actual Medical Assistance expenditure from the social/human services fund. This Medical Assistance expenditure shall be paid to the County Department or other County entity that owns the building(s).

c. Allowable Office Space Costs in Addition to Capital Costs Office space costs that are allowable for reimbursement are as follows, but are not limited to, utilities such as heating, lighting or cooling the building, normal repairs and maintenance that are not capitalized, ordinary and normal rearrangement and alterations that are not capitalized, security, janitorial, building insurance, elevator service, and upkeep of grounds, as required by 2 C.F.R. § 200.452, which is hereby incorporated by reference.

d. Allowable Interest on Office Space Costs Costs incurred for interest on borrowed capital or the use of a governmental unit's own funds, however represented, are unallowable except as specifically provided below in accordance with 2 C.F.R. § 200.449, which is hereby incorporated by reference.

i. Office Space Interest Expense Limitations Financing costs (including interest) associated with the otherwise allowable costs of building acquisition, construction, or fabrication, reconstruction or remodeling completed on or after October 1,1980, is allowable, subject to the following three conditions:

A. Bona Fide Third Party Funding The financing is provided (from other than tax or user fee sources) by a bona fide third party external to the governmental unit, B. Support Federal Awards The assets are used in support of federal awards, and C. Interest Earnings Earnings on debt service reserve funds or interest earned on borrowed funds pending payment of the construction or acquisition costs are used to offset the current period's cost or the capitalized interest, as appropriate. Earnings subject to being reported to the federal Internal Revenue Service under arbitrage requirements are excludable.

Allowable Costs for Leased Office Space a. Allowable Office Space Costs for Leased Office Space The allowable cost for non-county owned office space is the lower of the actual lease cost or a rate that is reasonable in light of such factors as rental costs of comparable property, if any; market conditions in the area; alternatives available; and, the type, life expectancy, condition, and value of the property leased.

b. Allowable Office Space Costs in Addition to Lease Costs Office space costs that are allowable for reimbursement if not already provided for in the lease agreement are as follows but are not limited to utilities such as heating, lighting or cooling the building, normal repairs and maintenance that are not capitalized, ordinary and normal rearrangement and alterations that are not capitalized, security, janitorial, building insurance, elevator service, upkeep of grounds, and appraisal fees required by the County Department for cost comparisons.

c. Allowable Office Space Costs in a Sale and Leaseback Costs under sale and leaseback arrangements are allowable only up to the amount that would be allowed had the County continued to own the property, as set forth in 2 C.F.R. § 200.465, which is hereby incorporated by reference.

d. Office Space Costs in a Less-Than-Arms-Length Lease Office space costs under a less-than-arms-length lease are allowable at an amount that is reasonable in light of such factors as rental costs of comparable property, if any; market conditions in the area; alternatives available; and the type, life expectancy, condition, and value of the property leased, as set forth in 2 C.F.R. § 200.465, which is hereby e. Authority Created to Acquire and Lease Office Space Prior approval from the State Department is required for reimbursement of office space costs when the County creates an authority or similar entity to acquire and lease the office space to the County Department.

f. Capital Lease of Office Space Costs under leases, which are required to be treated as finance leases are allowable only up to the amount that would be allowed had the governmental unit purchased the property on the date the lease agreement was executed. This amount would include expenses such as depreciation or use allowance, maintenance, and insurance. Interest costs related to capital leases are allowable to the extent they meet the criteria for allowability of interest in section 1.010.11.3 of these Rules.

Office Space Costs to be Excluded from Reimbursement a. Office Space Funded by Others Office space cost to be excluded is space that is funded by another State or private agency.

b. Sublet Office Space Office space cost to be excluded is space sublet to a local, state, or federal agency or other user.

c. Used by Others Office space cost to be excluded is space used solely by staff not authorized by the State Department.

d. Not Authorized for Use Office space cost to be excluded is space used solely for functions not authorized by the State Department.

e. Not Incurred Office space cost to be excluded is cost that has not been incurred by or paid from the County Department. Costs excluded are the value of donated materials, labor, or buildings. Other costs excluded are those paid from a grant, or a cost used as matching funds for a grant.

f. Idle or Empty Office Space Office space cost to be excluded is idle facilities or idle capacity unless necessary to meet fluctuations in workload, as set forth in 2 C.F.R. § 200.446, which is hereby incorporated by reference. 1.010.19. Cost Accounting 1. Application of Costs Requires a Plan Where an accumulation of Indirect Costs will ultimately result in charges to a federal award, a cost allocation plan, indirect rate proposal, or application of random moment sampling shall be required in accordance with Appendix V to 2 C.F.R. Part 200 and 2 C.F.R. § 200.416, which are hereby incorporated by 2. Direct or Indirect Cost a. Consistent Treatment Each item of cost shall be treated consistently in like circumstances either as a direct or an indirect cost.

b. No Universal Rule There is no universal rule for classifying certain costs as either direct or indirect under every accounting system. A cost may be direct with respect to some specific service or function, but indirect with respect to the federal award or other final cost objective.

Reasonable and Based on Generally Accepted Accounting Principles All costs incurred shall be allocated to the Program/activity/Cost Pool based on generally accepted governmental accounting principles. Direct Costs shall be allocated to the project on a reasonable basis relating directly to the benefit or value added to the program. Indirect Costs shall be allocated from indirect cost pools on a reasonable basis consistent with that of other similar or related projects/grants/activities.
All Inclusive Cost Accounting Plan All activities that benefit from an indirect cost, including unallowable activities and services, shall receive an appropriate allocation of Indirect Costs.

a. Submission Requirements i. The large County is required to submit a plan to its cognizant agency for Indirect Costs annually pursuant to Appendix V to Part 200 D(2).

ii. Where the small and medium County only receives federal funds as a Subrecipient, they must develop a plan and maintain the plan and related supporting documentation for audit pursuant to Appendix V to Part 200 D(3). 1.010.20. Random Moment Sampling 1. Participation in Random Moment Sampling Participation in random moment sample reporting shall be required by all County Department employees as determined by the Colorado Department of Human Services and the Department of Health Care Policy and Financing.

Purpose of Reporting Under Random Moment Sampling The purpose of this reporting is to measure time expended by employees on certain programs in order to substantiate Medical Assistance expenditures eligible for federal reimbursement. Reporting on random moment sampling measures the direct services provided by the County Departments. The results of the statistical analysis is used to distribute the Indirect Costs of the County Departments to direct service areas. 1.010.21. Countywide Cost Allocation Plan 1. Availability of Funds Based on the availability of State and federal funds, a County's allowable indirect countywide costs shall be reimbursed.
Purpose of the Countywide Cost Allocation Plan Counties shall prepare a countywide cost allocation plan that allocates Indirect Costs across the County operations relative to the benefit derived. Countywide cost allocation plans shall be used in determining rates, fees, or the cost of services provided, and by management in determining the cost effectiveness of a program or activity.
Countywide Cost Allocation Plan Availability Certified countywide cost allocation plans must be prepared in accordance with the cost principles found in the 2 C.F.R. Part 200 which is hereby incorporated by reference, or other cost principles as required by a specific grant.
Responsibility for the Countywide Cost Allocation Plan Responsibility for preparation and submission of an indirect countywide cost allocation plan is with the County.
Countywide Cost Allocation Plan Submission Upon request, the County Department must submit an electronic copy of the countywide cost allocation plan to the State Department. 1.010.22. Single Audit by an Independent Certified Public Accountant Each County shall annually have a financial and, if required by the Uniform Guidance, a single audit made by a certified public accountant. An electronic copy of these audits shall be submitted to the State Department via electronic mail to HCPF_CountyRelations@state.co.us . The report must be submitted no later than seven months following the end of the fiscal year. The County may request a 3-month extension to September 30th by filing the request with the State of Colorado, Office of the State Auditor. The State Department may suspend reimbursements of Medical Assistance expenditures until such time as the audit report is received. 1.010.23. Audits by the Colorado Department of Health Care Policy and Financing Information requested by the State Department personnel resulting from desk audits, site reviews or any other audit of County Department records, shall be provided by the County Department within the time frame specified in the request. If responses are not received by the due date (including State Department-approved extensions), the State Department may suspend reimbursements of Medical Assistance expenditures until such time as the responses are received. See audits as listed in 10 C.C.R. 2505-5 § 1.020.13 for more guidance.
Recovery of Money Owed by a County Pursuant to C.R.S. § 25.5-1-114, the State Department has the power to recover any monies owed by a County Department to the State Department by reducing the amount of any payments due from the State Department in connection with any program or activity. Unallowable costs which are identified during either desk audits or field audits will be disallowed despite similar costs which may have been reimbursed in the past.
Interest on Wrongful Claims a. Statutory Interest When money or property has been wrongfully claimed, withheld, or reimbursed, and when there is no agreement as to the interest rate, interest charged by the State may be at the rate of eight percent per annum compounded annually commencing on the date of the wrongful claim, withholding, or reimbursement to the date of settlement for all moneys or the value of property wrongfully claimed withheld, withheld, or reimbursed. Interest paid to the State may not be claimed for 3. Federal Department of Health and Human Services, and Other Federal Department or Agencies The federal Department of Health and Human Services and other federal departments or agencies with which the County Department expends funds and is reimbursed with federal funds may make periodic audits in the selected County Department to verify the correctness of payments, and fiscal compliance. The County Departments shall comply with requests from these federal auditors.

These audits may result in adjustments in County Department claims for 1.010.24 Confidentiality 1. Confidentiality of Financial Data Pursuant to C.R.S. § 25.5-1-116, C.R.S., financial systems contain both public and confidential information; therefore access to financial data shall not be granted to anyone for general perusal of financial records. However, fiscal data, budgets, financial statements, and reports that do not identify social/human services Recipients by name, number, or other identifying information are open records.

1.020. COUNTY ADMINISTRATIVE RULES

The incorporation by reference (as indicated within) throughout section 1.020 excludes later amendments to, or editions of, the referenced materials. Pursuant to C.R.S. § 24- 4- 103(12.5) the Department maintains copies of this incorporated text in its entirety available for public inspection during regular business hours, at: Colorado Department of Health Care Policy and Financing, 303 E 17th Ave, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

Incorporated materials are found in the following sections: 1.020.1, 1.020.2, 1.020.3, 1.020.4, 1.020.6, 1.020.8, 1.020.11 and 1.020.13 . The definitions set forth at section 1.010.1 of these Rules are also applicable to section 1.020. 1.020.1. Purpose and Scope 1. Administrative Rules These Rules are the administrative Rules for County Departments concerning the operations and the administration of Medical Assistance by County Departments, including but not limited to administrative Internal Controls, County Department Director responsibilities and oversight of compliance by the County Department with State Department and federal requirements. The State Department’s authority for County Administrative Rules is as allowed by C.R.S. §§ 25.5-1-114 and 117–122.

State Department Responsibilities As the federally designated single state agency, per 42 C.F.R. § 431.10(b), for the Medical Assistance Program in Colorado, the Colorado Department of Health Care Policy and Financing (State Department) is charged with administering and supervising the Medicaid State Plan. As the single state agency, the State Department issues Rules and Regulations that are binding on the County Department. Additionally, the State Department must exercise appropriate oversight over eligibility determinations, appeals and overall County Department operations. The State Department is federally prohibited from delegating to anyone other than its own officials, the authority to supervise the Medicaid State Plan and its delegation of eligibility and enrollment activities, or the authority to develop or issue policies, Rules, and Regulations on Program matters. The State Department has the sole authority to set statewide policies, Rules and Regulations, and manage State Information Technology Systems.
County Department Responsibilities The County Department is charged with the responsibility for administering all Medical Assistance Program eligibility and enrollment functions that were delegated by the State Department, in accordance with Regulations and Rules established by the State Department, per 42 C.F.R. § 431.10(c)(2)). The County Department will only be reimbursed for payments under the Colorado Medical Assistance Act and the administration of these Programs if said Programs are administered in accordance with the State Department Rules as well as all other applicable federal, State, and local laws, Rules and Regulations.
Knowledge of Laws and Regulations There are many federal, State, and local laws, Rules and Regulations that govern the administration of grants, the employment of personnel, and the health and safety of our lands and the general population. When in doubt as to the existence, applicability, or intent of any law, Rule or Regulation, County Department personnel shall make inquiries with the State Department and/or the applicable federal department or agency. 1.020.2. County Board of Social/Human Services Administrative Responsibilities 1. Formal Agreements between the County Board and the State Department a. To ensure the State Department’s compliance with 42 C.F.R. § 431.10(d), the County Board shall enter into a formal Inter Governmental Agreement (IGA) with the State Department that authorizes the delegation of eligibility and enrollment activities for Medical Assistance Programs to the County Department. This agreement shall be in place for the duration of the State Department’s delegation of eligibility and enrollment activities to the County Department.

b. The formal IGA between the County Board and the State Department shall include:

i. The relationships and respective responsibilities of the County Department and State Department, including but not limited to the respective responsibilities to effectuate the fair hearing Rules as dictated by the federal government and State Department ii. Quality control and oversight by the State Department, including any reporting requirements needed to facilitate such control and oversight iii. Assurances that the County Department, to which the State Department has delegated authority to determine eligibility or conduct fair hearings, will comply with the State Department oversight and compliance requirements and monitoring iv. For appeals, procedures to ensure that individuals have notice and a full opportunity to have their fair hearing.v. Performance metrics, targets and deliverables for any local share reimbursements, if any, as provided by the State Department K. Performance metrics, targets and deliverables shall be updated annually and issued through sub-regulatory guidance 2. Cooperation and Reporting The County Board shall cooperate with the State and federal government in any reasonable manner, in conformity with the laws of the State, which may be necessary to qualify for federal aid, including the preparation of plans, making reports in such form and containing such information as any federal agency may require from time to time, and compliance with such provisions as the federal government may from time to time find necessary to assure correctness and verification of the reports.

County Board Responsibilities a. Appoint a County Department Director i. The County Board shall appoint a County Department Director or shall appoint someone acting in the capacity of a director. At no time will the County Department be without the services of a County Department Director or an Acting Director.

ii. Upon appointment of a County Department Director, or someone acting in the capacity of the director, the County Board shall formally notify the State Department, within five (5) business days of the effective date of the appointment, of the individual appointed and contact information, including phone and email addresses.

Notification should be emailed to hcpf_countyrelations@state.co.us iii. The State Department will contact the appointed individual within five (5) business days of receiving the notification to provide support around the County Department Director’s responsibilities for Medical Assistance administration.

iv. The County Board shall ensure the County Department Director completes an onboarding training for Medical Assistance administration, to be provided by the State Department, within six (6) months of the effective date of appointment. 1.020.3. County Department Director Administrative Responsibilities 1. Director Responsibilities a. The County Department Director shall be charged with the executive and administrative duties and responsibilities of the County Department, subject to the policies, Rules, and Regulations of the State Department.

b. Delegation of County Department Director Administrative Responsibilities The County Department Director can delegate administrative responsibilities to a County designee so long as the County Department Director is ultimately responsible for those delegated functions and the County Department maintains written documentation of the delegation.

Continuity of Operations a. To ensure the Continuity of Operations for Medical Assistance eligibility and enrollment, the County Department or Department Director shall be charged with drafting and implementing a Continuity of Operations Plan (COOP). The COOP shall address how the County Department continues to provide eligibility and enrollment services in the event of a disaster, public health emergency, or other emergency situation, including situations where continuing services may not be possible such as system, phone or internet outages.

i. Plans may be submitted to the State Department at any time for pre-approval ii. Existing COOP plans may also be submitted for approval iii. Plans may be drafted by the County or County Department iv. The County Department COOP shall meet the minimum requirements dictated in both the Colorado Information Security Policies, and the Division of Homeland Security and Emergency Management’s Continuity of State Government Operations as outlined in 8 C.C.R. § 1507-40 which is hereby incorporated by v. The County Department COOP Plans must also include the following data security controls. Additional guidance on each of the following requirements can be found in the Colorado Information Security Policies (CISPs) listed below, which are available through the Governor’s Office of Information Technology (https://oit.colorado.gov/standards-policies-guides/technicalstandards-policies).

A. Access Control & Authentication (CISP 001)

i. Multi-factor Authentication (MFA): Ensure that systems involved in eligibility and enrollment processes require multiple layers of authentication, especially when remote work or system access is needed during an emergency.

ii. Role-Based Access Control (RBAC): Ensure that only authorized personnel have access to sensitive information based on their job roles.

iii. Emergency Access Procedures: Establish secure emergency access protocols to systems or data in case of disruption. This could include backup admin credentials or access granted to specific individuals to ensure continuity.

B. Data Protection & Encryption (CISP 010)

i. Data Encryption: All sensitive data related to medical assistance eligibility and enrollment should be encrypted in transit and at rest to protect against unauthorized access or leaks, particularly when systems are functioning in crisis mode.

ii. Third-Party Access Control: If third-party Vendors are involved in providing services or technology for eligibility and enrollment, ensure that their systems also comply with the COOP's security measures, including access controls, data protection, and incident reporting.

C. Contingency Plan (CISP 006)

i. Disaster Recovery Plan: Establish a robust disaster recovery strategy to restore services after an emergency. This includes system restoration, data recovery, and operational continuity.

D. Incident Response & Reporting (CISP 008)

i. Incident Management Protocols: Develop clear procedures for identifying, reporting, and addressing security incidents or breaches during a disaster or emergency. This should include escalation procedures and contact information for relevant stakeholders.

E. Training & Awareness (CISP 002)

i. Employee Training: Ensure that all staff are trained on the COOP, particularly on how to handle emergencies and maintain security controls under crisis conditions.

vi. The COOP is not required to be submitted to the State Department but is subject to review during any compliance review as found in

section 1.020.13 of these Rules.

County Department Contacts By January 5 and July 5 of each calendar year, the County Department shall provide the most recent, updated contact information, including names, phone numbers and email addresses, for certain County Department employee types to the State Department. The employee types include contact information for the County Department Director, Deputy Director(s) and/or Eligibility Director(s) and other critical personnel determined by the State Department.
Reporting from the County Department to the State Department The County Department is required to report any information to the State Department, at such times and in which manner and form the State Department may from time to time direct, in accordance with C.R.S. § 25.5-1-118. This includes any and all information that is pertinent to the County Department’s role in Medical Assistance eligibility and enrollment.

In these situations, the State Department shall provide proper noticing to the County Departments and allow a reasonable timeline for responses.

Administrative Internal Controls and Responsibilities for Medical Assistance Administration a. Establish Adequate Internal Controls The County Department Director shall be responsible for organizing operations and staff functions to assure the effectiveness and efficiencies of operations of the County Department and compliance with applicable State and federal requirements, laws, and Regulations. The County Department Director shall establish adequate Internal Controls that include, but are not limited to:

b. Operations of the overall County Department, such as Accounting or Administrative Support c. Eligibility determinations d. Quality, accuracy and compliance with audits and reviews e. Performance management. As part of establishing adequate Internal Controls regarding performance management, the County Department Director shall:

i. Designate County Department staff as Medical Assistance performance owners ii. Document processes and procedures for performance management, which shall include how staff will be trained.

iii. Train County Department staff on the importance of performance management and meeting performance targets, and how they impact Members.

f. Internal communications g. Knowledge and information sharing, such that the County Department Director can assure knowledge of and compliance with applicable State and federal requirements, laws, and Regulations h. Program integrity activities i. Customer service that is provided in a timely, respectful and culturally appropriate manner 6. Business Process Standards Business Process Standards are intended to ensure all applicants and members receive quality customer service and timely and accurate program information and eligibility determinations.

a. Process for Developing Business Process Standards No later than January 1, 2026, there shall be a defined process for determining Business Process Standards in collaboration with County Departments, including:

i. That the process shall include interested parties beyond County Departments, such as providers, members, advocacy organizations and other Programs in the development of Business Process Standards.

a. The State Department shall establish transparent criteria for selecting provider, member and advocacy organization representatives. The selection process shall include public notice and application opportunities made available on the State Department’s public website.

ii. The process must allow for expedited adoption of Business Process Standards when required for compliance with federal and state laws and Regulations.

iii. The process must identify what data will be reviewed to determine Business Process Standards.

iv. The process must include a review of all available data sources to determine a need for implementing a new or updated Business Process Standard. Business Process Standards will address only systemic issues impacting either timeliness, accuracy and/or quality customer service of determining eligibility.

v. Business Process Standards addressing quality customer service shall only be identified after customer service is defined through the Business Process Standards process.

vi. The Business Process Standards process shall include a joint data review between County Departments and the State Department of potential fiscal and/or other resource implications for both the State Department and County Departments prior to implementation.

vii. The process to determine a new standard shall focus on processes that have an impact on the timeliness, accuracy and/or customer service of the County Department’s Medical Assistance process of determining eligibility.

b. Considerations for Business Process Standards i. Business Process Standards must be replicable between counties across all sizes and locations and shall consider County Department processes and organizational structure.

ii. The process shall consider options to mitigate the impacts on the administration of other Programs.

iii. At the discretion of the State Department, a newly developed Business Process Standard may be piloted by a selected group of County Departments prior to statewide implementation.

c. Implementation of Business Process Standards Upon conclusion of the development of any new Business Process Standards, the State Department shall initiate rulemaking prior to requiring implementation by County Departments.

i. If the State Department determines that a new Business Process Standard requires funding and that funding is available, the State Department shall allocate the necessary funding to the County Departments.

ii. In collaboration with County Departments, the State Department shall work to identify opportunities to improve efficiencies and consistencies among Programs, as well as to identify efficiencies and best practices across county administration.

iii. The State Department may engage with County Departments to solicit input and feedback on strategies to address potential funding gaps associated with new Business Process Standards.

iv. If the State Department requires implementation of a Business Process Standard, the State Department shall provide proper notice and Reasonable Timeline for the County Department to plan for and implement the Business Process Standard.

v. Business Process Standards shall be supported by sub regulatory guidance that provides details of the minimum standards for the Business Process Standard.

d. Term-Limited Waiver for Temporary Exemption from a Business Process Standard i. A County Department may individually request a term-limited waiver to delay the implementation, or pause ongoing compliance, of a Business Process Standard from the State Department by submitting an action plan that will demonstrate when and how the County Department will be able to implement, or regain compliance with, the temporarily waived Business Process Standard.

ii. The State Department will provide a form or template for term-limited waiver action plans, which must include estimated timelines for resolution and interim measures to safeguard member access to eligibility and enrollment services.

iii. A State Department-approved term-limited waiver shall not diminish member access to services, extend processing times beyond federal requirements or absolve the County Department of complying with federal and state requirements e . County Department Compliance with Business Process Standards As part of the approved review types listed in 10 CCR 2505-5 1.020.13, the State Department shall assure compliance by the County Department with the approved Business Process Standards that have been promulgated in rule, including initiating noncompliance actions detailed in 10 CCR 2505-5 1.020.14. 1.020.4. County Personnel/Staffing Standards and Requirements 1. Responsibility for Merit-Based, Governmental Staff a. The County Department Director, with the approval of the County Board, shall appoint such staff as may be necessary to administer Medical Assistance within the County Department. Such staff shall be appointed and shall serve in accordance with a merit system for the selection, retention, and promotion of the County Department employees as described in the County merit system.

b. The salaries of the County Department staff shall be fixed in accordance with the County’s merit system prescribed by the Board of County Commissioners and must conform to the Code of Colorado Regulations, 9 C.C.R. § 2502-1, Volume 2, and 5 C.F.R. § 900.601. 9 C.C.R. § 2502-1, Volume 2 (2021) and 5 C.F.R. § 900.601 (2021) are hereby incorporated by reference into this rule.

c. The County Department, or Department Director may directly hire another County staff member, enter into an IGA with another County, or subcontract with other County Departments for the term-limited assignment of staff from those County Departments, so long as in the last two options there is a signed agreement in place between those County Departments; and those staff under Contract are merit-based, governmental employees i. If a County Department directly hires staff currently employed by another County Department, the hiring County is responsible for the quality and Internal Controls related to the hires ii. If a County Department enters into an IGA with another County, the County whose employees are formally being used by another County, would be responsible for the quality and Internal Controls related to the employees iii. If a County Department subcontracts with a staff member from another County it must be through a formalized agreement in place, and they must be merit based. The responsibility for the quality and Internal Controls related to the employees involved, will rest with the County of hire d. Any signed agreement shall address performance standards and expectations, record retention requirements, cost-sharing, and quality assurance expectations.

e. Every two years beginning January 1, 2027 each County shall submit to the State Department a certification that the above criteria are being maintained by the County Department. This certification must be received as prescribed by the State Department on or before January 1 of every other year beginning January 2027. The certification must be validated by the County Board or designee.

Staffing Safeguards for State-Owned Data a. Personnel screenings are required for all employees of the County Department; personnel screenings must include criminal background checks on all staff with access to any State-owned Information Technology System in which either the State or the County Department grant access to County Department personnel.

b. Effective July 1, 2026, when hiring an employee of the County Department, the County Department Director shall ensure that employees being hired from other County Departments have not had their access to any State-owned Information Technology System terminated by those County Departments.

i. If a County Department has terminated access to any State-owned Information Technology System for any current or previous employee for reasons including, but not limited to, fraud or conflicts of interest, the County Department is prohibited by the State Department from granting the current or previous employee access to those State-owned systems.

Responsibility for Staff Completion of Training a. The County Department Director shall ensure staff hired to fulfill duties relating to the administration of Medical Assistance complete adequate initial hire and ongoing training. Adequate initial hire training shall be completed prior to the County Department allowing the initial hire to conduct eligibility determinations or other related duties independently of any staff who previously completed initial hire training. Ongoing training shall be completed in keeping with provided guidance from the State b. Adequacy of initial and ongoing training is determined by the State Department and the Staff Development Division and is reflected by new hire training plans and ongoing, mandatory trainings as communicated by the State Department.

i. The State Department shall provide proper notice to County Departments related to any mandatory training, and a reasonable timeline for completion.

c. The County Department Director shall ensure that required training is obtained through the Staff Development Division (SDD) or an SDDcertified County trainer and that all County Department-created training has been submitted and approved by the State Department and the SDD.

This includes the formalized trainer certification process by the SDD, which consists of initial certification for new County Department trainers and ongoing recertification of those trainers.

d. Required Trainings provided by the State Department, SDD or SDD- Certified Trainers i. Staff appointed to fulfill duties relating to the administration of Medical Assistance and who have direct contact with Applicants and enrollees or supervise those staff who have direct contact shall complete, on an annual basis, State Department-provided trainings relating to civil rights/non-discrimination and disability/cultural competency.

ii. Trainings related to eligibility determination, the eligibility determination system and other trainings as communicated by the State Department shall be considered mandatory trainings and shall be completed within the timeframe designated by the State 4. Conflicts of Interest No County Department employee shall accept fees, compensation, gifts, payment of expenses, or any other item of monetary value under circumstances in which the acceptance could result in:

a. An undertaking to give preferential treatment to any person or business, or, b. Impeding governmental efficiency or economy, or, c. Any loss of complete independence or impartiality, or, d. The making of governmental decisions outside official channels, or, e. County Department employees engaging in any activity that may be perceived as detrimental to the discharge of assigned duties and responsibilities, or, f. The reasonable inference that any of the provisions in this subsection have happened or might happen, or, g. Any adverse effect on the confidence of the public in the integrity of the government of the State of Colorado or its County Department.

Personal Business Interests County commissioners, County Department Directors, or any other County Department employees shall not perform an official act directly and substantially affecting an economic benefit for a business or other undertaking in which they either have a substantial financial interest or are engaged as counsel, consultant, representative, or agent.
Outside Employment All outside employment of County Department employees shall have the prior written approval of their Appointing Authority. The outside employment shall not conflict with the interests of the County Department involved, the State of Colorado, or the federal government.
Private Business with People Inspected or Supervised by County Employees County commissioners, County Boards, County Department Directors, or any other County Department employee shall not engage in a substantial financial transaction for their private business purpose with a person whom they supervise in the course of their official duties.
Employment within Six Months of Termination County commissioners, County Boards, County Department Directors, or any other County Department employee shall not, within six months following the termination of their office or employment, take advantage, unavailable to others, of matters with which they were directly involved during their employment.
Voting or Attempting to Influence Pursuant to C.R.S. § 24-18-109, County commissioners, County Boards, County Department Directors, or any other County Department employee shall not vote and shall refrain from attempting to influence the decision of other members of the governing body in voting on matters in which they have a personal or private interest.
Partisan Politics Pursuant to the Hatch Act, 5 United State Code (USC) Chapter 15, Section 1502 (2020), County Department employees whose salary is reimbursed partially or fully with federal funds shall not be candidates for partisan elective office.
Non-Partisan Politics Activity with respect to the proposed adoption of constitutional amendments, the approval of matters specified in referendums, the proposed adoption of charter amendments, the approval of municipal ordinances, or with respect to other matters of a similar non-partisan character, shall not be deemed to be political activity.
Employee Defalcation No County Department employee shall use County Department time, property, Equipment, or supplies for private or any other use not in the pursuit of County Department business.
Reporting of Employee Theft or Embezzlement Any suspected or substantiated theft or embezzlement of federal, State, or local funds shall be immediately reported to at least one level of management above the party(s) suspected or to the County Board. In addition, suspected thefts or embezzlements shall be submitted electronically to HCPF_CountyRelations@state.co.us. A theft or embezzlement of State and/or federal funds or assets totaling $5,000.00 or more shall be reported in writing to the County Board and submitted electronically to the State Department at HCPF_CountyRelations@state.co.us. 1.020.5. Colorado Department of Health Care Policy and Financing Statewide Automated Systems 1. Required Use of Statewide Automated Systems a. The County Departments shall use the State of Colorado automated statewide financial, member and/or provider information systems. These systems are designed to collect and store financial records and program data; assist with eligibility and payment determinations; generate forms and reports; create electronic benefit authorizations; and add to, delete, or make changes to the information on file.

b. The County Department shall seek prior approval from the State Department to grant access to any individual and/or entity outside of the County Department; this includes other entities within the County that act independently of the County Department.

Granting Access to Statewide Computer or Electronic Systems The County Departments shall only grant access to the use of State of Colorado statewide member information systems to County Department employees whose duties are directly related to the administration of Medical Assistance or unless approval is otherwise granted by the State Department.
Ownership and Usage of Data in Statewide Automated Systems Medical Assistance data within statewide member and/or provider information automated systems is considered owned by the State of Colorado. All usage of Medical Assistance data from the statewide automated systems is subject to approval by the State Department. If usage of Medical Assistance data is determined to be non-compliant with State Department requirements, the State Department may require Corrective Actions as specified in section 1.020.14 (Non-Compliance Findings and Action Plan Processes) of these rules.
Protection of Data While Using Statewide Automated Systems Medical Assistance data used by County Departments for the purpose of administering the Medical Assistance Program on behalf of the State Department shall be protected at a minimum according to the Colorado Information Security Policies as determined by the Chief Information Security Officer in the Governor’s Office of Information Technology or a higher federal standard, if applicable.
Sharing of Data originating from Statewide Automated Systems Medical Assistance data originating from statewide member and/or provider information automated systems shall be used only by those County Department employees whose job duties pertain to the administration of Medical Assistance.

Medical Assistance data will not be shared except under those conditions as specified by the State Department. If sharing of Medical Assistance data is determined to be non-compliant with State Department requirements, the State Department may require Corrective Actions as specified in section 1.020.14 (Non-Compliance Findings and Action Plan Processes) of these rules.

County Automated Systems Security a. For all automated systems originating from or purchased by the County Departments, the County Department shall:

i. Obtain the approval of the State Department before such systems interface with or download information from statewide automated systems; and ii. Ensure the compliance of such systems with the Colorado Information Security Policies as determined by the Chief Information Security Officer in the Governor’s Office of Information Technology or a higher federal standard, if applicable; and iii. Include these requirements in any contractual agreements entered into by the County Department for these automated systems. 1.020.6. Confidentiality 1. Confidentiality of Applicant/Member Financial Data Pursuant to federal and State law, Medical Assistance Program Regulations, and State of Colorado privacy guidance, information collected and maintained in the Colorado Benefits Management System (CBMS) is private and confidential.

Information, which is collected or created by the County Departments, acting as the statutory agent for the State Department for the administration of the Medical Assistance Program, is confidential information and shall be protected from disclosure by the County Departments. The County Departments, as agents of the State Department, shall comply with 42 C.F.R. § 431.300, et seq, which regulates the use and disclosure of information used to determine eligibility for the Medical Assistance Program and is hereby incorporated by reference.

Access to financial data shall be role-based and only permitted for the administration of the Medical Assistance Program. The County Departments may, to the extent that they are able to de-identify information in compliance with HIPAA, release fiscal data, budgets, financial statements and reports that do not identify a beneficiary. The counties may only disclose de-identified information pursuant to the Colorado Open Records Act (CORA), if the County’s legal advisor has declared the records subject to release under CORA.

Non-Confidential Information a. The following information not identified with any individual is not confidential and may be released for any purpose related to the administration of the Medical Assistance Program:

i. Total expenditures;

ii. Number of Recipients;

iii. Statistical data obtained from studies;

iv. Social data obtained from studies, reports, or surveys.

Confidential Information Information secured and stored by the County Department for the purpose of conducting the administration of Medicaid or other Medical Assistance Programs, such as for determining eligibility, is deemed confidential.
Restricted Use for Purpose of Administration of Medical Assistance Unless disclosure is specifically permitted by the State Department, the following types of information are the exclusive property of and are restricted to use by the State Department and the County Departments for the purpose of administration of the Medical Assistance Program:

a. Information contained in applications;

b. reports of medical examinations;

c. income and wage information;

d. citizenship information;

e. correspondence;

f. other information concerning any person from whom, or about whom, information is obtained by the County Department;

g. records of the State Department or County Department and/or evaluations of the above information.

Disclosure of Confidential Information a. Access to County Department Records i. No Access Outside County Department No one outside the County Department shall have access to records of the County Department, including records collected for or held in CBMS.

ii. County Access When Necessary for Administering Medical Assistance County Department employees who are acting as the agent of the State Department shall have access to confidential records when they are performing work pursuant to 42 C.F.R. § 431.302. These individuals shall have access only for purposes necessary for the administration of Medical Assistance Programs.

iii. Allowable Disclosures Federal and State auditors and private auditors for the County Department, and the Applicant/Recipient of Medical Assistance and their legal representative may also have access when they comply with HIPAA, 42 C.F.R. Part 2 and all other federal and state statutes and Regulations which regulate the privacy of Medical Assistance information. iv.) Release of Information to Applicants/Recipients or Legal Representatives The County Department shall accept the State Department Release of Information form if presented by the Applicant/Recipient of Medical Assistance, or their legal representative, which requests access to their confidential information. The County Department may not require any additional forms from the Applicant/Recipient and any Signature as allowed in 10 CCR § 2505-5 1.010.1 is permissible.

Responsibility for Record Retention The County Department Director shall assure that the County Department has available all necessary and complete records for audit purposes and that adequate prior years' expenditure documents are maintained for use in the budgeting process.

a. Record Retention Requirements Medical Assistance data of any form shall be retained for the current year plus three previous years for cases that are open, and for one year from the date a case is closed plus three previous years for cases that are closed, unless:

i. There is a written statutory requirement, Rule, or Regulation available from a County Department, State, or federal agency requiring a longer retention period; or ii. There has been a claim, audit, negotiation, litigation, or other action started before the expiration of the retention period. 1.020.7 Non-Discrimination 1. Responsibility for Non-Discrimination County Departments shall administer Medical Assistance Programs in such a manner that no person will, on the basis of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or Disability, be excluded from participation, be denied any aid, care, services, or other benefits of, or be otherwise subjected to discrimination in such program. Aid, care, services or other benefits includes all forms of assistance, including direct and Vendor payments, work programs, social services, and information and referral services.

a. Protection Against Discrimination The County Department shall not, directly or through contractual or other arrangements, on the grounds of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or Disability:

i. Provide to an individual any aid, care, services, or other benefits that are not equally accessible to individuals based on their protected class status;

ii. subject an individual to segregation barriers or separate treatment in any manner related to access to or receipt of assistance, care services, or other benefits;

iii. restrict an individual in any way in the enjoyment of any advantage or privilege enjoyed by others receiving aid, care, services, or other benefits provided under assistance Programs;

iv. treat an individual differently from others in determining whether he or she satisfies any eligibility or other requirements or conditions which individuals must meet in order to receive aid, care, services, or other benefits provided under Medical Assistance Programs;

v. deny an individual an opportunity to participate in Programs of assistance through the provision of services or otherwise, or afford him or her an opportunity to do so which is different from that afforded others under Programs of assistance;

vi. deny a person the opportunity to participate as a member of a planning or advisory body that is an integral part of the Program.

b. Administrative Protection Against Discrimination No discrimination on the grounds of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or Disability is permitted in relation to:

i. the use of physical facilities;

ii. intake and application procedures;

iii. caseload assignments;

iv. determination of eligibility;

v. the amount and type of benefits extended by the County Department to Medical Assistance Program Recipients.

c. Protection Against Discrimination from Other Entities The County Department shall assure that other agencies, persons, Contractors and other entities with which it does business are in compliance with the above prohibition of discrimination requirements on a continuing basis. The County Department staff are responsible for being alert to any discriminatory activity of other agencies and for notifying the State Department concerning the situation.

d. Notification by the State Department The State Department, through its various contacts with agencies, persons, and referral sources, will be continuously alert to discriminatory activity and will take appropriate action to assure compliance by the offender. If corrective action is not taken, the State Department will notify the agency of termination of payments and association in regard to Recipients or Applicants. The County Department, on notification by the State Department, will also terminate payments to or association with any agency, person, or resource being used which has been found to continue discriminatory activity in regard to Applicants or Recipients.

e. Responsibility to Investigate Individual Complaints of Discrimination An individual who believes he or she is being discriminated against may file a complaint with the County Department, the State Department, or directly with the federal government. When a complaint is filed with the County Department, the County Department Director is responsible for an immediate investigation of the matter and taking necessary corrective action to eliminate any discriminatory activities found. If such activities are not found, the individual shall be given an explanation. If the person is not satisfied, he or she is requested to direct his or her complaint, in writing, to the State Department, which will be responsible for further investigation and other necessary action consistent with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title II of the Americans with Disabilities Act (ADA), and the Age Discrimination Act of 1975.

f. State Receipt of Complaint Alleging Discrimination by County Department Upon receipt of a complaint alleging discrimination by the County Department due to race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or Disability, the State Department shall explain the Medical Assistance Program’s non-discrimination policy to the individual. If there is insufficient information as to the nature or other detail concerning the complaint, the State Department shall contact the County Department in writing to obtain such information. Copies of the letter shall be sent to the complainant. The County Department shall reply in writing.

i. State Department Determines Action Non-Discriminatory If the State Department determines the County Department action is not discriminatory and the Applicant/Recipient disagrees, the Applicant/Recipient has the right to appeal the case to the State Department. This appeal shall be filed in accordance with the appeal Rules as described in the “Protections to the Individual,” 9 C.C.R. § 2503-6 Section 3.609.73.

ii. State Department Determines Action Discriminatory If it is found that a County Department practice or action is discriminatory, the State Department shall initiate a Corrective Action per section 1.020.11 to assure that any and all discriminatory practices are permanently terminated. 1.020.8 Civil Rights Procedures 1. Procedure and/or Information a. Civil Rights Contact Person In an effort to comply with 28 C.F.R. § 42.410, 45 C.F.R. § 84.7 and state statute, County Departments are required to appoint an Individual as the Civil Rights Contact Person (“Contact Person”) to assist in administering Medical Assistance Programs and practices in accordance with the above referenced civil rights laws. The Contact Person will perform the following responsibilities: (1) act as the central point of contact for the State Department relative to information sharing regarding Member civil rights;

(2) maintain up-to-date knowledge of changes in Member related civil rights laws, their impact on Programs and also disseminate this information to County staff and program areas; (3) act as the first point of contact for Member civil rights complaints; and (4) post federally required civil rights notices in conspicuous locations (e.g., reception areas, intake areas or other key entry points). The County Department will provide civil rights training and consulting as necessary.

b. Notices County Departments are required to post the State Department’s Nondiscrimination Statement (or substantially similar notice) in a conspicuous place and in appropriate languages (at minimum both English and Spanish). Recommended locations are reception areas, intake areas or other key entry points. The State Department will provide copies of the Nondiscrimination Statement to the various County Department Programs. County Departments may also develop and utilize their own nondiscrimination policy statement, as long it subscribes to federal laws and Regulations.

c. Compliance County Departments are required to adhere to the Regulations/guidelines established by the various federal departments providing federal financial assistance through the State Department. Questions regarding compliance with such Regulations/guidelines may be made directly to the following federal departments:

U.S. Department of Health and Human Services Office for Civil Rights 1961 Stout Street, Room 08-148 Denver, CO 80294-3538 Voice Phone: (800) 368-1019 FAX: (202) 619-3818 TDD: (800) 537-7697 Email: ocrmail@hhs.gov U.S. Department of Education Office for Civil Rights 1244 Speer Boulevard, Suite 310 Denver, CO 80204-3582 Voice Phone: 303-844-5695 FAX: 303-844-4303 TDD: 303-877-8339 Email: OCR.Denver@ed.gov U.S. Department of Agriculture Office of Civil Rights 1400 Independence Avenue, SW, Mail Stop 9410 Washington, DC 20250-9410 Voice Phone: 202-260-1026 Toll-free: 866-632-9992 Local or Federal relay: 800-877-8339 Spanish relay: 800-845-6136 Fax: 202-690-7442 Email: program.intake@usda.gov Fair Housing U.S. Department of Housing and Urban Development 1670 Broadway Denver, Colorado 80202-4801 Voice Phone: (303) 672-5437 Toll-free: 1-800-877-7353 TDD: (303) 672-5248 d. Civil Rights Plan County Departments should develop a Member Civil Rights Plan that outlines how they will ensure Members, potential Members, employees, and others that their programs and services are provided without regard to race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or disability. This plan should identify how the availability of auxiliary aids and services to individuals with disabilities and languages services to individuals whose first language is not English will be communicated and their complaint filing process.

e. Investigation of Discrimination:

i. Investigation of Complaints In recognition of the fact that complaints may vary in kind and complexity, the County Department should conduct an investigation appropriate to each complaint. Investigative procedures will depend on the nature and extent of the discrimination alleged and the context in which the alleged incidents occurred. Appropriate investigative procedures may include informal review or a formal investigation. Investigations should be conducted in a timely manner.

ii. County and Member Participation County Departments and Recipients of services are expected to cooperate in all phases of an investigation and ensuing actions.

Retaliation against the person filing the complaint or persons participating or cooperating in the Investigation is prohibited by federal law.

iii. Inform Upon Completion The complainant and the person against whom the allegation was made shall receive a written notice upon the completion of the investigation and whether the allegations were substantiated. This notice shall include information about how to file a complaint with the state or federal government if they disagree with the findings.

iv. Action Upon Substantiation If, after an investigation is concluded, there is reason to believe that the federal laws referenced above have been violated, or that there was inappropriate behavior or action, the State Department will strive to obtain the cooperation necessary to ensure that satisfactory resolutions in accordance with federal and state statutes are utilized.

f. Language Access Services i. County Departments are required to inform individuals that language services are available and how individuals can access services ii. County Departments are required to provide language services free of charge to anyone that requests them 1.020.9. Customer Service 1. Customer Service Standards To ensure the effective and efficient operations of the County Department, the State Department shall establish customer service standards in collaboration with the County Department. The customer service standards shall ensure Applicants and Members have access to eligibility and enrollment services provided by the County Department.

Public Posting of Operating Hours and Closures a. The County Department shall post its hours of operations in which eligibility and enrollment services are provided. These operating hours shall be made available to the general public through as many of the following modalities as possible:

i. Public signage that is posted conspicuously, both internally and externally, of the County Department’s physical location. Operating hours shall be posted at all of the County Department’s physical locations.

ii. Messages on the County Department’s phone lines or call center systems iii. Notices and language on the County Department’s public website 3. Availability of Customer Service Modalities a. The County Department shall provide access to eligibility and enrollment services through those modalities required by the federal government and the State Department, and shall not discourage Applicants or Members from accessing any specific modalities. The modalities required to be provided include:

i. In Person services at the County Department’s physical location ii. Telephonic services with call answer times that do not discourage Program participation iii. Fax submissions iv. Email Inbox(es) that are regularly monitored b. The State Department’s online platform to apply for and manage benefits c. Mailing of material through the United States Postal Service or other delivery service 4. Implementation of Customer Relations Process (CRP)

a. To ensure eligible Coloradans can access eligibility and enrollment services if they are unable to navigate the system, the County Department shall establish a Customer Relations Process (CRP). The CRP shall act as an escalation process for Applicants and Members if they are unable to get support through the County Department’s regular modalities of providing customer service.

b. The County Department CRP shall be available to Applicants, Members, families, advocacy groups and providers to assist in completing applications, redeterminations or submitting necessary documentation so they can gain or retain eligibility for Medical Assistance Programs c. The County Department CRP is an internal process that must be able to successfully resolve initial escalations within the timeframes specified by the State Department d. The County Department CRP must make a reasonable attempt to locally resolve the specific issue in each complaint raised by any individual that was not able to access eligibility and enrollment services e. The County Department CRP must support any individual attempting to submit a State Department complaint or escalation if the individual believes the County Department did not make a reasonable attempt to locally resolve the specific complaint f. The County Department must post conspicuously in the County Department’s physical location the State Department’s Customer Service Poster, which publicly identifies the County Department CRP and the State Department’s complaint and escalation process g. The County Department CRP shall be available to any individual through all modalities listed in 10 C.C.R. 2505-5, §1.020.9.3 5. Compliance with State Department Complaints and Escalations Process a. The State Department shall establish standards for County Department expectations relating to the State Department’s complaints and escalations process. This includes expectations for usage of established processes and systems, compliance with established timeframes for resolution and customer service expectations. 1.020.10 Communications 1. Responsibility for Timely and Accurate Communications The State Department has a statutory responsibility to ensure timely and accurate communications to Applicants and Recipients of the Medical Assistance Program. The County Department, as an agent of the state, is also bound by this requirement. Medical Assistance-specific communications issued by the County Department to Applicants and enrollees are considered communications issued by the Medical Assistance Program, which also must be timely and accurate.

Such communications issued by the County Department are subject to review and approval by the State Department to ensure timeliness and accuracy.

Communications Subject to Review Communications subject to review by the State Department include written and electronic notices and forms provided to Applicants or Recipients of the Medical Assistance Program as part of ongoing operations of the County Department.

a. State Review of County Department Communications The State Department may, at its discretion, review communications issued by County Departments sent through various communication mediums such as websites, online postings, or social media for timeliness and accuracy.

i. Non-Compliant Communications County Department communications deemed by the State Department to be untimely and/or inaccurate shall be issued a finding of non-compliance and will be subject to the Corrective Action processes as described in section 1.020.14 (Non- Compliance Findings and Action Plan Processes) by the State 1.020.11 County Department Collaborative Agreements with External Entities to Facilitate Eligibility and Enrollment 1. Purpose and Scope of Collaboration Agreements a. To discharge its statutory responsibilities in C.R.S. § 25.5-4-205 to provide eligibility and enrollment for Medical Assistance Programs to its residents, the County Department shall enter into formal agreements with Medical Assistance-related external entities, unless the County Department meets exemption criteria listed in 10 C.C.R. 2505-5, § 1.020.11.6. These agreements are referenced as either Collaboration Agreements or Cost Sharing Agreements.

b. The purpose of these agreements is to facilitate timely enrollment of Medical Assistance Applicants, ensure coordination between entities for ongoing eligibility and case maintenance, provide for dedicated County Department personnel, and to provide opportunities for external entity cost sharing between the State and County Departments, the federal government and the external entities for dedicated eligibility and enrollment personnel.

Types of Collaboration Agreements a. The State Department shall make available two types of standardized agreements that facilitate eligibility and enrollment between County Departments and Medicaid-related external entities. Either type of agreement may include more than one County Department, if all County Departments party to the agreement agree on its provisions.

b. Eligibility and Enrollment Collaboration Agreement (“Collaboration Agreement”): this type of agreement is utilized by the County Department to partner with external entities to enroll and re-enroll eligible Applicants and Members using and reinforcing existing processes. This type of agreement does not involve cost sharing, nor does it change the County Department’s existing processes for eligibility and enrollment. The agreement has minimum standards from the State Department and County Department-specific language approved by the State Department. i The County Department may enter into these types of agreements without the approval of the State Department, but is subject to the reporting requirements listed in 10 C.C.R. § 2505-5, § 1.020.11.8. ii The Collaboration Agreement is not limited to the external entities mentioned in 10 C.C.R. 2505-5, § 1.020.11.6 and § 1.020.11.7 but can be signed with any Medical Assistance-related external entity c. Eligibility and Enrollment Collaboration Agreement with Cost Sharing (“ Cost Sharing Agreement”): this type of agreement is utilized by the County Department to partner with external entities to enroll and re-enroll eligible Applicants and Members by facilitating cost sharing participation and dedicated County Department personnel with the external entity, as allowed per 42 C.F.R. § 433.66 , which is hereby incorporated by i. The County Department shall seek State Department approval to enter into an Eligibility and Enrollment Cost Sharing Agreement with any external entity prior to any agreement execution. The State Department shall review and render a decision on the County Department’s request within 30 calendar days.

Minimum Requirements for Collaboration Agreements a. Collaboration Agreements shall contain, at minimum, the Medical Assistance requirements listed below, unless the State Department has granted a County Department request to waive a specific requirement i. The term of the agreement, to be no less than one year, but with County option to extend to no more than five years from the date of agreement execution ii. Specific points of contact for the State Department, County Department and external entity that would implement the agreement iii. Defined roles and responsibilities related to the County Department and the external entity for eligibility and enrollment iv. Confidentiality and state-owned data protection requirements per 10 C.C.R. 2505-5, §1.020.5 and 10 C.C.R. 2505-5, § 1.020.6 v. Language ensuring that all Applicants and Members will be served and will not be limited by the external entity participating in the Collaboration Agreement vi. Arbitration and dispute resolution procedures, including a procedure for either party to escalate issues to the State Department vii. Workload, performance and timeliness expectations set by the County Department and procedures to update expectations as needed by the County Department or external entity viii. Procedures if one County Department provides eligibility and enrollment services for another County Department, if the agreement includes multiple County Departments; this would also apply to Cost Sharing Agreements ix. Procedures to ensure at least one annual meeting occurs between the County Department and external entity regarding the status of the agreement x. County Department, local or regionally-specific provisions that facilitate eligibility and enrollment, if such provisions are approved by the State Department 4. Minimum Requirements for Cost Sharing Agreements a. Cost Sharing Agreements must include, at minimum, the provisions required for Collaboration Agreements as detailed in 10 C.C.R. 2505-5, §1.020.11.3; in addition, Cost Sharing Agreements must also include the minimum standards detailed in 10 C.C.R. 2505-5, § 1.020.11.4 i. Mechanisms for cost-sharing reimbursement between County Department and the external entity that facilitate County Department personnel assignment to the external entity ii. Required reporting for in-kind contributions made by the external entity, such as office space for County Department personnel iii. Procedures to adjust the external entity’s cost sharing participation based on the County Department’s budgetary actions, including cost of living adjustments or other pay actions that are approved by the County Board iv. Provisions ensuring that all Applicants and Members will be served, regardless of whether the Applicant or Member accesses services through the external entity participating in cost sharing b. Allowable Costs i. External entities participating in cost sharing shall provide the County Department reimbursement for all Direct Costs of dedicated County Department eligibility personnel (staff and supervisors), as well as Direct Costs of administrative personnel that support the personnel assigned to the external entity, including customer service, quality assurance and other direct, related costs for Medical Assistance eligibility and enrollment ii. Direct Costs refers to the costs of training, salaries and fringe benefits associated with each dedicated County Department eligibility worker and similar allocated costs of County Department support personnel c. Nonallowable Costs and Activities i. Nonallowable costs are limited to those that are not direct program costs, including County Department overhead and office space.

ii. Outreach activities and costs for work by the County Department related to Medical Assistance eligible but not enrolled individuals are nonallowable.

d. Non-Federal Share of Costs i. External entities participating in Cost-Sharing Agreements with counties shall be responsible for the entire non-federal portion of costs, including the State Department and County Department share of costs, related to the dedicated County Department personnel.

ii. External entities cannot use federal funds to cover the non-federal share of costs through the Cost Sharing Agreement.

iii. The Cost Sharing Agreement shall include information on the source of funding for the external entity’s non-federal share of costs.

e. Provision of Services under Cost Sharing Agreement i. The County Department shall only be required to provide eligibility and enrollment services for Applicants and Members for its County residents, unless another County Department is also a party to the Cost Sharing Agreement. If the external entity participating in the Cost Sharing Agreement with one County Department may benefit from another County Department being a party to the Cost Sharing Agreement, the County Department with the original Cost Sharing Agreement shall explore expanding the agreement to include additional County Departments that are not a party to the Cost Sharing Agreement, to allow those County residents to be served under the agreement.

ii. If a County Department is a party to a Cost Sharing Agreement with an external entity and an Applicant or Member from a County that is not party to the Cost Sharing Agreement, the County Department shall refer the applicant or member to the State Department’s online application platform or the appropriate County Department for eligibility and enrollment services based on the applicant or member’s address of residence.

f. County Department Protections for Cost Sharing Agreements i. The County Department shall have the sole responsibility of determining eligibility for Medical Assistance Programs, even if the County Department has entered into a State Department-approved Cost Sharing Agreement. To determine eligibility, County Departments’ employees meet the federal requirement of meritbased, governmental employees ii. The provisions of the Cost Sharing Agreements do not impact the external entity’s ability to determine their own personnel needs or staffing, such as financial navigators the external entity may already employ, or State Department-approved participation in eligibility and enrollment, such as being a Presumptive Eligibility (PE) Site or Certified Application Assistance Site (CAAS)

iii. The County Department retains the sole right to set salaries based on the salary schedules of the county’s merit system, employment schedules, work locations, engage in performance management and take other employer-employee actions even if a Cost Sharing Agreement is in place.

A. Cost Sharing Agreements must cover at minimum one Full Time Equivalent (FTE) position; if external entity funding is insufficient to cover at least one FTE, then the County Department and external entity may l pursue a Collaboration Agreement B. Cost Sharing Agreements must also include provisions for the County Department and external entity to adjust the total amount of cost sharing participation, including if the County Department provides cost of living adjustments to salaries and if new needs are identified that would require adjusting the total amount of cost sharing iv. County Department employees dedicated to an external entity by way of a Cost Sharing Agreement are limited to providing services for the Medical Assistance Program only; any individual seeking services for other Programs, including adult or child protective services, shall be referred to the appropriate County Department for resolution.

v. Disputes and appeals for eligibility determinations and redeterminations shall follow the existing processes outlined in eligibility determination and appeals rules found in 10 C.C.R. § 2505-10 8.057 5. External Entities Requiring Collaboration Agreements or Cost Sharing Agreements a. Hospital(s)

i. The County Department shall enter into formal agreement(s), as described in this section, with at least one Hospital(s) within the county’s boundaries by January 1, 2027.

ii. This agreement may be between the individual Hospital and the County Department or a single agreement across multiple Hospitals and the County Department within county’s boundaries. This agreement may also include more than one County Department, as allowed per 10 C.C.R. 2505-5, §1.020.11.2.

b. Case Management Agency ii. The County Department shall enter into a Collaboration Agreement, as described in this section, with the Case Management Agency that serves the County Department in providing functional eligibility determinations by January 1, 2027.

iv. If the County Department also serves as a Case Management Agency, the County Department shall be exempt from the required Collaboration Agreement and must implement Internal Controls in place of the agreement. The Internal Controls must address the same collaboration requirements listed in 10 C.C.R. 2505-5, §1.020.11.3.

c. Nursing Facilities i. The County Department shall enter into formal agreement(s), as described in this section, with at least one nursing facility within the County’s boundaries by January 1, 2027.

ii. This agreement may be between the individual nursing facility and the County Department or a single agreement across multiple nursing facilities within the county’s boundaries. This agreement may also include more than one County Department, as allowed per 10 C.C.R. § 2505-5, §1.020.11.2.

Exemption from Required Agreements The County Department may be exempt from these agreements (Cost Sharing Agreements or Collaboration Agreements) if any of the following conditions are met:

a. If the County Department does not contain the required external entity within the county’s boundaries b. If the County Department is unable to obtain approval from the County Board i. If the County Department is unable to obtain approval from the County Board for the Cost Sharing Agreement, the County Department shall instead pursue a Collaboration Agreement, unless the County Board declines to approve both the Collaboration Agreement or Cost Sharing Agreement c. If the County Department has attempted to sign an agreement with the required external entity, but the external entity does not take action 7. Other External Entities eligible for Eligibility and Enrollment Collaboration Agreements with Cost Sharing a. The County Department may enter into Cost Sharing Agreements with the following entities, with prior approval from the State Department, so long as all the conditions of 10 C.C.R. 2505-5, §1.020.11 are met.

i. Federally Qualified Health Centers ii. State-licensed Nursing Facilities iii. Clinics iv. Program for All Inclusive Care for the Elderly (PACE) facilities v. Other external entities not listed may be eligible for a Cost Sharing Agreement with prior approval from the State Department 8. County Department reporting on Collaboration and Cost Sharing Agreements a. The County Department shall provide a copy of each executed Agreement within 30 calendar days of execution of the agreement. The copy shall be sent to hcpf_countyrelations@state.co.us.

b. For Cost Sharing Agreements, the County Department shall provide an annual report for the prior state fiscal year, by July 5 of each year, to the State Department on the total amount of costs shared or reimbursed by the external entity and the total number and type of County Department personnel included in the Cost Sharing Agreement.

State Department Technical Assistance and Authority to Require Termination of Collaboration Agreements or Cost Sharing Agreements a. If, in the ongoing operations of the Collaboration Agreement or Cost Sharing Agreement, the County Department and external entity face challenges or require technical assistance to meet the requirements of the agreement, the County Department or the external entity may request assistance from the State Department.

b. The State Department retains the authority to require the termination of any active Collaboration Agreement or Cost Sharing Agreements.

i. Prior to any termination of a Collaboration Agreement or Cost Sharing Agreement, the State Department shall provide technical assistance to resolve any outstanding issues.

ii. If the State Department determines that a Collaboration Agreement or Cost Sharing Agreement must be terminated, the State Department shall provide at least a 60 calendar day notice to the County Department, including the reason for termination.

iii. The County Department shall provide at least a 30 calendar day notice to the external entity for which the Collaboration Agreement or Cost Sharing Agreement was terminated by the State iv. If a Cost Sharing Agreement is terminated by the State Department, the State Department may collaborate with other County Departments to revise their Cost Sharing Agreement to include Applicants and Members from the County where the Cost Sharing Agreement was terminated. 1.020.12 State Department Oversight of County Department Compliance with Medical Assistance Program Requirements 1. Purpose and Scope This section and sections 1.020.13, 1.020.14, and 1.020.15 authorize the Colorado Department of Health Care Policy and Financing to enter into informal and formal corrective action plans for financial and non-financial findings of noncompliance identified by the State Department through audits, quality assurance and compliance checks. 1.020.13. Audits, Quality Assurance and Reviews by the State Department 1. Federal and State Audits County Departments shall promptly respond to and comply with State Department requests related to federal and State audit requirements, such as Medicaid Eligibility Quality Control (MEQC), Payment Error Rate Measurement (PERM), Office of the State Auditor (OSA), Office of the Inspector General (OIG) audits and any other required federal or State audit.

Quality Assurance Program All County Department eligibility determinations and actions performed to administer Medical Assistance Programs are subject to review by the State Department Quality Assurance Program. The County Departments shall comply with all State Department Quality Assurance Program requirements and any other federal or state audits.

County Departments shall implement appropriate quality assurance measures for activities and expenditures utilizing state and federal funding for the purposes of the administration of Medical Assistance. These measures shall be documented in the County Department Quality Assurance/Quality Control Plan, which is subject to review during any of the State Department’s review processes.

Desk Reviews To ensure compliance with State and federal Rules, the State Department may conduct desk reviews of County Departments. Desk reviews may review any aspect, including fiscal requirements, of a County Department’s administration of the Medical Assistance Program at any given time.
Site Audits To ensure compliance with 42 C.F.R. Part 431.50, the State Department shall conduct site audits, known as Management Evaluation Reviews, of the County Department at least once every three (3) years. The site audit is a review of all aspects, including fiscal, administrative, and eligibility determination requirements, of the County Department’s Medical Assistance operations.
Performance Review The State Department shall conduct monthly reviews of Medical Assistance performance measures to ensure the County Department’s compliance with federal and state performance requirements.
Training Review The State Department may conduct reviews of the County Department’s progress of State Department-mandated training; these reviews ensure the applicable staff have completed the mandated trainings within the required timeframes.
Escalation, Complaint and Appeal Review The State Department may conduct reviews of any Applicant or Member case escalation, complaint, or appeal that pertains to, or was conducted by, the County Department. The review shall consist of a root cause analysis and determine County Department compliance with the applicable federal and state requirements.
Self-Report Audits and Post-Audits At the request of the State Department, the County Department shall submit a self-report audit or self-review data. This County Department self-report audit or self-review data is subject to Post-Audits by the State Department to verify the accuracy of the data.
Failure to Comply with Audit and Review Requirements Failure by the County Department to comply with any aspect of this section 1.020.13. (Audits, Quality Assurance and Reviews) shall result in action plan processes as described in section 1.020.14 (Non-Compliance Findings and Action Plan Processes). 1.020.14. Non-Compliance Findings and Action Plan Processes 1. Non-Compliance Findings After conducting an audit or review as specified in section 1.020.13. (Audits, Quality Assurance, and Reviews), the State Department shall issue any unresolved findings of non-compliance through Notices of Compliance Concerns and Management Decision Letters. Findings of non-compliance will be grouped into the following categories:

a. Administrative Non-compliance with administrative requirements reflected in 10 C.C.R. 2505-5, §1.020, including missing or incomplete policies, procedures, or processes; legal non-compliance; or other types of non-compliance not defined below.

b. Fair Hearings and Appeals Non-compliance with fair hearings and appeals requirements set forth in 10 CCR § 2505-3 and 10 CCR § 2505-10; this also includes noncompliance with any federal fair hearings and appeals regulation or sub regulatory guidance c. Eligibility Determination Non-compliance with eligibility determination requirements set forth in 10 CCR § 2505-3 and 10 CCR § 2505-10; this also includes non-compliance with any federal eligibility Regulation or sub regulatory guidance.

d. Fiscal Non-compliance with fiscal requirements reflected in 10 C.C.R. 2505-5, §1.010.

e. Quality Non-compliance with quality assurance, audit, or review requirements set forth in 10 C.C.R. 2505-5, § 1.020.13.

f. Performance Non-compliance with performance measures as determined by State Department performance reviews set forth in 10 C.C.R. 2505-5, §1.020.13.

Types of Non-Compliance Notices The State Department will provide one of the following notices of non-compliance when the County Department has been determined to be non-compliant. There are two types of non-compliance notices.

a. Notice of Compliance Concerns (“Compliance Notice”)

A Notice of Compliance Concerns may be issued by the State Department to the County Department as a first, informal step in resolving noncompliance issues; this type of notice may be tied to a Level 1 Improvement Action Plan. The notice communicates non-compliance findings informally and what actions are necessary to address or resolve those findings.

b. Management Decision Letter (“MDL”)

A Management Decision Letter may be issued by the State Department to the County Department as a formal step in resolving non-compliance issues; this type of notice may be tied to a Level 2 Corrective Action Plan.

The notice communicates non-compliance findings and the corrective actions necessary to address those findings. County Department noncompliance with a Management Decision Letter may be subject to Sanctions as set forth in 10 C.C.R. 2505-5, §1.020.15.

Notifications of Non-Compliance to County Department Director The State Department will provide a copy of any Notice of Compliance Concerns or Management Decision Letter regarding findings of non-compliance that may lead to improvement or corrective actions or fiscal sanctions as described in this

section 1.020.14 (Non-Compliance Findings and Action Plan Processes) to the County Department Director.

Improvement Action Plans and Corrective Action Plans (“Action Plans”)

When addressing non-compliance by the County Department that may lead to or has resulted in the issuance of a Notice of Compliance Concerns or Management Decision Letter, the State Department may require the County Department to submit an action plan to address the non-compliance identified. If an action plan is required, the State Department shall specify to the County Department the type of action plan that must be implemented.

a. Level 1 Improvement Action Plan An informal plan implemented with technical assistance to address noncompliance and/or performance that may lead to non-compliance. This type of plan is not subject to fiscal sanctions as defined in section 1.020.15 (Sanctions). The State Department may convert a Level 1Improvement Action Plan to a Level 2Corrective Action Plan for any Level 1 plans that have failed to be adequately or timely implemented.

b. Level 2 Corrective Action Plan A formal plan implemented with technical assistance to address noncompliance and/or performance that may lead to non-compliance. This type of plan is subject to fiscal sanctions as defined in section 1.020.12 (Sanctions). The State Department may communicate with the County Board regarding any Level 2 Corrective Action Plans.

Completion of Level 1 and Level 2 Action Plans:

Upon request of the State Department, the County Department shall complete a Level 1 Improvement Action Plan or Level 2 Corrective Action Plan. The Level 1 or Level 2 Action Plan submitted by the County Department shall include:

a. Non-compliance previously addressed Description, in writing, of how both the individual and systemic root cause of each non-compliance issue has been previously corrected; the date in which the correction took place; the staff involved in the correction; and documentation, if applicable, supporting the correction that took place.

b. Non-compliance to be addressed Plan, in writing, explaining how each root cause, both individual and systemic, of the non-compliance issue will be corrected. Such a plan must contain the following information for each non-compliance issue:

i. Identify the non-compliance issue, ii. List the specific action(s) to be taken to correct the non-compliance, iii. List the specific time frames for completion of each specific action not to exceed six months without the written consent of the State Department, and iv. Provide the name of the contact person responsible for each corrective action. The corrective action plan should proceed as rapidly as possible to correct all non-compliance.

v. Provide documentation demonstrating that the actions to address non-compliance will be completed, if necessary or applicable.

c. Technical Assistance The County Department may request technical assistance from the State Department in developing either a Level 1 or Level 2 Plan. This request must occur within 15 calendar days of notification to the County Department of the requirement to complete a Level 1 or Level 2 Plan.

d. Timeframe to Complete Plan and Extension of Time i. Timeframe to Complete Plan If notified of the requirement to complete a Level 1 or Level 2 Action Plan, the County Department shall complete such Plan within 30 calendar days of receiving notification from the State Department.

ii. Extension of Time If the County Department needs additional time to develop a Level 1 or Level 2 Action Plan, the County Department Director must submit a request electronically to the State Department at HCPF_CountyRelations@state.co.us specifying the new timeframe requested and providing an explanation for the extension request.

iii. Review of Extension Request The State Department will review the request for time extension within five business days of receipt and respond to the County Department Director.

Acceptance or Rejection of a Level 1 or Level 2 Action Plan Within 30 calendar days of receipt of the proposed Level 1 or Level 2 action plan from the County Department, the State Department will review and either accept or reject the proposed Level 1 or Level Tier Action Plan.

a. Accepted Level1 or Level 2 Action Plan If the submitted Level 1 or Level 2 action plan is accepted by the State Department, the County Department Director will be notified electronically of the approval within ten calendar days and implementation of the plan may begin immediately.

b. Rejected Level 1 or Level 2 Action Plan If the submitted Level1 or Level 2 action plan is rejected by the State Department, the County Department Director will be notified electronically of the decision and will be required to resubmit a Level 1 or Level 2 Plan after participating in technical assistance provided by the State Department to address the individual and systemic root cause of noncompliance.

i. Initial Technical Assistance Meeting The County Department is required to successfully complete an initial technical assistance meeting within 15 calendar days of receipt of the Level 1 or Level 2 Plan rejection.

ii. Request for Time Extension If the County Department cannot complete the initial technical assistance meeting within 15 calendar days, the County Department may request additional time to complete the initial technical assistance meeting. The State Department will review the request for time extension within five business days of receipt and respond to the County Department Director electronically.

Ongoing Monitoring of any Level 1 or Level 2 Plan Upon acceptance of the Level1 or Level 2 Plan, the State Department begins monitoring the implementation of the plan. Monitoring may include but is not limited to routine reviews of reports, field observations, periodic check-ins, plan amendments, and technical assistance.

a. Follow-Up The State Department will verify that the County Department has complied with the approved Level 1 or Level 2 Plan. The County Department may be required to submit any documentation needed to verify compliance with the accepted Plan.

b. Non-Compliance with Accepted Plan If the State Department has verified that the County Department has not complied with the accepted Level 1 or Level 2 Plan, then:

i. The State Department shall convert a Level 1 Improvement Action Plan to a Level 2 Corrective Action Plan ii. The State Department shall implement fiscal sanctions for noncompliance on a Level 2 Corrective Action Plan as defined in

section 1.020.15 (Sanctions).

c. g. Closure of an Accepted Plan Upon County Department completion of a Level 1 Improvement Action Plan or Level 2 Corrective Action Plan and verification of completion by the State Department, a closure letter will be sent to the County Department Director electronically. 1.020.15 Sanctions If the County Department does not meet the requirements of 10 C.C.R. 2505-10, § § 8.000, 8.100, 8.400, 8.500, 8.940 through 8.943, and 8.1000; 10 C.C.R. 2505-5, § § 1.010 and 1.020; or 10 C.C.R. 2505-3, § § 100, 300, 400, and 600; or fails to comply with an approved Level 2 Corrective Action Plan as described in section 1.020.14.4 (Improvement Action Plans and Corrective Action Plans), the State Department may impose the following sanctions:

Type 1 Sanction: Disallowance of State and federal funds not to exceed 2.5% of the County Department’s current state fiscal year allocation provided by the State Department. This amount shall be divided by the number of months in the state fiscal year and disallowed monthly until the County Department attains compliance. Level 1 Sanctions that cross state fiscal years shall utilize the County Department allocation from the state fiscal year in which the Level 1 Sanction originated.

The State Department may elect to disallow less than 2.5% of the County Department’s State and federal funds allocation at its discretion 2. Type 2 Sanction: The State Department’s undertaking of the administration of the Medical Assistance Program for which the County Department has not met State and federal requirements or the requirements of a Level 2 Corrective Action Plan; and 3. Any other action which may be necessary or desirable for carrying out the provisions of Title 25.5 of the Colorado Revised Statutes and its implementing regulations.

a. If the State Department has made a determination to impose fiscal sanctions as allowed in 10 C.C.R. 2505-5, §1.020.15, the County Department Director will receive the following sanctions notifications i. The first notification of fiscal sanctions due to non-compliance on a Level 2 Corrective Action Plan shall be sent to the County Department Director sixty calendar days prior to the implementation of fiscal sanctions. The first notification shall include the dollar amount of fiscal sanctions, or any other sanction implemented per

section 1.020.15 (Sanctions) and the date the sanction will be implemented. The County Department shall have thirty calendar days after notification of fiscal sanctions to cure non-compliance with the Level 2 Plan to avoid implementation of fiscal sanctions.

ii. The second notification of fiscal sanctions due to non-compliance on a Level 2 Corrective Action Plan shall be sent to the County Department Director thirty calendar days prior to the implementation of fiscal sanctions. The second notification shall include the dollar amount of fiscal sanctions, or any other sanction implemented per section 1.020.15 (Sanctions) and the date the sanction will be implemented. The County Department shall have thirty calendar days to cure non-compliance with the Level 2 Plan to avoid fiscal sanctions. iii The third notification of fiscal sanctions due to non-compliance on a Level 2 Corrective Action Plan shall be sent to the County Department Director five (5) calendar days prior to the implementation of fiscal sanctions. The third notification shall include the dollar amount of fiscal sanctions, or any other sanction implemented per section 1.020.15 (Sanctions) and the date the sanction will be implemented. After receiving a third notification, the County Department will no longer be able to cure non-compliance with the Level 2 Plan and fiscal sanctions will be implemented.

A. Compliance with the Level 2 Plan after fiscal sanctions have been implemented shall cure the non-compliance with the Level 2 Plan but will not reverse fiscal sanctions implemented from non-compliance for the timeframe the County Department was non-compliant.

b. Appeals of Sanctions Notifications The County Department may appeal any first or second notification of fiscal sanctions. These appeals shall be submitted within the 10 calendar days by sending an electronic communication to the State Department at HCPF_CountyRelations@state.co.us. The basis for the appeal shall be limited to a factual error in the report or an incorrect interpretation of law,

Rule, or Regulations. The County Department may submit documents or evidence with its appeal. Within five calendar days of receiving the appeal, the State Department shall issue a final decision in writing, which will be sent electronically to the County Department Director. The effective date of the final decision is the date it is signed by the State Department. The State Department’s determination on the County Department appeal is final and not subject to further appeal. The third notification of fiscal sanctions is also not subject to appeal by the County Department.

i. State Department Delay of Fiscal Sanctions The State Department may, at its own discretion, provide a onetime delay on the imposition of any fiscal sanction as described in 10 C.C.R. 2505-5, § 1.020.14, if the County Department has demonstrated progress towards resolution of any Level 2 Corrective Action Plan. The State Department will determine an appropriate amount of time to delay imposing any sanctions to allow for the County Department to successfully complete its Level 2 Corrective Action Plan. The County Department may be required to provide documentation demonstrating reasons outside of the County Department’s control that have prevented the County Department from successfully resolving its Level 2 Corrective Action Plan.

c. Timeframe for Fiscal Sanctions Fiscal sanctions enacted by the State Department shall go into effect the month in which the third notification of fiscal sanctions was issued and shall remain in place until the month following the State Department’s determination that the County Department is compliant with the Level 2 Corrective Action Plan that was associated with the fiscal sanctions notifications.

1.200 ALL-PAYERS CLAIMS DATABASE 1.200.1 Definitions “administrator” means the administrator of the APCD appointed by the director of the department.

“APCD” means the Colorado All-Payer Claims Database.

“Alternative Payment Model (APM) file” means a detailed file that captures payments made to providers outside of the traditional fee-for-service model. This includes:

Foundation Payments for Infrastructure and Operations, Pay for Reporting, Pay for Performance, Shared Savings, Shared Savings and Downside Risk, Risk Based Payments NOT Linked to Quality, Condition-Specific Population-Based Payment, Comprehensive Population-Based Payment, Integrated Finance and Delivery Systems, and Capitated Payments NOT Linked to Quality. APM files are submitted according to the requirements contained in the submission guide.

“APM Contract Supplement file” means a file that captures qualitative information related to alternative arrangements between carriers and providers; submitted according to the requirements contained in the submission guide.

“Anti-trust safety zone” means the exchange of information that antitrust agencies have identified as unlikely to raise substantial concerns if: 1) the exchange is managed by a third-party, like a trade association; 2) the information provided by participants is more than three months old; and 3) at least five participants provide the data underlying each statistic shared, no single provider’s data contributes more than 25% of the “weight” of any statistic shared, and the shared statistics are sufficiently aggregated that no participant can discern the data of any other participant.

“control total file” means a file that captures aggregated data related to payments made to providers outside of the traditional fee-for-service model. This includes: Foundation Payments for Infrastructure and Operations, Pay for Reporting, Pay for Performance, Shared Savings, Shared Savings and Downside Risk, Risk Based Payments NOT Linked to Quality, Condition-Specific Population-Based Payment, Comprehensive Population-Based Payment, Integrated Finance and Delivery Systems, and Capitated Payments NOT Linked to Quality. APM files are submitted according to the requirements contained in the submission guide.

“dental claims data file” means a file that includes data about dental claims and other “department” means the Colorado Department of Health Care Policy and Financing.

“director” means the Executive Director of the department.

“eligibility data file” means a file that includes data about a person who receives health care coverage from a payer, according to the requirements contained in the submission “ERISA” means the Employee Retirement Income Security Act of 1974, as codified at 29 U.S.C. ch. 18.

“HIPAA” means the Health Insurance Portability and Accountability Act, U.S.C. § 1320d – 1320d-8, and its implementing regulations, 45 C.F.R. Parts 160, 162 and 164, as may be amended.

“historic data” means eligibility data file(s), medical claims data file(s), pharmacy file(s) and provider file(s) for the period commencing January 1, 2009 through December 31, 2014 (except in the case of a self-insured employer-sponsored health plan, in which case, “historic data” shall mean, at minimum, such data file(s) for the period commencing January 1, 2015 through December 31, 2015).

“medical claims data file” means a file that includes data about medical claims and other “payer” means a private health care payer and a public health care payer.

“pharmacy benefit manager contract information file” means a file that includes information related to contracts between carriers and pharmacy benefit managers; and is submitted according to the requirements contained in the submission guide.

“pharmacy file” means a file that includes data about prescription claims for medications filled by pharmacies, according to the requirements contained in the submission guide.

“PMPM” means Per Member Per Month and is submitted according to the requirements in the submission guide.

“prescription drug affordability board file” means a file that includes required information about prescription drugs as outlined in SB21-175; and is submitted according to the requirements contained in the submission guide.

“Prescription Drug Rebate” means aggregated information regarding the total amount of any prescription drug rebates and other pharmaceutical manufacturer compensation or price concessions paid by pharmaceutical manufacturers to a payer or their pharmacy benefit manager(s).

“private health care payer” means an insurance carrier as defined in C.R.S. § 10-16- 102(8) covering an aggregate of 1,000 or more enrolled lives in health coverage plans as defined in C.R.S. § 10-16-102(34). For purposes, of this regulation, “private health care payer” includes carriers, third-party administrators, administrative services only organizations, and pharmacy benefit managers offering health benefits plans under C.R.S. § 10-16-102(32)(a), dental, vision, pharmacy, Medicare Advantage, Medicare supplemental plans, limited benefit health insurance, or short-term limited-duration health insurance. For the purposes of this regulation, a “private health care payer” also means a self-insured employer-sponsored health or pharmacy plan covering an aggregate of 100 or more enrolled lives in Colorado if the employer is not subject to ERISA. It does not include a self-insured employer-sponsored health or pharmacy plan if the employer is subject to ERISA; carriers offering accident only; credit; benefits for long term care, home health care, community-based care, or any combination thereof under Article 19 of Title 10; disability income insurance; liability insurance including general liability insurance and automobile liability insurance; coverage issued as a supplement to liability insurance; worker’s compensation or similar insurance; or automobile medical payment insurance, specified disease, or hospital indemnity and other fixed indemnity insurance.

“protected health information” shall have the same meaning as in the HIPAA Privacy

Rule in 45 C.F.R. § 160.103.

“provider file” means a file that includes additional information about the individuals and entities that submitted claims that are included in the medical claims file; and is submitted according to the requirements contained in the submission guide.

“public health care payer” means the Colorado Medicaid program established under articles 4, 5 and 6 of title 25.5, C.R.S., the children’s basic health plan established under

article 8 of title 25.5, C.R.S. and Cover Colorado established under part 5 article 8 of title 10, C.R.S.

“self-funded employee health plans” means health plans where the financial risk associated with medical claims is held by the organization sponsoring the health coverage.

“submission guide” means the document entitled “Colorado All-Payer Claims Database Data Submission Guide” developed by the administrator that sets forth the required schedules, data file format, record specifications, data elements, definitions, code tables and edit specifications for payer submission of eligibility data files, medical, dental and pharmacy claims data files and provider data files in accordance with the APCD Data Submission Guide Version 17 dated March 2026 which document is hereby “third party administrator (TPA)” or “administrative services only (APO)” means a business organization that performs administrative services for a health plan such as billing, plan design, claims processing, record keeping, and regulatory compliance activities.

“value-based purchasing contract file” means a file that includes information about pharmacy value-based purchasing contracts between carriers/PBMs and drug manufacturers; and is submitted according to the requirements contained in the submission guide.

“vision claims data file” means a file that includes data about vision claims and other 1.200.2 Reporting Requirements 1.200.2.A Payers shall submit complete and accurate eligibility data files, paid and denied medical claims data files, paid and denied pharmacy claims data files, paid and denied dental claims data files, alternative payment model data files, control total files, APM contract supplement files, prescription drug rebate data files, PBM contract files, prescription drug affordability board information files, pharmacy value based purchasing contract files, provider files, paid and denied vision claims data files, and annual member capitation files to the APCD pursuant to the submission guide. The administrator may amend the submission guide and shall provide notice of the revisions to payers. Any revision to the submission guide will be effective only when incorporated into this rule and issued in compliance with the requirements of C.R.S. § 24-4-103 (12.5). Reports submitted 120 days following the effective date of the revision of this rule and the submission guide shall follow the revised submission guide. 1.200.2.B. A private health care payer subject to the provisions of ERISA is not required under this rule to submit claims data to the APCD but may continue to submit claims data or elect to submit claims data at any time in accordance with the procedures described in Sections 1.200.2.A and 1.200.3. 1.200.3 Schedule for Mandatory Data Reporting 1.200.3.A. Payers shall submit a test file of its eligibility data, medical and pharmacy claims data and provider files for a consecutive twelve-month period to the administrator no later than March 31, 2012 or no later than 160 calendar days after the effective date of this rule, whichever is later. 1.200.3.B. Payers shall submit complete and accurate historic data to the administrator that conforms to submission guide requirements by no later than June 30, 2012, or no later than 250 calendar days after the effective date of this

rule, whichever is later. 1.200.3.C. Payers will transmit complete and accurate eligibility data, medical claims data, pharmacy claims data, dental claims data, and provider files covering the period from January 1, 2012 and ending June 30, 2012 to the administrator by no later than August 15, 2012, or for the period as specified by the administrator no later than 305 days after the effective date of this rule, whichever is later. 1.200.3.D. On a monthly basis thereafter, payers will transmit complete and accurate monthly eligibility data, paid and denied medical claims data, paid and denied pharmacy claims data, paid and denied dental claims data, paid and denied vision claims data and provider files to the administrator. These data files for the period ending July 31, 2012, shall be submitted no later than September 15, 2012, or for the period as specified by the administrator, no later than 305 days after the effective date of this rule, whichever is later. For each month thereafter, files shall be submitted no later than 30 days after the end of the reporting month.

Any time extension shall be provided to payers in writing by administrator at least 30 days prior to established deadlines. 1.200.4 APCD Reports 1.200.4.A. The administrator shall, at a minimum, issue reports from the APCD data at an aggregate level to describe patterns of incidence and variation of targeted medical conditions, state and regional cost patterns and utilization of services. 1.200.4.B. The APCD reports shall be available to the public on consumer facing websites and shall provide aggregate and summary reports to achieve the purposes of the APCD. Any such reports shall protect patient identity in accordance with HIPAA’s standard for the de-identification of protected health information. 1.200.5 Requests for Data and Reports 1.200.5.A. A state agency or private entity engaged in efforts to improve health care quality, value or public health outcomes for Colorado residents may request a specialized report or data set from the APCD by submitting to the administrator a written request detailing the purpose of the project, the methodology, the qualifications of the research entity, and by executing a data use agreement, to comply with the requirements of HIPAA. 1.200.5.B. A data release review committee shall review those requests for reports or data sets containing protected health information and shall advise the administrator on whether release of the data is consistent with the statutory

purpose of the APCD, will contribute to efforts to improve health care quality, value or public health outcomes for Colorado residents, complies with the requirements of HIPAA, and does not violate antitrust law, using the Anti-trust Safety Zone as guidance. The administrator shall include a representative of a physician organization, hospital organization, non-physician provider organization and a payer organization on the data release review committee. 1.200.5.C. The administrator may charge a reasonable fee to provide the requested data. 1.200.5.D The administrator may not release data from the Alternative Payment Model, Control Total, APM Contract Supplement, Drug Rebate, PBM Contract Supplement, or Pharmacy Value Based Purchasing Contract files to external requestors. These data are only to be used for aggregated reporting by the administrator and direct reporting to the State of Colorado. 1.200.5.E The administrator may not release data from the premium payment or deductible fields to any external requestors or use the data for aggregate public reporting. Premium and deductible field data may only be released to the Colorado Division of insurance through June 2027. 1.200.6 Penalties 1.200.6.A. If any payer fails to submit required data to the APCD in a timely basis, or fails to correct submissions rejected because of errors, the administrator shall provide written notice to the payer. The administrator may grant an extension of time for just cause. If the payer fails to provide the required information within thirty days following receipt of said written notice, the administrator shall provide the payer with notice of the failure to report and will notify the director of the payer’s failure to report. The director shall assess a penalty of up to $100 per day per issue for the first thirty days that a payer fails to provide the required data to the APCD and $1,000 for each day thereafter. In determining whether to impose a penalty, the director may consider mitigating factors such as the size and sophistication of a payer, the reasons for the failure to report and the detrimental impact upon the public purpose served by the APCD. 1.200.6.B The penalties specified in Section 1.200.6.A shall not apply to a private health care payer that is subject to the provisions of ERISA, since those payers are not required under this rule to submit claims data to the APCD. 1.200.7 Interagency Agreement 1.200.7.A. The director may enter into an Interagency Agreement on behalf of the APCD and the administrator with the Division of Insurance in the Colorado Department of Regulatory Agencies to assist in the enforcement of these regulations and under the Divisions’ authority in Title 10 of the Colorado Revised Statues. 1.200.8 Privacy and Confidentiality 1.200.8.A. Pursuant to C.R.S. § 24-72-204(3)(a)(I) medical and other health care data on individual persons is not an open record and the department shall deny any open records request for such information. 1.200.8.B. Certain aggregate and de-identified data reports from the APCD shall be available to the public pursuant to C.R.S. § 25.5-1-204(7) when disclosed in a form and manner that ensures the privacy and security of protected health information in compliance with HIPAA. 1.200.8.C. The administrator shall institute appropriate administrative, physical and technical safeguards to ensure that the APCD, its operations, data collection and storage, and reporting disclosures are in compliance with the requirements of HIPAA, and does not violate antitrust law, using the Anti-trust Safety Zone as guidance. All eligibility, claims data; medical, dental, pharmacy, and vision, shall be transmitted to the APCD and stored by the APCD in a secure manner compliant with HIPAA. 1.200.9 Incorporation by Reference 1.200.9A The rules incorporate by reference (as indicated within) material originally published elsewhere. Such incorporation, however, excludes later amendments to or editions of the referenced material. Pursuant to C.R.S. § 24-4-103(12.5), the Department of Health Care Policy and Financing maintains copies of the incorporated texts in their entirety which shall be available for public inspection during regular business hours at:

Colorado Department of Health Care Policy and Financing Medical Services Board Coordinator 303 E. 17th Avenue, Suite 1100 Denver, CO 80203 Copies of material shall be provided by:

Center for Improving Value in Health Care 4500 Cherry Creek Drive South, Suite 350 Denver, CO 80246 www.civhc.org info@civhc.org ______________________________________________________________________ Editor’s Notes

History Entire rule eff. 01/30/2011.

Rule 1.200 eff. 10/15/2011.

Rule 1.200.1 eff. 05/15/2013.

Rule 1.200.2.B repealed eff. 06/30/2013.

Rule 1.200.1 eff. 06/30/2014.

Rules 1.200.1, 1.200.2.B, 1.200.3, 1.200.6.B eff. 08/30/2015.

Rules 1.200.1-1.200.3, 1.200.6.B, 1.200.8 eff. 07/30/2016.

Rules 1.200.1, 1.200.3.D, 1.200.5 eff. 07/30/2017.

Rules 1.200.1, 1.200.2.A eff.12/15/2018.

Rule 1.200.1 eff. 03/02/2020.

Rule 1.200.1 eff. 05/30/2020.

Rule 1.200.1 eff. 03/17/2021.

Rules 1.010-1.020.12 eff. 09/30/2021.

Rules 1.200.1, 1.200.2.A, 1.200.5, 1.200.6.A, 1.200.8.C emer. rules eff. 03/01/2022.

Rules 1.200.1, 1.200.2 A, 1.200.5, 1.200.6 A, 1.200.8 C eff. 03/30/2022.

Rule 1.200 eff. 12/30/2022.

Rule 1.200 eff. 01/30/2024.

Rules 1.200.1, 1.200.2 A, 1.200.3 A, 1.200.5 E, 1.200.9 A eff. 01/30/2025.

Rules 1.010, 1.020 eff. 06/30/2025.

Rules 1.010.1, 1.020, 1.020.3.6 eff. 09/01/2025.

Rules 1.200.1, 1.200.2.A, 1.200.3.A, 1.200.5.E, 1.200.8.C, 1.200.9 eff. 03/01/2026.

Code of Colorado Regulations — Department of Health Care Policy and Financing

1305 Health Data Commission - [Rules repealed eff. 03/04/2007]

8 CCR 1305-1 COLLECTION, VERIFICATION, EXEMPTION OF DATA - Repealed eff. 03/04/2007 {#sec-8-ccr-1305-1 omnilex-key=us-co-regs-official--department-7--8 CCR 1305-1}

2505 Cooperative Health Care Agreements Board [Rules repealed eff. 04/30/2013]

10 CCR 2505-1 REGULATIONS - [Repealed eff. 04/30/2013] {#sec-10-ccr-2505-1 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-1}

2505 Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)

10 CCR 2505-3 Financial Management of the Children's Basic Health Plan {#sec-10-ccr-2505-3 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-3}

10 CCR 2505-10 Medical Assistance - Statements of Basis and Purpose and Rule History {#sec-10-ccr-2505-10 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10}

10 CCR 2505-10 8.000 MEDICAL ASSISTANCE - SECTION 8.000 Emergency Medical Transportation, Program Integrity {#sec-10-ccr-2505-10-8.000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.000}

10 CCR 2505-10 8.100 MEDICAL ASSISTANCE - SECTION 8.100 Eligibility, Provider Screening, NPI {#sec-10-ccr-2505-10-8.100 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.100}

10 CCR 2505-10 8.200 MEDICAL ASSISTANCE - SECTION 8.200 Physician Services, Dental, Vision Services, Medicaid Managed Care Program, EPSDT {#sec-10-ccr-2505-10-8.200 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.200}

10 CCR 2505-10 8.300 MEDICAL ASSISTANCE - SECTION 8.300 Hospital Services {#sec-10-ccr-2505-10-8.300 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.300}

10 CCR 2505-10 8.400 MEDICAL ASSISTANCE - SECTION 8.400 Long Term Care, Nursing Facility Care, Adult Day Care Services {#sec-10-ccr-2505-10-8.400 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.400}

10 CCR 2505-10 8.500 MEDICAL ASSISTANCE - SECTION 8.500 Home Health Services, Hospice, Oxygen, DME {#sec-10-ccr-2505-10-8.500 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.500}

10 CCR 2505-10 8.600 MEDICAL ASSISTANCE - SECTION 8.600 Case Management, Supports Intensity Scale, Laboratory and X-Ray {#sec-10-ccr-2505-10-8.600 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.600}

10 CCR 2505-10 8.700 MEDICAL ASSISTANCE - SECTION 8.700 Federally Qualified Health Centers, Women's Health Services {#sec-10-ccr-2505-10-8.700 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.700}

10 CCR 2505-10 8.800 MEDICAL ASSISTANCE - SECTION 8.800 Pharmaceuticals, Podiatry Services, Immunization Services {#sec-10-ccr-2505-10-8.800 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.800}

10 CCR 2505-10 8.900 MEDICAL ASSISTANCE - SECTION 8.900 OAP, Primary Care Fund, Dental Health Care {#sec-10-ccr-2505-10-8.900 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.900}

10 CCR 2505-10 8.1000 MEDICAL ASSISTANCE - SECTION 8.1000 Medicare Modernization Act {#sec-10-ccr-2505-10-8.1000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.1000}

10 CCR 2505-10 8.2000 MEDICAL ASSISTANCE - SECTION 8.2000 [Repealed eff. 10/30/2017] {#sec-10-ccr-2505-10-8.2000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.2000}

10 CCR 2505-10 8.3000 MEDICAL ASSISTANCE - SECTION 8.3000 Healthcare Affordability and Sustainability Fee {#sec-10-ccr-2505-10-8.3000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.3000}

10 CCR 2505-10 8.4000 MEDICAL ASSISTANCE - SECTION 8.4000 Hospital Expenditure Report Data Collection {#sec-10-ccr-2505-10-8.4000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.4000}

10 CCR 2505-10 8.5000 MEDICAL ASSISTANCE - SECTION 8.5000 Hospital Community Benefit Accountability {#sec-10-ccr-2505-10-8.5000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.5000}

10 CCR 2505-10 8.6000 MEDICAL ASSISTANCE - SECTION 8.6000 Novel Coronavirus Disease (COVID-19) Rules [Emergency rules expired 01/06/2024] {#sec-10-ccr-2505-10-8.6000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.6000}

10 CCR 2505-10 8.7000 MEDICAL ASSISTANCE - SECTION 8.7000 Home and Community Based Services {#sec-10-ccr-2505-10-8.7000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.7000}

10 CCR 2505-10 8.8000 MEDICAL ASSISTANCE - SECTION 8.8000 Rural Provider Access and Affordability Stimulus Grant Program {#sec-10-ccr-2505-10-8.8000 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 8.8000}

10 CCR 2505-10 MED 11E MEDICAL ASSISTANCE - FORM MED-11E [Repealed eff. 06/30/2014] {#sec-10-ccr-2505-10-med-11e omnilex-key=us-co-regs-official--department-7--10 CCR 2505-10 MED 11E}

2505 Office of Public and Private Initiatives [Rules repealed eff. 05/15/2013]

10 CCR 2505-2 HEALTH CARE COVERAGE COOPERATIVES - [Repealed eff. 05/15/2013] {#sec-10-ccr-2505-2 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-2}

2505 Executive Director of Health Care Policy and Financing

10 CCR 2505-5 Executive Director of Health Care Policy and Financing Rules {#sec-10-ccr-2505-5 omnilex-key=us-co-regs-official--department-7--10 CCR 2505-5}

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