DEPARTMENT OF REGULATORY AGENCIES Office of Acupuncture Licensure ACUPUNCTURE LICENSURE 4 CCR 738-1 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ 1.1 Requirement for Licensure The purpose of this Rule is to establish the qualifications for an acupuncturist license as required in sections 12-200-106(3) and 12-20-202(4), C.R.S.

A. In order to qualify for licensure, section 12-200-106(3), C.R.S., requires an applicant to either successfully complete an education program that conforms to the standards approved by the Director of the Division of Professions and Occupations (Director) or provide documentation of qualifications that are substantially similar to an approved education program. The Director approved education program includes any diploma program in acupuncture and Oriental medicine accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) or a successor organization.

B. To satisfy the licensure requirement in section 12-200-106(3), C.R.S., the Director requires an applicant to have a current certification at the time of initial license application by the National Certification Commission for Acupuncture and Oriental Medicine (“NCCAOM”) or a successor organization. The applicant shall provide verification of this current certification in a manner prescribed by the Director.

C. Education, training, or service gained in military services outlined in section 12-20-202(4), C.R.S., to be accepted and applied towards receiving a license, must be substantially equivalent, as determined by the Director, to the qualifications otherwise applicable at the time of receipt of application. It is the applicant’s responsibility to provide timely and complete evidence for review and consideration. Satisfactory evidence of such education, training, or service will be assessed on a case by case basis.

1.2 Licensure by Endorsement The purpose of this Rule is to establish the qualifications that are substantially equivalent for an acupuncturist license by endorsement pursuant to section 12-200-107(2), C.R.S. A. For an applicant to establish “substantially equivalent credentials and qualifications” under section 12-200-107(2), C.R.S., the Director requires the applicant to submit a certification by NCCAOM or a successor organization. Verification of the certification shall be provided directly from NCCAOM or its successor in a manner prescribed by the Director; and B. Verification of licensure in another state shall be provided in a manner prescribed by the Director. 1 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure 1.3 Requirements for Reinstatement The purpose of this Rule is to state the requirements for reinstatement of a license that has expired, pursuant to section 12-200-106(4), C.R.S.

A. An applicant seeking reinstatement of an expired license shall complete a reinstatement application, pay a reinstatement fee, and attest to malpractice insurance in the amount required by statute.

B. If the license has been expired for more than two years from the date of receipt of the reinstatement application, but less than five years an applicant shall establish competency to practice under sections 12-20-202(2)(c)(II), C.R.S., and 12-20-105, C.R.S., by demonstrating one of the following:

1. Licensure in good standing from another state along with proof of active practice in that state for two years of the previous five years from the date of application for reinstatement.

2. Completion of thirty hours of continuing education courses related to the practice of acupuncture during the two years immediately preceding the application for reinstatement. The continuing education must meet the approval of and shall be attested to in a manner prescribed by the Director.

3. Active certification by NCCAOM or a successor organization. 4. Competency to practice by any other means approved by the Director. C. An applicant seeking to reinstate a license that has been expired for more than five years shall establish competency to practice as required in section 12-20-202(2)(c)(II), C.R.S. by demonstrating one of the following:

1. Licensure in good standing from another state along with proof of active practice for two years of the previous five years from the date of application for reinstatement. 2. Completion of supervised practice for a period no less than six months subject to the terms established by the Director.

3. Competency to practice by any other means approved by the Director. 1.4 Unlicensed Persons in Acupuncture Training Programs The purpose of this Rule is to identify the circumstances and conditions under which a person in training may practice acupuncture without a valid and current license on file with the Division of Professions and Occupations pursuant to section 12-200-108(3), C.R.S.

A. A person in training may practice acupuncture without a valid and current license issued by the Division of Professions and Occupations if such practice takes place in the course of a bona fide training program. A bona fide training program is a training or apprenticeship program with an accredited school of acupuncture.

B. A person in training shall be supervised by an acupuncturist licensed in Colorado who holds an active and unrestricted license to practice acupuncture in Colorado. 2 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure C. Section 12-200-108(3), C.R.S., requires a supervising acupuncturist to provide direct, on-site supervision of persons in training. Direct supervision shall mean supervision that is on the premises and in the same building where any such persons in training are practicing. D. A person in training may engage in the full scope of the practice of acupuncture as defined in section 12-200-103(5)(a), C.R.S.

E. The supervising acupuncturist is responsible for maintaining documentation detailing the beginning and ending dates of the bona fide training program and for ensuring that the names and current addresses of all supervised persons in training are maintained by the supervising acupuncturist and are readily available for inspection at the request of the Director or designee. 1.5 Use of Title and Restrictions The purpose of this Rule is to clarify the use of title “licensed acupuncturist” and “diplomat of acupuncture”, and use of the designations “L.Ac.” and “Dipl. Ac.” under section 12-200-108(2)(b)(II), C.R.S.

A. Obtaining an acupuncturist license does not automatically entitle or confer upon the licensee the right to use the title “Dr.” or “Doctor.”

B. A licensed acupuncturist can use the title “Doctor” or Dr. only when such licensee has, in fact, been awarded a doctorate degree from an acupuncture or oriental medicine academic/educational institution and satisfies the requirements of section 6-1-707, C.R.S. C. In such instances where a licensee qualifies to use the title “Doctor” or “Dr.”, an acupuncturist can use the title “Doctor” or “Dr.” only when accompanied by the words “Doctor of Acupuncture” or letters “D.Ac.”, “Oriental Medicine Doctor” or “OMD”, “Doctor of Acupuncture and Oriental Medicine” or “D.Ac.OM”, “Doctor of Traditional Chinese Medicine” or “DTCM”, “Doctor of Acupuncture and Oriental Medicine” or “DAOM”, or any other doctoral degree recognized and approved by the Director.

1.6 Declaratory Orders The purpose of this Rule is to establish procedures for the handling of requests for declaratory orders filed pursuant to the Colorado Administrative Procedures Act at section 24-4-105(11), C.R.S. A. Any person or entity may petition the Director for a declaratory order to terminate controversies or remove uncertainties as to the applicability of any statutory provision or of any rule or order of the Director.

B. The Director will determine, at her discretion and without notice to petitioner, whether to rule upon such petition. If the Director determines that the Director will not rule upon such a petition, the Director shall promptly notify the petitioner of the action and state the reasons for such decision. C. In determining whether to rule upon a petition filed pursuant to this rule, the Director will consider the following matters, among others:

1. Whether a ruling on the petition will terminate a controversy or remove uncertainties as to the applicability to petitioner of any statutory provisions or rule or order of the Director. 2. Whether the petition involves any subject, question or issue that is the subject of a formal or informal matter or investigation currently pending before the Director or a court involving one or more petitioners.

3 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure 3. Whether the petition involves any subject, question or issue that is the subject of a formal or informal matter or investigation currently pending before the Director or a court but not involving any petitioner.

4. Whether the petition seeks a ruling on a moot or hypothetical question or will result in an advisory ruling or opinion.

5. Whether the petitioner has some other adequate legal remedy, other than an action for declaratory relief pursuant to Colorado Rules of Civil Procedure 57, which will terminate the controversy or remove any uncertainty as to the applicability to the petitioner of the statute, rule, or order in question.

D. Any petition filed pursuant to this rule shall set forth the following: 1. The name and address of the petitioner and whether the petitioner is licensed pursuant to Title 12, Article 200.

2. The statute, rule, or order to which the petition relates. 3. A concise statement of all of the facts necessary to show the nature of the controversy or uncertainty and the manner in which the statute, rule, or order in question applies or potentially applies to the petitioner.

E. If the Director decides to rule on the petition, the following procedures shall apply: 1. The Director may rule upon the petition based solely upon the facts presented in the petition. In such a case:

a. Any ruling of the Director will apply only to the extent of the facts presented in the petition and any amendment to the petition.

b. The Director may order the petitioner to file a written brief, memorandum, or statement of position.

c. The Director may set the petition, upon due notice to petitioner, for a non- evidentiary hearing.

d. The Director may dispose of the petition on the sole basis of the matters set forth in the petition.

e. The Director may request the petitioner to submit additional facts in writing. In such event, such additional facts will be considered as an amendment to the petition.

f. The Director may take administrative notice of facts pursuant to the Colorado Administrative Procedures Act at section 24-4-105(8), C.R.S., and may utilize the Director’s experience, technical competence, and specialized knowledge in the disposition of the petition.

2. If the Director rules upon the petition without a hearing, the Director shall promptly notify the petitioner of her decision.

4 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure 3. The Director may, at the Director’s discretion, set the petition for hearing, upon due notice to petitioner, for the purpose of obtaining additional facts or information or to determine the truth of any facts set forth in the petition or to hear oral argument on the petition. The hearing notice to the petitioner shall set forth, to the extent known, the factual or other matters that the Director intends to inquire.

For the purpose of such a hearing, to the extent necessary, the petitioner shall have the burden of proving all the facts stated in the petition; all of the facts necessary to show the nature of the controversy or uncertainty; and the manner in which the statute, rule, or order in question applies or potentially applies to the petitioner and any other facts the petitioner desires the Director to consider.

F. The parties to any proceeding pursuant to this rule shall be the Director and the petitioner. Any other person may seek leave of the Director to intervene in such a proceeding, and leave to intervene will be granted at the sole discretion of the Director. A petition to intervene shall set forth the same matters as are required by Section D of this Rule. Any reference to a “petitioner” in this rule also refers to any person who has been granted leave to intervene by the Director. G. Any declaratory order or other order disposing of a petition pursuant to this rule shall constitute agency action subject to judicial review pursuant to the Colorado Administrative Procedures Act at section 24-4-106, C.R.S.

1.7 Reporting Convictions, Judgments and Administrative Proceedings The purpose of the Rule is to clarify the procedures for reporting convictions, and other adverse actions to include judgments and administrative proceedings pursuant to sections 12-200-105, 12-200-106, and 12- 200-109, C.R.S.

A licensee as defined in section 12-200-103, C.R.S., shall inform the Director, in a manner set forth by the Director, within thirty days of any of the following events: A. The conviction of the licensee of a felony under the laws of any state or of the United States, which would be a violation of section 12-200-109(1)(n), C.R.S. A guilty verdict, a plea of guilty or a plea of nolo contendere (no contest) accepted by the court is considered a conviction; B. A disciplinary action imposed upon the licensee by another jurisdiction that licenses acupuncturists, which would be a violation of section 12-200-109, C.R.S., including, but not limited to, a citation, sanction, probation, civil penalty, or a denial, suspension, revocation, or modification of a license whether it is imposed by consent decree, order, or other decision, for any cause other than failure to pay a license fee by the due date or failure to meet continuing professional education requirements;

C. Revocation or suspension by another state board, municipality, federal or state agency of any health services related license, other than a lapsed license for acupuncture as described in Section 12-200-109, C.R.S.;

D. Any judgment, award or settlement of a civil action or arbitration in which there was a final judgment or settlement against the licensee for malpractice of acupuncture. E. The notice to the Director shall include the following information; 1. If the event is an action by a governmental agency (as described above), the name of the agency, its jurisdiction, the case name, court docket, proceeding or case number by which the event is designated, and a copy of the consent decree, order or decision; 5 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure 2. If the event is a felony conviction, the court, its jurisdiction, the case name, the case number, a description of the matter or a copy of the indictment or charges, and any plea or verdict entered by the court. The licensee shall also provide to the Director a copy of the imposition of sentence or judgment, whether deferred or immediate, related to the felony conviction and the completion of all terms of the sentence or judgment with thirty (30) days of such action;

3. If the event concerns a civil action or arbitration proceeding, the court or arbiter, the jurisdiction, the case name, the case number, court docket, a description of the matter or a copy of the complaint, and a copy of the verdict, the court or arbitration decision, or, if settled, the settlement agreement and court’s order of dismissal; F. The licensee notifying the Director may submit a written statement with the notice to be included with the licensee records.

1.8 Exceptions and Director’s Review of Initial Decisions (Repealed) 1.9 Duty to Self-Report Certain Medical Conditions (Section 12-200-112, C.R.S.) A. No later than thirty days from the date a physical or mental illness or condition that affects a licensee’s ability to perform acupuncture services with reasonable skill and safety, the licensee shall provide the Director, in writing, the following information: 1. The diagnosis and a description of the illness or condition; 2. The date that the illness or condition was first diagnosed; 3. The name of the current treatment provider and documentation from the current treatment provider confirming the diagnosis, date of onset, and treatment plan; and 4. A description of the acupuncturist’s practice and any modifications, limitations or restrictions to that practice that have been made as a result of the illness or condition. B. The licensee shall notify the Director of any worsening of any worsening of the illness or condition, or any significant change in the illness or condition that affects the licensee’s ability to practice with reasonable skill and safety, within thirty days of the change of the illness or condition. The acupuncturist shall provide to the Director, in writing, the following information: 1. The name of the current treatment provider, documentation from the current treatment provider confirming the change of the illness or condition, the date that the illness or condition changed, the nature of the change of the illness or condition, and the current treatment plan; and 2. A description of the licensee’s practice, and any modifications, limitations, or restrictions to that practice that have been made as a result of the change of condition. C. Compliance with this Rule is a prerequisite for eligibility to enter into a Confidential Agreement with the Director pursuant to section 12-200-112(1), C.R.S. However, mere compliance with this rule does not require the Director to enter into a Confidential Agreement. Rather, the Director will evaluate all facts and circumstances to determine whether a Confidential Agreement is appropriate.

6 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure D. If the Director discovers that a licensee has a mental or physical illness or condition that affects the licensee’s ability to practice with reasonable skill and safety, and the licensee has not timely notified the Director of such illness or condition, the licensee may be subject to disciplinary action pursuant to section 12-200-109(1)(l), C.R.S.

1.10 Injection Therapy A. Definitions. For purposes of this Rule only:

1. The Director recognizes that “Injection therapy” is the stimulation of acupuncture points, including trigger points(historically known as “AHSHI” points), by the injection of saline, sterile herbs, vitamins, minerals, homeopathic substances, glucose, lidocaine, procaine, and sarapin, or other similar substances specifically manufactured for nonintravenous injection by means of hypodermic needles.

B. Except as restricted by paragraph (C) of this Rule, an acupuncturist with an active license may practice injection therapy in the treatment of patients in his or her care, C. Requirements to Practice Injection Therapy. The acupuncturist shall: 1. Possess a Colorado acupuncture license in good standing; 2. Hold a current Clean Needle Technique Certificate through the NCCAOM (or successor organization); and 3. Be current in basic life support (BLS) or cardiopulmonary resuscitation (CPR) approved by the American Heart Association or American Red Cross; 4. Complete educational coursework covered in subsection D. D. Acupuncturists employing injection therapy shall use only those substances and techniques for which they have received training. Required Educational Coursework shall include: 1. Anatomy and Physiology;

2. Acupuncture physical exam and differential diagnosis; 3. Acupuncture point location, including underlying anatomy; 4. Acupuncture needling technique;

5. General injection safety;

3. Acupuncture point injection therapy;

7. Pharmacology; and 8. Clean Needle Technique.

9. For the use of injectable substances prepared from oriental herbs, completion of training in Chinese herbology and injection of Chinese herbal injectables is required. To demonstrate satisfying the training requirements in Chinese herbology and injection of Chinese herbal injectables the Director will accept NCCAOM, or a successor organization’s, certification in Chinese herbology and/or certification in Oriental Medicine. 7 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure 10. For the use of substances listed in (E)(3)(a)(12-17), instruction on the use of inhaled O2 and IM epinephrine for emergency use is required.

E. Permissible Substances 1. An acupuncturist shall comply with all federal and state laws that pertain to obtaining, possessing and administering any drug;

2. A substance shall only be approved for use if procured in compliance with all federal and state laws;

3. The following drugs are authorized in the modes of administration that are specified except as limited or restricted by federal or state law: a. Permissible substances that an acupuncturist may obtain for injection therapy as permitted per section 12-200-103(4), C.R.S and as permitted by the Director: (1) Dextrose;

(2) d-glucose;

(3) Enzymes except urokinase;

(4) Glucose;

(4) Homeopathic Substances (to only include those that are within the US Pharmacopia);

(5) Hyaluronic Acid;

(6) Minerals;

(7) Saline;

(8) Sarapin;

(9) Sodium chloride;

(9) Sterile water;

(10) Traumeel;

(11) Vitamins;

(12) Cyanocobalamin;

(13) Lidocaine;

(14) Marcaine (Bupivacaine Hydrochloride) with or without epinephrine; (15) Oriental Herbs;

(16) Procaine; and (17) Vitamin B-12.

8 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure F. Patient safety.

1. Acupuncturists shall have an adverse event/emergency plan in place. 2. An acupuncturist practicing injection therapy of substances listed in (E)(3)(a)(12)-(17) shall be equipped and trained to treat patients with oxygen and epinephrine. The oxygen and emergency epinephrine kit shall be on site where injection therapy utilizing substances with potential allergic side effects are being rendered. 3. An acupuncturist authorized to practice injection therapy shall not inject any substance intravenously.

G. Acupuncturists shall show current medical malpractice coverage for this procedure and maintain coverage.

1. It is the acupuncturist’s responsibility to only inject substances that are listed in subsection E and are explicitly covered by the acupuncturist’s insurance policy obtained in compliance with section 12-200-106(6), C.R.S.

1.11 Concerning Health Care Provider Disclosures to Consumers about the Potential Effects of Receiving Emergency or Nonemergency Services from an Out-of-Network Provider This Rule is promulgated and adopted by the Director of the Division of Professions and Occupations (“Director”), pursuant to the rulemaking authority in sections 12-20-204, 12-200-114(1)(a), and 24-34- 113(3), C.R.S., in consultation with the Commissioner of Insurance and the State Board of Health under the authority of section 24-34-113(2), C.R.S.

The purpose of this Rule is to establish requirements for health care providers to provide disclosures to consumers about the potential effects of receiving emergency or non-emergency services from an out-of- network provider as required by section 24-34-113(2), C.R.S. This Rule applies to health care providers as defined in sections 24-34-113(1)(f) and 10-16-102(56), C.R.S.

A. Disclosure requirements. Pursuant to section 24-34-113, C.R.S., health care providers shall provide the disclosure contained in Appendix A to all clients about the potential effects of receiving emergency or nonemergency services from an out-of-network facility or agency or an out-of-network provider who provides services at an in-network facility or agency. The health care provider shall provide the disclosure contained in Appendix A at all of the following occasions: 1. For emergency services: after performing an appropriate screening examination and after determining that a client does not have an emergency medical condition or after treatment has been provided to stabilize an emergency medical condition. The disclosure shall be signed by the client or their designated representative prior to discharge; 2. At the time the client consents to care or treatment by the health care provider for nonemergency services. The disclosure shall be signed by the client or their designated representative before the start of services;

3. On billing statements and billing notices issued by the health care provider; and 4. On other forms or communications related to the services being provided pursuant to insurance coverage.

9 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure B. Noncompliance with this Rule may result in the imposition of any of discipline made available by sections 12-200-109(1)(i) and 12-200-110, C.R.S.

10 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure APPENDIX A Surprise Billing – Know Your Rights Beginning January 1, 2020, Colorado state law protects you* from “surprise billing,” also known as “balance billing.” These protections apply when:

• You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or • You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado What is surprise/balance billing, and when does it happen? If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing. When you CANNOT be balance-billed:

Emergency Services If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost- sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.

Nonemergency Services at an In-Network or Out-of-Network Health Care Provider The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider.

You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.

Additional Protections • Your insurer will pay out-of-network providers and facilities directly. • Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit. • Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.

• No one, including a provider, hospital, or insurer can ask you to limit or give up these rights. If you receive services from an out-of-network provider or facility or agency OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive nonemergency services from an out-of-network provider or facility, you may also be balance billed.

11 CODE OF COLORADO REGULATIONS 4 CCR 738-1 Office of Acupuncture Licensure If you want to file a complaint against your health care provider, you can submit an online complaint by visiting this website: https://www.colorado.gov/pacific/dora/DPO_File_Complaint. If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894- 7490 or 1-800-930-3745.

*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.

Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.

________________________________________________________________________ Editor’s Notes 4 CCR 738-2 through 4 CCR 738-6 were recodified as 4 CCR 738-1 Rules 2 through 6 effective 10/01/2009.

History Entire rule eff. 10/01/2009.

Entire rule eff. 01/01/2011.

Rule 1 eff. 11/14/2012.

Entire rule eff. 05/30/2016.

Rule 1.11, Appendix A emer. rules eff. 01/01/2020.

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