10 CCR 2505-10
DEPARTMENT OF HEALTH CARE POLICY AND FINANCING Medical Services Board MEDICAL ASSISTANCE - SECTION 8.200 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 DEFINITIONS
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. 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. Medically Necessary means a covered 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.
8.200.2 COVERED PHYSICIAN SERVICES
8.200.2.A. Physician services are authorized when the service is Medically Necessary, a benefit of Medicaid and provided by the appropriate physician specialty. 8.200.2.B. Physician services in regard to family planning are considered in the same manner as any other medical visit.
8.200.2.C. 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 fracture of the jaw or facial bones. Service includes dental splints or other devices. A provider of dental care surgery can either be enrolled as a dentist or oral surgeon, not both.
8.200.2.D. Physician services in regard to foot care are a benefit when provided by a physician or licensed podiatrist.
8.200.2.E. Physician services in regard to vision care are a benefit. 8.200.2.F. Physician services in regard to laboratory testing are a benefit in accordance with 10 C.C.R. 2505-10, Section 8.660.
8.200.2.G. Physician services in regard to the provision of immunizations are a benefit. Vaccines provided to enrolled children shall be obtained through the Colorado Department of Public Health and Environment.
8.200.2.H. Physician services in regard to mental health are a benefit. Outpatient individual and individual brief counseling visits are limited to 35 visits per state fiscal year.
8.200.3 QUALIFIED NON-PHYSICIAN PRACTITIONERS ELIGIBILE TO PROVIDE PHYSICIAN’S
SERVICES 8.200.3.A. A doctor of medicine or osteopathy shall order all medical care services or goods that are benefits of Section 8.200 except for dental, podiatry, optometric and mental health services. 8.200.3.B. The following requirements apply to non-physician practitioners rendering Medicaid services: Certified registered nurse anesthetists, certified nurse practitioners, certified occupational therapists, licensed physical therapists, certified audiologists, certified speech pathologists, licensed/certified respiratory therapists and licensed physician assistants may provide services under the following conditions:
1. Services shall be rendered under the General Supervision of a physician.
2. There is appropriate consultation between the non-physician personnel who administers the service. Continuing consultation is the responsibility of the physician. Periodic review of the client’s plan of care is required and shall be documented in the client’s record. Periodic review shall be at the level required by the medical necessity of the patient, no less than once every two months.
3. A physician may prescribe occupational or physical therapy for clients when Medically Necessary. Clients are allowed a set number of units of occupational and physical therapy without prior authorization as established by the Department. If a client requires additional therapy, the provider shall obtain prior authorization before rendering services. Services not properly prior authorized shall not be reimbursed. 8.200.3.C. Reimbursement for certified registered nurse anesthetists, certified pediatric nurse practitioners, certified occupational therapists, licensed physical therapists, certified family nurse practitioners, certified audiologists, certified speech pathologists and certified/licensed respiratory therapists shall be as follows:
1. Services rendered shall be reimbursed by the methodology described in Section 8.200.8.C.
2. Services shall be reimbursed directly to the non-physician provider unless the non-physician provider 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.
8.200.3.D. Services provided by licensed physician assistants shall be billed through an enrolled physician.
8.200.3.E. All other non-physician practitioners shall provide services under the Direct Supervision of a physician. Direct Supervision means the physician shall be on-site during the rendering of services and immediately available to give assistance and direction throughout the performance of the service.
1. Reimbursement for other non-physician practitioners shall be made as described in Section 8.200.8.A and billed to Medicaid by the enrolled physician.
2. Reimbursement shall not be made if the practitioner is acting within the scope of their graduate education training program or as contract agents or employees of a nursing home, hospital, FQHC, clinic, home heath agency, school or physician. 8.200.3.F. Supervision shall meet the specific requirements of the state laws governing each medical specialty when those supervision requirements are more stringent than the requirements contained in Section 8.200 et seq.
8.200.3.G. Licensure and required certification for non-physician providers shall be in accordance with their specific specialty practice act and with current state licensure statutes and regulations. 8.200.3.H. Certified nurse midwives shall work in coordination with a physician as described in their practice act. Reimbursements shall be made as described in Section 8.200.8.A. 8.200.3.I. Licensed dental hygienists shall be directly reimbursed for unsupervised dental hygiene services. Hygienists who serve enrolled children shall provide the child with the name of a licensed dentist. Hygienists employed by a dentist, clinic or institution shall submit claims under the employer’s provider number. Reimbursements shall be made as described in Section 8.200.8.E.
8.200.4 TELEMEDICINE
8.200.4.A. Telemedicine means the delivery of medical services and any diagnosis, consultation, treatment, transfer of medical data or education related to health care services using interactive audio, interactive video or interactive data communication instead of in-person contact. 8.200.4.B. No enrolled managed care organization may require face-to-face contact between a provider and a client for services appropriately provided through telemedicine if the client resides in a county with a population of 150,000 or fewer residents and the county has the technology necessary for the provision of telemedicine. The use of telemedicine is not required when in- person care by a participating provider is available to an enrolled client within a reasonable distance.
8.200.4.C. Any health benefits provided through telemedicine shall meet the same standard of care as in- person care.
8.200.5 MENTAL HEALTH
8.200.5.A. Services of licensed psychologists are a benefit. Services are not required to be under the direct supervision of a physician.
8.200.5.B. Psychology services shall be reimbursed under the same methodology as physician services described in Section 8.200.8.A.
8.200.5.C. Services ordered by a psychologist, but rendered by another provider shall be billed under the psychologist. The psychologist shall order the service and provide supervision as outlined under the Psychology Practice Act.
8.200.6 PHYSICAL EXAMINATIONS
8.200.6.A. Physical examinations are a benefit for annual preventative service, diagnosis and evaluation of disease or early and periodic screening, diagnosis and treatment as described in 10 C.C.R. 2505-10, Section 8.282. For the purpose of the adult annual preventive service benefit, annual shall mean state fiscal year.
8.200.7 CERTIFIED FAMILY PLANNING CLINICS
8.200.7.A. Laboratory services provided by Certified Family Planning Clinics shall be reimbursed if the laboratory has met all Clinical Laboratory Improvement Amendment requirements. 8.200.7.B. Services shall be rendered under the General Supervision of a physician. 8.200.7.C. The Certified Family Planning Clinic shall contact the client’s PCP or managed care organization if applicable prior to rendering services that require a referral. 8.200.7.D. Clinic services shall be reimbursed under the same methodology as physician services described in section 8.200.8.A and paid directly to the clinic.
8.200.8 REIMBURSEMENT
8.200.8.A. Physician services shall be reimbursed at the lower of the following:
1. Submitted charges; or 2. Fee schedule as determined by the Department.
8.200.8.B. Physician surgery shall be reimbursed at the lower of the following:
1. Submitted charges; or 2. Fee schedule as determined by the Department.
8.200.8.C. Non-physician practitioners consisting of certified nurse midwives, certified registered nurse anesthetists, certified nurse practitioners, certified audiologists, certified speech pathologists, licensed/certified respiratory therapists, and licensed physician assistants, services shall be reimbursed at the lower of the following:
1. Submitted charges; or 2. Fee schedule as determined by the Department.
8.200.8.D. Out patient clinical diagnostic laboratory tests preformed by a physician or independent lab shall be reimbursed at the lower of the following:
1. Submitted charges; or 2. Fee schedule as determined by the Department.
8.200.8.E. Dental services shall be reimbursed at the lower of:
1. Submitted charges; or 2. Fee schedule as determined by the Department.
8.201 TREATMENT OF ORAL MEDICAL CONDITIONS FOR ADULT CLIENTS
8.201.1 DEFINITIONS
Adult Client means an individual who is 21 years or older and eligible for medical assistance benefits. Condition of the Oral Cavity means a problem in the oral cavity requiring treatment. Concurrent Medical Condition means a pre-existing medically-diagnosed state that can be exacerbated by a condition present in the oral cavity.
Emergency Treatment means the need for immediate intervention by a physician, osteopath or dentist to stabilize an oral cavity condition.
Immediate Intervention or Treatment means services rendered within twelve (12) hours. Oral Cavity means the jaw, mouth or any structure contiguous to the jaw.
8.201.2 BENEFITS
8.201.2.A. Treatment of a Condition of the Oral Cavity for Adult Clients with a Concurrent Medical Condition is a benefit.
1. Allowable Concurrent Medical Conditions include:
8.201.2.B. Exclusions.
1. The following services/treatments are not a benefit for Adult Clients under any circumstances:
8.201.2.C. Emergency Treatment.
1. Emergency Treatment can be provided to an Adult Client who:
2. Emergency Treatment provided to an Adult Client includes, but is not limited to:
8.201.3 PRIOR AUTHORIZATION REQUEST
8.201.3.A. Prior authorization is required for treatment rendered for an Adult Client with a Concurrent Medical Condition.
1. Emergency Services do not require a prior authorization before services can be rendered.
2. All prior authorization requests shall include:
1. Enroll as a physician and bill according to all medical billing requirements including using Current Procedural Terminology (CPT) codes.
2. Enroll as a dentist and bill according to all dental billing requirements including using Current Dental Terminology (CDT) codes.
8.205 MEDICAID MANAGED CARE PROGRAM
8.205.1 CLIENT ELIGIBILITY
8.205.1.A. A Medicaid client may choose to enroll in any Medicaid Managed Care Program for which the client meets the eligibility criteria.
1. For the purposes of this rule, Medicaid Managed Care Programs include any Managed Care Organization (MCO), Primary Care Case Management program (PCCM), or any Prepaid Inpatient Health Plan (PIHP) that is not a part of the Community Mental Health Services Program.
2. Rules for the Community Mental Health Services program PIHPs are located in Section 8.212 of these rules, "Community Mental Health Services."
8.205.1.B. A Medicaid client who receives limited benefits and is not otherwise eligible for Medicaid, is not eligible to receive services through a Medicaid Managed Care Program.
8.205.2 CLIENT RESPONSIBILITIES
8.205.2.A. A client in a PCCM program agrees to comply with the following responsibilities:
1. Select a primary care provider from those participating in the PCCM program.
2. Obtain a referral from his/her primary care provider for care that requires a referral according to the program guidance, when the care is provided by anyone other than his/her primary care provider.
3. Request any change of primary care provider from the Department or its designee.
4. Pay for any services received which are not Medicaid covered services.
5. Notify the primary care provider of any third party insurance, including Medicare. 8.205.2.B. A client in an MCO or PIHP agrees to comply with the following responsibilities:
1. Select a primary care provider from those providers available in the MCO or PIHP.
2. Follow all requirements of the Medicaid managed care program as described in the Member Handbook for the MCO or PIHP.
3. Obtain a referral from his/her primary care provider for specialty care as required by the MCO or PIHP.
4. Follow MCO’s or PIHP’s procedures for complaints and grievances.
5. Request any change of primary care provider from the MCO or PIHP.
6. Pay for any services received which are not Medicaid covered services.
7. Notify the Managed Care Organization of any third party insurance, including Medicare.
8.205.3 CLIENT RIGHTS AND PROTECTIONS
8.205.3.A. A client enrolled in a PCCM, MCO, or PIHP has the following rights and protections:
1. To be treated with respect and with due consideration for his/her dignity and privacy.
2. To receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee's condition and ability to understand.
3. To participate in decisions regarding his/her health care, including the right to refuse treatment and the right to a second opinion.
4. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
5. To obtain family planning services directly from any provider duly licensed or certified to provide such services without regard to enrollment in a PCCM, MCO, or PIHP, without referral.
6. To request and receive a copy of his/her medical records and to request that they be amended or corrected, as specified in 45. CFR Part 164.
7. To exercise his/her rights without any adverse effect on the way he/she is treated.
8.205.4 CLIENT ENROLLMENT AND DISENROLLMENT
8.205.4.A. Enrollment in a PCCM, MCO, or PIHP is voluntary, except for the following:
1. Clients in the Adults without Dependent Children eligibility category are mandatorily enrolled into the Accountable Care Collaborative program.
8.205.4.B. Members who are disenrolled from a PCCM, 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.C. A client who is enrolled with a PCCM, MCO, or PIHP remains assigned to that PCCM, MCO, or PIHP for a period of twelve (12) months except as otherwise provided in these rules. 8.205.4.D. A client who is not subject to mandatory enrollment may request disenrollment from their PCCM, MCO, or PIHP 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.E. A client who is not subject to mandatory enrollment may request disenrollment without cause at least every twelve (12) months after the date of initial enrollment with a PCCM, MCO, or PIHP.
1. A client who is not subject to mandatory enrollment may request disenrollment within 30 days of automatic enrollment into a PCC, MCO, or PIHP if the client was ineligible during the annual disenrollment opportunity and was automatically enrolled after becoming eligible for Medicaid again.
8.205.4.F. A client may request disenrollment when the Department imposes intermediate sanctions as set forth in the Department's contract with the PCCM, MCO, or PIHP. 8.205.4.G. A client who is not subject to mandatory enrollment may request disenrollment for cause at any time. Cause shall be defined as any of the following:
1. The client moves out of the PCCM, MCO, or PIHP service area.
2. The plan or program does not, because of moral or religious objections, cover the service the client needs.
3. The client needs related services to be performed at the same time and not all related services are available within the plan or program network, and the client's provider determines that receiving the services separately would subject the client to unnecessary risk.
4. The Department or its designee unintentionally enrolls a client into the wrong plan.
5. Poor quality of care, as documented by the Department.
6. Lack of access to covered services, as documented by the Department.
7. Lack of access to providers experienced in dealing with the client's health care needs, as documented by the Department.
8. The client's primary care provider leaves the PCCM, MCO, or PIHP.
9. Other reasons satisfactory to the Department.
8.205.4.H A client who is subject to mandatory enrollment may request to be exempt from enrollment, or request to be disenrolled from the program if:
1. The client does not have access to a primary care provider contracted with the program.
2. There is poor quality of care, as documented by the Department, and there is no access to another primary care provider contracted with the program.
3. The client and the program have been unable to develop a healthy working relationship and continued best clinical interest of the client.
4. The Department, at its discretion, decides that it would meet the considerations of equity to do so.
8.205.4.I. For clients who are unable to make decisions for themselves, a family member, legal guardian or designated advocate shall be included in all decision-making concerning enrollment and disenrollment of the client.
8.205.4.J. Primary care providers participating in a PCCM, MCO, or PIHP may dismiss an enrolled client from their practice for cause at any time. The primary care provider shall give no less than 45 days notice to both the Department and the client Cause shall be defined as any of the following:
1. The client misses multiple scheduled appointments.
2. The client fails to follow the recommended treatment plan or medical instructions.
3. The primary care provider cannot provide the level of care necessary to meet the client's needs.
4. The client and /or client's family is abusive to provider and/or staff in compliance with 42 CFR 438.56(a)(2).
5. The provider moves out of the service area.
6. Other reasons satisfactory to the Department.
8.205.5 ESSENTIAL COMMUNITY PROVIDERS
8.205.5.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:
1. Disproportionate share hospitals.
2. Local county and district health departments, county nursing services and regional health department operating pursuant to Title 25, C.R.S., as amended.
3. Federally Qualified Health Centers (FQHCs).
4. 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.
5. Family Medicine Residency Training Programs that can verify that 25 % of the patients served are at or below 185% of the Federal Poverty Level.
6. Rural Health Clinics that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
7. 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.
8. 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.
9. New health care providers operating under a sponsoring or participating entity that qualifies as an Essential Community Provider.
10. 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 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.
8.205.7 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.
8.205.8 QUALIFIED PHARMACY PROVIDERS
8.205.8.A. A Managed Care Organization shall contract with qualified pharmacy providers in a manner permitting a nursing facility to continue to comply with federal Medicaid requirements of participation.
8.205.8.B. A qualified pharmacy provider shall meet all of the following requirements:
1. Employ, on a full-time basis, a pharmacist licensed by the State of Colorado.
2. Demonstrate a capability of procuring, preparing, dispensing and distributing pharmaceutical products in an institutional setting.
3. Demonstrate a capability of monitoring clients 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.
4. Provide pharmaceutical consulting services twenty-four (24) hours per day.
5. 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 client-centered, ensuring that the client's medication regimen meets his or her needs.
6. Participate with the client's physicians, nurses, dieticians and other health care professionals in inter-disciplinary care planning.
7. Provide continuous pharmaceutical care and services to clients twenty-four (24) hours per day every day.
8. Reasonably respond to emergency situations and maintain an emergency kit registered with
9. Utilize appropriate unit dose or unit of issue distribution systems to ensure that clients receive proper medications, at the proper time, and at the proper dosage.
10. Demonstrate its capability to provide physician orders and medication administration records on a monthly basis.
8.205.9 PERSONS WITH SPECIAL HEALTH CARE NEEDS
8.205.9.A. Persons with Special Health Care Needs shall mean persons having ongoing health conditions that 1. Have a biologic, psychologic or cognitive basis;
2. Have lasted or are virtually certain to last for at least one year; and 3. Produce one or more of the following sequelae:
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) 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 or Prepaid Inpatient Health Plan (PIHP) level and access to the State fair hearing process for appeals.
8.209.2 DEFINITIONS
Action shall mean:
1. The denial or limited authorization of a requested service, including the type or level of service;
2. The reduction, suspension or termination of a previously authorized service;
3. The denial, in whole or in part, of payment for a service;
4. The failure to provide services in a timely manner;
5. The failure to act within the timeframes provided below; or 6. 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.
Appeal shall mean a request for review of an action.
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. Fair Hearing shall mean the formal adjudication process for appeals described at 10 CCR 2505- 10, §8.057.
Grievance shall mean an oral or written expression of dissatisfaction about any matter other than an action, 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.
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. Quality of Care Complaint shall mean any grievance made in regards to the professional competence and/or conduct of a physician or other health care provider, which could adversely affect the health, or welfare of a member.
Timely Filing shall mean filing on or before the later of the following: within ten days of the MCO or PIHP postmarking the notice of action; or the intended effective date of the MCO’s or PIHP’s proposed action.
8.209.3 GRIEVANCE SYSTEM
8.209.3.A. The Grievance System is the overall system that includes grievances and appeals handled at the MCO and PIHP level and access to the State fair hearing process for appeals. 8.209.3.B. The MCO or PIHP shall provide a Department approved description of the grievance, appeal and fair hearing procedures and timeframes to all providers and subcontractors at the time the provider or subcontractor enters into a contract with the MCO or PIHP. The description shall include:
1. The member’s right to a State fair hearing for appeals.
2. The member’s right to file grievances and appeals.
3. The requirements and timeframes for filing grievances and appeals.
4. The availability of assistance in the filing process.
5. The toll-free numbers that the member can use to file a grievance or an appeal by telephone.
6. The fact that, when requested by a member:
8.209.4 APPEAL PROCESS
8.209.4.A. Notice of Action 1. The MCO or PIHP shall send the member written notice for each action. 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.
2. The notice shall state the following:
3. The MCO or PIHP shall mail the notice of action within the following timeframes:
8.209.4.B. The member of an MCO or PIHP shall file an appeal within thirty (30) calendar days from the date of the MCO’s or PIHP’s notice of action.
8.209.4.C. The MCO or PIHP shall give members reasonable assistance in completing any forms required by the MCO or PIHP, 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 or PIHP 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 or PIHP 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 and who have the appropriate clinical expertise 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 appeals that involves clinical issues.
8.209.4.F The MCO or PIHP shall accept appeals orally or in writing, and shall follow an oral appeal with a written appeal.
8.209.4.G The MCO or PIHP shall provide the member a reasonable opportunity to present evidence, and allegations of fact or law, in person as well as in writing. The MCO or PIHP shall inform the member of the limited time available in the case of expedited resolution. 8.209.4.H The MCO or PIHP 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 or PIHP 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 or PIHP shall resolve each appeal, and provide notice as expeditiously as the member’s health condition requires, not to exceed the following:
1. For standard resolution of an appeal and notice to the affected parties, ten (10) working days from the day the MCO or PIHP receives the appeal.
2. For expedited resolution of an appeal and notice to affected parties, three (3) working days after the MCO or PIHP receives the appeal.
8.209.4.K. The MCO or PIHP may extend timeframes for the resolution of appeals by up to fourteen (14) calendar days:
1. If the member requests the extension; or 2. The MCO or PIHP shows that there is a need for additional information and that the delay is in the member’s best interest. The MCO or PIHP shall give the member prior written notice of the reason for delay if the timeframe is extended.
8.209.4.L. The MCO or PIHP shall notify the member in writing of the resolution of an appeal. For notice of an expedited resolution, the MCO or PIHP 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.
1. For appeals not resolved wholly in favor of the member,
8.209.4.N. The member of an MCO or PIHP need not exhaust the MCO or PIHP level appeal process before requesting a state fair hearing. The member shall request a state fair hearing within thirty (30) calendars days from the date of the MCO’s or PIHP’s notice of action. 8.209.4.O. In cases where the parent or guardian submits a request for a third party review to the Department of Human Services under 27-10.3-104 (1)(b) 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 recipient appeal. 8.209.4.P. The MCO or PIHP shall establish and maintain an expedited review process for appeals when the MCO or PIHP 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.Q. The MCO or PIHP shall ensure that punitive action is not taken against a provider who requests an expedited resolution or supports a member’s appeal. 8.209.4.R. If the MCO or PIHP 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.
8.209.4.S. The MCO or PIHP shall provide for the continuation of benefits while the MCO or PIHP level appeal and the State fair hearing are pending if the member files the appeal timely, 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 the member requests extension of benefits. 8.209.4.T. If at the member’s request, the MCO or PIHP continues or reinstates the member’s benefits while the appeal is pending, the benefits shall be continued until the member withdraws the appeal, ten days pass after the MCO or PIHP mails the notice providing the resolution of the appeal against the member, a State fair hearing office issues a final agency decision adverse to the member, or the time period or service limits of a previously authorized service has been met. 8.209.4.U. If the final resolution of the appeal upholds the MCO’s or PIHP’s action, the MCO or PIHP 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.V. If the final resolution of the appeal reverses the MCO's or PIHP's action to deny, limit or delay services that were not furnished while the appeal was pending, the MCO or PIHP shall authorize or provide the disputed services promptly and as expeditiously as the member’s health condition requires.
8.209.4.W. If the final resolution of the appeal reverses the MCO's or PIHP's action to deny authorization of services and the member received the services while the appeal was pending, the MCO or PIHP must pay for those services.
8.209.5 GRIEVANCE PROCESS
8.209.5.A The member of the MCO or PIHP shall have thirty (30) calendar days from the date of the incident to file a grievance expressing his/her dissatisfaction with any matter other than an action. 8.209.B. The MCO or PIHP shall send the member written acknowledgement of each grievance within two (2) working days of receipt.
8.209.5.C. The MCO or PIHP 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 and who have the appropriate clinical expertise in treating the member’s condition or disease if deciding a grievance that involves clinical issues.
8.209.5.D. The MCO or PIHP shall accept grievances orally or in writing.
1. The MCO or PIHP shall dispose of each grievance and provide notice as expeditiously as the member’s health condition requires, not to exceed fifteen (15) working days from the day the MCO or PIHP receives the grievance.
8.209.5.E. The MCO or PIHP may extend timeframes for the disposition of grievances by up to fourteen (14) calendar days:
1. If the member requests the extension; or 2. The MCO or PIHP shows that there is a need for additional information and that the delay is in the member’s best interest. The MCO or PIHP shall give the member prior written notice of the reason for delay if the timeframe is extended.
8.209.5.F. The MCO or PIHP shall notify the member in writing of the disposition of a grievance. 8.209.5.G. The written notice shall include the results of the disposition/resolution process and the date it was completed.
8.209.5.H. If the member is dissatisfied with the disposition of a grievance provided by the MCO or PHIP, the member may bring the unresolved grievance to the Department.
1. The Department will acknowledge receipt of the grievance and dispose of the issue.
2. The disposition offered by the Department will be final.
8.209.6 OMBUDSMAN ASSISTANCE CONCERNING SERVICES FOR CLIENTS ENROLLED IN
MANAGED CARE ORGANIZATIONS A. An Ombudsman under contract with the Department of Health Care Policy and Financing shall provide Ombudsman assistance concerning services for clients enrolled in Medicaid managed care organizations (MCOs).
B. Upon request, the Ombudsman shall respond to and analyze a complaint from a client enrolled in a Medicaid managed care organization (MCO), or that client’s designated client representative (DCR), by:
1. Assisting the client or DCR to articulate the complaint, to understand the options available to resolve the complaint and his/her rights and responsibilities, and to negotiate the appropriate complaint process for his/her MCO;
2. Acting as the client’s DCR if the client requests except that the Ombudsman shall not act as the DCR in any State fair hearing as described at 10 CCR 2505-10, §8.057;
3. Facilitating problem resolution with the MCO or its network providers;
4. Referring clients to other agencies as appropriate, including agencies that can directly assist clients in a State fair hearing;
5. Conducting and reporting client satisfaction studies and/or quality assessment surveys authorized by the Department to measure client experience and satisfaction with Ombudsman staff and services;
6. Providing clients with information on the exclusions and limitations that may be imposed on care, services, equipment and supplies under the Medicaid benefits structure;
7. 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 AND THE OMBUDSMAN
A. MCOs and the Ombudsman shall recognize and ensure clients’ rights to make and file complaints and to appeal adverse determinations through the complaint and appeal process for any reason.
B. For clients with a disability, if the medical necessity of a requested procedure has not been established by the MCO, 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 client/DCR’s choice shall be consulted. Such consultation shall be referenced in the notice. If the requesting physician is not available and the client/DCR does not choose another network provider within two working days of the MCO’s request to make such a choice, the MCO may proceed without consultation.
C. MCOs and the Ombudsman shall develop written procedures for accepting, processing, and responding to all complaints from Medicaid clients. For MCOs, 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 shall provide its complete complaint and appeal procedures to subcontractors and ensure subcontractor compliance with these rules and the MCO’s procedures. MCOs and the Ombudsman shall obtain written approval from the Department for their internal Complaint procedures.
D. MCOs and the Ombudsman shall establish and maintain a timely and organized system(s) for recording, tracking, and resolving Medicaid clients’ complaints and appeals as specified in contract.
E. MCOs and the Ombudsman shall confidentially maintain original records of all Complaints from Medicaid clients, including the original Complaint, action, or resolution taken by the entity, and evidence of review activities. All such information shall be archived for six (6) years from the date of the initial Complaint.
F. MCOs shall ensure that neither cultural, expressive, or receptive communication differences negatively impact the Complaint process. MCOs shall provide services to facilitate clients’ and DCRs’ effective use of the Complaint process, inclusive of qualified interpreters for (1) persons with communication disabilities or differences and (2) non-English-speaking clients. The MCO shall consult with the client or the DCR about the individual or medium that will assist, and such assistance shall be at the cost of the MCO.
G. MCOs shall provide the client, DCR, or any other person, upon written release from the client or the client's legal guardian, access to or a copy of medical records, at no cost to the client, for dates of service occurring during enrollment in the MCO. Such records shall be provided within a time frame that provides clients copies of their records prior to any decision on a Complaint or appeal, or in two weeks or less, if required by C.R.S. § § 25-1-801 and 25-1-802. The MCO is only obligated to provide one copy of the client's medical records free of charge for each of the Medicaid client's Complaints.
H. MCOs shall monitor participating network subcontractors or providers to ensure compliance with all Complaint rules and contract requirements.
I. MCOs and the Ombudsman shall handle specific Medicaid client Complaint information in the same way that medical record information is handled confidentially under State and Federal law and regulations.
J. Upon request by a client, the client's DCR, or the client's provider, the MCO 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.
K. To assist clients in making inquiries and filing Complaints, MCOs and the Ombudsman shall ensure that clients and DCRs can contact them during routine business hours through a toll-free telephone number.
8.212 COMMUNITY MENTAL HEALTH SERVICES
8.212.1 ENROLLMENT
8.212.1.A. The following individuals are not eligible for enrollment in the Community Mental Health Services program:
1. Qualified Medicare Beneficiary only (QMB-only).
2. Qualified Working Disabled Individuals (QWDI).
3. Qualified Individuals 1 (QI 1).
4. Special Low Income Medicare Beneficiaries (SLMB).
5. Undocumented aliens, including non-qualified, undocumented and qualified aliens who have not met the five-year bar who are eligible for Federal Medicaid for care and services related to the treatment of an approved medical condition.
6. Program of All-Inclusive Care for the Elderly (PACE).
7. Individuals who are inpatient at the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan who are:
8. Individuals between ages 21 and 64 who receive inpatient treatment who are inpatient at the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan.
9. Individuals who are NGRI and who are in the community on Temporary Physical Removal
10. Classes of individuals determined by the Department to require exclusion from the Community Mental Health Services program, defined as individuals residing in State Regional Centers for people with developmental disabilities and associated satellite residences for more than 90 days.
11. Individuals who receive an individual exemption as set forth at 8.212.2.
12. Individuals while determined presumptively eligible for Medicaid.
13. Children or youth in the custody of the Colorado Department of Human Services -Division of Child Welfare or Division of Youth Corrections who are placed by those agencies in a Psychiatric Residential Treatment Facility (PRTF) as defined in C.R.S. 25.5-4-103 or a Residential Child Care Facility (RCCF) as defined in C.R.S. 26-6-102. 8.212.1.B. All other Medicaid clients shall be enrolled in the Community Mental Health Services program, into a behavioral health organization in the client’s geographic area.
1. The Department automatically re-enrolls a client into the same behavioral health organization if there is a loss of Medicaid eligibility of two months or less.
8.212.2 INDIVIDUAL EXEMPTIONS
8.212.2.A. A client may request to be exempt from enrollment in the Community Mental Health Services program if:
1. The client has a clinical relationship with a provider of mental health services that the client wishes to maintain and that provider is not part of the provider network of the behavioral health organization in the client’s geographic area; or 2. The client and the behavioral health organization have been unable to develop a healthy working relationship and continued enrollment would not be in the best clinical interest of the client.
8.212.2.B. If the client requests an exemption because the client’s existing provider is not in the provider network, based on Section 8.212.2.A.1:
1. The client shall notify the behavioral health organization of his/her request to receive necessary mental health services from the provider with whom the client has established a clinical relationship.
2. Within fourteen (14) calendar days of receiving notice from the client, the behavioral health organization shall determine whether it can contract with the client’s chosen provider to provide necessary mental health services to the client and provide written notice to the client and the client’s provider of that determination.
3. If the behavioral health organization is unable to approve the client’s request, the notice shall:
4. The client may request an exemption with the Department within fourteen (14) calendar days of the date of the notice from the behavioral health organization disapproving the client’s request.
5. Within thirty (30) calendar days after receipt of the client’s request for exemption, the Department shall provide written notice of its determination to the client, the client’s provider and the behavioral health organization.
8.212.2.C. If the client requests an exemption because continued enrollment would not be in the best clinical interest of the client, based on Section 8.212.2.A.2:
1. The client shall request an exemption from the Department.
2. Within thirty (30) calendar days after receipt of the client’s request for exemption, the Department shall provide written notice of its determination to the client, the client’s provider and the behavioral health organization.
8.212.2.D. A client whose request for exemption has been denied by the Department has the right to appeal the determination pursuant to Section 8.057.
8.212.2.E. A newly Medicaid eligible client who requests an exemption shall be enrolled in the Community Mental Health Services program pending the outcome of the request for exemption and any appeal pursuant to Section 8.057.
8.212.2.F. A client who is enrolled in the Community Mental Health Services program and is requesting an exemption shall continue to be enrolled in the Community Mental Health Services program pending the outcome of the request for exemption and any appeal pursuant to Section 8.057. 8.212.2.G. A client who wants to reenroll in the Community Mental Health Services program shall notify the Department. The client will be reenrolled within thirty (30) calendar days of receipt of the client’s request. The Department shall notify the client and the behavioral health organization of the reenrollment prior to the effective date of reenrollment. 8.212.2.H. A client who has been exempted from enrollment in the Community Mental Health Services program because the program was not in the best clinical interest of the client, as described in Section 8.212.2.A.2, may be re-enrolled by the Department into the Community Mental Health Services program after a period of exemption, if the client demonstrates a clear need for a behavioral health organization to manage his or her mental health care.
1. The Department shall notify the client and the behavioral health organization of the re- enrollment at least ten (10) calendar days prior to the effective date of re-enrollment.
8.212.3 CLIENT RIGHTS AND PROTECTIONS
8.212.3.A. A client enrolled in the Community Mental Health Services program shall have the following rights and protections:
1. To be treated with respect and with due consideration for his/her dignity and privacy.
2. To receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand.
3. To participate in decisions regarding his/her health care, including the right to refuse treatment and the right to a second opinion.
4. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
5. To request and receive a copy of his/her medical records and to request that they be amended or corrected, as specified in 45 CFR Part 164.
6. To exercise his/her rights without any adverse effect on the way he/she is treated.
7. To enforce, pursuant to Section 8.209, the provisions of the community mental health services contracting regarding rights or duties owed to the client under the contract.
8.212.4 MENTAL HEALTH SERVICES
8.212.4.A. The following are required services of the Community Mental Health Services program:
1. Inpatient Hospital -- A program of psychiatric care in which the client remains 24 hours a day in a facility licensed as a hospital by the State. This service is limited to forty-five (45) days per State fiscal year, except as otherwise required by EPSDT as described in 10 C.C.R. 2505-10, Section 8.282.
2. Under 21 Psychiatric -- A program of care for clients under age 21 in which the client remains 24 hours a day in a psychiatric hospital, or other facility licensed as a hospital by the State. This service is limited to forty-five (45) days per State fiscal year, except as otherwise required by EPSDT as described in 10 C.C.R. 2505-10, Section 8.282.
3. 65 and Over Psychiatric -- A program of care for clients age 65 and over in which the client remains 24 hours a day in an institution for mental diseases, or other facility licensed as a hospital by the State. This service is limited to forty-five (45) days per State fiscal year.
4. Outpatient -- A program of care in which the client receives services in a hospital or other health care facility, but does not remain in the facility 24 hours a day, including:
5. Physician services, including psychiatric care – Services provided within the scope of practice of medicine as defined by State law.
6. 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 mental/emotional disability and restoration of a client to his/her best possible functional level, including:
7. Pharmacy Services – Prescribed drugs when used in accordance with 10 CCR 2505-10 Section 8.800, Pharmaceuticals.
8. Case Management - Medically necessary case management services provided in a licensed community mental health center or clinic by a licensed/qualified non-physician practitioner or physician.
9. School-Based Mental Health Services - Mental health services provided to school aged children and adolescents on site in their schools, with the cooperation of the schools. 8.212.4.B. Alternative services of the Community Mental Health Services program are:
1. 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.
2. Assertive Community Treatment (ACT) – Comprehensive, locally-based, individualized treatment for adults with serious mental illness, that is available 24 hours a day, 365 days a year. Services include case management, initial and ongoing mental health assessment, psychiatric services, employment and housing assistance, family support and education, and substance abuse services for individuals with co-occurring diagnoses of substance abuse and mental illness.
3. Intensive Case Management -- Community-based services averaging more than one hour per week, provided to adults with serious mental illness 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 EPSDT.
4. Clubhouse and drop-in center services – Peer support services for people who have mental illness, 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.
5. Recovery Services – Community-based services that promote self-management of psychiatric 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.
6. Residential Services – Twenty-four (24) hour care, excluding room and board, provided in a non-hospital, non-nursing home setting, appropriate for adults 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.
7. Prevention/Early Intervention Services – Proactive efforts to educate and empower individuals to choose and maintain health life behaviors and lifestyles that promote mental health. Services include mental health screenings; educational programs promoting safe and stable families; senior workshops related to common aging disorders; and parenting skills classes.
8. 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 client normally resides with. Respite is designed to give the caregivers some time away from the client 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 mental health issues.
8.212.5 EMERGENCY SERVICES
8.212.5.A. A client enrolled in the Community Mental Health Services program shall seek all mental health services from the behavioral health organization with which he/she is enrolled except as specified in 8.212.5.B.
8.212.5.B. Clients with an emergency medical condition may seek emergency services outside of the network of the behavioral health organization in which they are enrolled. 8.212.5.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 mental health services to result in the following:
1. 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.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
8.212.5.D. Emergency services means covered inpatient and outpatient services that are as follows:
1. Furnished by a provider that is qualified to furnish these services.
2. Needed to evaluate or stabilize an emergency medical condition.
8.212.6 ESSENTIAL COMMUNITY PROVIDERS
8.212.6.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:
1. Disproportionate share hospitals.
2. Local county and district health departments, county nursing services and regional health department operating pursuant to Title 25, C.R.S., as amended.
3. Federally Qualified Health Centers (FQHCs).
4. 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.
5. Family Medicine Residency Training Programs that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
6. Rural Health Clinics that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
7. 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.
8. 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.
9. New health care providers operating under a sponsoring or participating entity that qualifies as an Essential Community Provider.
10. Health care providers that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
8.212.6.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.
8.212.6.C. Health care providers, except those set forth a 8.212.6.A(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.
8.215 COMMUNITY MENTAL HEALTH SERVICES PROGRAM CAPITATION RATE SETTING
8.215.1 DEFINITIONS
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.
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.
Behavioral health organization – the managed care entity contracting with the Department to provide behavioral health services to Medicaid eligible individuals on a risk contracting basis. Enrollee – A person who is eligible for mental health services provided for in 10 CCR 2505-10 Section 8.212.4 from a behavioral health organization under a risk contract with the Department. 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 behavioral health organization during the rate setting or rate effective periods.
8.215.2 LEGAL BASIS
The Medicaid community mental health services program is authorized by state law at 25.5-5-411, C.R.S. (2009)
8.215.3 GENERAL PROVISIONS
8.215.3.A. The Department shall make prepaid capitation payments based on actuarially certified rates to behavioral health organizations based upon a scope of services defined in the behavioral health organization 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 behavioral health organizations 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:
1. Relevant to the expected or reasonable use of services by the behavioral health organization’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:
1. Shall be consistent with the principles of actuarial soundness.
2. May be based upon the Medicaid fee-for-service payment for like services, provider costs, behavioral health organization 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.
8.215.4 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.
1. 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.
2. Notwithstanding the above, the independent actuary is encouraged to adopt stakeholder feedback when, after consultation with the Department, 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 behavioral health organizations, the behavioral health organization shall provide a certification that the data supplied by the behavioral health organization to the Department are accurate, truthful and represent costs and utilization solely for services covered under the behavioral health organization contract for Medicaid eligible enrollees of that behavioral health organization. 8.215.5.B. In accordance with 25.5-5-404 (k) and prior to entering into a contract with the Department, the behavioral health organization shall certify that the rates set forth in the contract are sufficient to assure the financial stability of the behavioral health organization. 8.215.5.C. In accordance with 25.5-5-404 (l) and prior to entering into a contract with the Department, the behavioral health organization shall retain an actuary to certify that the capitation rates set forth in the contract between the behavioral health organization 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 community mental health services 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:
1. Limiting costs and data considered in rate setting to that reasonable based upon enrollees’ need for services within the scope of services in the behavioral health organizations’ contracts.
2. 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 BHOs an incentive for efficiency relative to peers.
3. Requiring that behavioral health organizations maintain medical loss ratios in excess of 77% of total Medicaid capitations. Medical loss ratios of less than 77% shall result in a refund due the Department in the amount the medical loss is less than that threshold. 8.215.6.D. The Department may, upon consultation and feedback from the behavioral health organizations and the stakeholder community, implement other cost containment mechanisms that it finds necessary to constrain rate growth to a level that is sustainable and appropriate.
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
The Colorado Department of Health Care Policy and Financing (the State) may enter into contracts to provide a range of health care benefits identified in the State Plan to persons determined eligible for medical care under Title XIX of the Social Security Act (Medicaid). The Department under provisions of State and Federal law and regulation, and contingent upon Federal waiver(s), may elect to competitively procure and/or selectively contract for organ and other transplant services.
A. Transplant Services 1. The Department, after consultation with affected groups, may issue Requests for Proposals from providers to contract with the State for the provision of certain organ transplants and related services. A limited number of contracts may be executed with providers whose proposals demonstrate that they are qualified to provide adequate access to quality services, and whose price proposals are most advantageous to the State.
2. Effective on or after July 1, 1995 the Department may contract with selected providers under a global fee arrangement for transplant services related to heart, lung, liver, kidney, and bone marrow transplants. Under these contracts providers will receive a single payment for all services related to the transplant procedure, and a monthly case management fee as the Primary Care Physician for six months following the transplant. The following services are included under the global transplant payment:
3. The method of payment to be used for transplants under this program will be an inclusive rate per discharge.
4. All transplant services will be prior authorized as described in 8.317.
5. All transplant services will be subject to Quality Assurance review by the Peer Review Organization as described at 8.312.12., and as required under provisions of the Federal waiver and/or specific contract provisions of the competitively procured transplant program.
8.280 EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT [Eff. 10/01/2007]
8.280.1 DEFINITIONS
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) means the child health component of Medicaid.
Early and Periodic Screening, Diagnosis and Treatment 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.
Medical necessity means that a covered service shall be deemed a medical necessity or medically necessary if, in a manner consistent with accepted standards of medical practice, it:
1. Is found to be an equally effective treatment among other less conservative or more costly treatment options, and 2. Meets at least one of the following criteria:
8.280.2 EPSDT ELIGIBILITY
A child or youth age 20 and under enrolled in Medicaid is eligible for EPSDT services.
8.280.3 EPSDT OUTREACH AND CASE MANAGEMENT
8.280.3.A. EPSDT Outreach and Case Management entities shall provide 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:
1. Information about EPSDT services and how to access them.
2. Education on the importance of preventive health care.
3. 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.
4. Assistance with coordinating primary health coverage with Medicaid benefits.
5. Assistance in arranging appointments with providers.
6. Follow-up when an appointment is not kept including efforts to assist with rescheduling the missed appointment.
7. Assistance with reporting newborns to the local department of human/social services.
8. A current list of covered and uncovered services available in the community.
9. Information regarding non-emergency medical transportation if such assistance is required and approved.
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.
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 periodicity schedules.
2. 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.
3. The components of a screen shall include:
4. 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.
5. 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.
2. 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. Other health care services Other health care services may include expanded EPSDT benefits if the need for such services is identified during a periodic screening or inter-periodic exam. The services are a benefit when they meet the following requirements:
1. The service is in accordance with generally accepted standards of medical practice.
2. The service is clinically appropriate in terms of type, frequency, extent, and duration.
3. The service provides a safe environment or situation for the child.
4. The service is not for the convenience of the caregiver.
5. The service is medically necessary.
6. The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
7. The service is the least costly, effective means.
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. Determination of the refractive state only is allowable as a partial vision screening. The code shall not be billed with general ophthalmologic examinations or other evaluation and management codes. Separate or “stand-alone” charges for refractions are not billable to clients as non-benefit services.
8.280.5.E. Eyeglasses are a benefit only when ordered by an ophthalmologist or an optometrist. Vision benefits are limited to single or multi-focal clear plastic lenses and one standard frame. Repair of eyeglasses is covered only when due to broken frames or lenses. Replacement glasses shall be provided when medically necessary or when the glasses are damaged to the extent that repairs are not cost effective.
1. If a child, parent or legal guardian desires options that have additional costs, the amount reimbursed for standard frames and clear lenses shall be applied to the total cost of these services. This shall also apply to repair or replacement of broken eyeglasses. The EPSDT provider shall be permitted to charge the child for the difference between the retail price of the service and the amount paid by the Department. Providers shall notify the child and the child’s parent or legal guardian or the child’s designated client representative in writing of the difference and obtain the signature of the child’s parent or guardian or designated client representative indicating agreement to pay the additional costs.
2. Contact lenses or orthoptic vision treatment services shall be a benefit when medically necessary and shall require prior authorization submitted by an Ophthalmologist, Optometrist, or Optician.
3. 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 services.
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 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. 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 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 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 Education-recognized 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:
1. Enrolled in Medicaid, 2. Enrolled with a Participating District;
3. Under the age of 21;
4. Has a Disability or is Medically at Risk; and 5. Receives a referral for School Health Services according to an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP).
8.290.3 PARTICIPATING DISTRICTS
8.290.3.A. Contracts may be executed with Districts throughout Colorado that meet the following minimum criteria:
1. Approval of a Local Service Plan (LSP) by the Colorado Department of Education and the Department;
2. 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 or IFSP.
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 health maintenance organizations that would normally be provided for clients by their health maintenance organization. 8.290.4.F. School Health Services shall be performed in a school setting, at the client’s home or at another site in the community and may include the following:
1. Physician Services
2. Nursing Services
3. Personal Care Services
4. Psychological, Counseling and Social Work Services
5. Orientation, Mobility and Vision Services
6. Speech, Language and Hearing Services
7. Occupational Therapy Services
8. Physical Therapy Services
9. Specialized Transportation Services
10. Targeted Case Management (TCM) 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 an Early Periodic Screening, Diagnostic and Treatment (EPSDT) screen or service.
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. When the client of the targeted population is receiving Case Management Services from another provider agency as the result of being members of other covered targeted groups, the Participating District shall ensure that case management activities are coordinated to avoid unnecessary duplication of Medicaid services.
8.290.5.E. 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.
8.290.5.F. The Participating District shall complete and submit to the Department, for approval, a Care Coordination Plan for the delivery of TCM services. The Participating District shall have a representative group of parents and community-based providers, including the local public health department, EPSDT case managers and any existing school-based health centers to assist in developing the Care Coordination Plan.
Included in the Care Coordination Plan shall be the provision for coordination of benefits and case management across multiple providers to:
1. Achieve service integration, monitoring, and advocacy;
2. Provide needed medical, social, educational, and other services;
3. Ensure that services effectively compliment one another; and 4. Prevent duplication of Medicaid services.
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 Medicaid-claimable School Health Services. 8.290.6.D. Claims Submission and Interim Payment 1. The Participating District shall submit a procedure code specific fee-for-service claim for each School Health Service provided for each client.
2. 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.
3. 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.
4. 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.
5. The Participating District shall receive the federal share of the rate, not to exceed 100% of the federal match rate, as interim payment.
6. School Health Services provided shall be billed as an encounter or in 15-minute 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.
7. Specialized Transportation services shall be billed as one-way trips to and from the destination.
8. 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 and 8.043. 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:
2. Each Participating District shall complete and submit to the Department a cost report on or before October 1 of the fiscal year following the end of the reporting period.
3. All annual cost reports shall be subject to an audit by the Department or its designee.
4. 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.
5. 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.
6. 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:
1. Medicaid Outreach
2. Facilitating Medicaid Eligibility Determination
3. Translation Related to Medicaid Services
4. Medical Program Planning, Policy Development and Interagency Coordination
5. Medical/Medicaid Related Training and Professional Development
6. Referral, Coordination and Monitoring of Medicaid Services
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.
1. The cost report shall document the Participating District’s total Medicaid allowable scope of costs for providing Medicaid Administrative Activities, based on a CMS approved cost allocation methodology.
2. 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.
3. By July 30 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 appropriate.
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.
2. All cost reports and claims for MAC shall be subject to an audit by the Department or its designee.
_____________________________________________________ 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]