DEPARTMENT OF HEALTH CARE POLICY AND FINANCING MEDICAL ASSISTANCE – SECTION 8.900 OAP, Primary Care Fund, Dental Health Care 10 CCR 2505-10 8.900 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________

8.900 [Repealed effective 7/1/2025]

8.920 Hospital Discounted Care

The Health Care Billing for Indigent Patients Act of 2021, C.R.S. § 25.5-3-501, et. seq., referred to as Hospital Discounted Care, establishes the maximum rate a Health Care Facility and Licensed Health Care Professional may bill low-income patients for Discounted Care provided in the hospital, requires written description of patient’s rights, establishes patient appeals and complaint processes, and imposes requirements on hospitals before assigning or selling patient debt to a medical creditor or before pursuing collection action. Senate Bill 24-116 added an increase in payment plan amounts for Health Care Facilities who bill for their own professionals, requires professionals who bill separately from the Health Care Facility to report their own data to the Department, and excludes primary care provided at rural or frontier clinics who have an approved sliding fee scale.

8.921 DEFINITIONS

A. Billing Statement means any patient-facing communication, whether electronic or in writing, that specifies an amount due for services and instructions for making payment.

B. Children’s Basic Health Plan or the Child Health Plan Plus (CHP+) means the Children’s Basic Health Plan as defined in Title 25.5, Article 8, C.R.S.

C. Department means the Department of Health Care Policy and Financing established pursuant to section 25.5-1-104, C.R.S.

D. Discounted Care means the amount a Provider may charge a Qualified Patient for Medically Necessary Health Care Services rendered.

E. Emergency Medicaid means short-term Medicaid coverage for eligible people who do not meet immigration or citizenship requirements for Medicaid and need treatment for life- and/or limb- threatening emergencies.

F. Emergency Hospital Services means treatment for conditions of an acute, severe nature which are life, limb, or disability threats requiring immediate attention, where any delay in treatment would, in the judgment of the responsible physician, threaten life or loss of function of a patient or viable fetus.

G. Federal Poverty Guidelines or FPG means a measure of income level issued annually by the United States Department of Health and Human Services. For Hospital Discounted Care, the FPG is updated annually every April 1.

H. Health Care Facility means a hospital licensed as a general hospital pursuant to Title 25, Article 3, Part 1, C.R.S., a hospital established pursuant to section 23-21-503, C.R.S. or section 25-29- 103, C.R.S., any freestanding emergency department licensed pursuant to section 25-1.5-114, C.R.S., or any outpatient health care facility that is licensed as an on-campus department or service of a hospital or that is listed as an off-campus location under a hospital’s license. Health Care Facility does not include a federally qualified health center as defined in the federal “Social Security Act”, 42 U.S.C. sec. 1395x(aa)(4), or a student-learning medical or dental clinic that is established for the purpose of student learning, offering Discounted Care as part of a program of student learning that is physically situated within a health sciences school, Health Care Facility does not apply to primary care services provided in a clinic located in a designated rural or frontier county that offers a sliding-fee scale equal to the Medicare rural health clinic all inclusive rate payment established in accordance with 42 U.S.C. 1395l (f)(3)(B) or payment rate that is lower than usual and customary charges and considers a patient’s household size and income size as approved by the Department.

I. Health Care Services has the same meaning as set forth in section 10-16-102(33), C.R.S.

J. Impermissible Extraordinary Collection Action means initiating foreclosure on an individual’s primary residence or homestead, including a mobile home, as defined in section 38-12-201.5(5), C.R.S.

K. Inpatient Hospital Service has the same meaning as set forth in 42 C.F.R. § 440.10. 42 C.F.R. § 440.10 (2024) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This regulation is available for public inspection at the Department of Health Care Policy and Financing, 303 E. 17th Ave, Denver, CO 80203. Pursuant to C.R.S § 24-4-410(12.5)(V)(b), the Department shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule.

L. Licensed Health Care Professional or Professional means any health care professional who is registered, certified, or licensed pursuant to Title 12, C.R.S. or who provides services under the supervision of a health care professional who is registered, certified, or licensed pursuant to Title 12, C.R.S. and who provides Health Care Services in a Health Care Facility.

M. Medicaid means the Colorado Medical Assistance Act set forth in Title 25.5, Articles 4, 5, and 6, C.R.S.

N. Medical Creditor means any entity that attempts to collect on a medical debt, including a Provider or Provider’s billing office, a collection agency as defined in section 5-16-103(3), a debt buyer as defined in section 5-16-103(8.5), C.R.S. and a debt collector as defined in 15 U.S.C. sec. 1692a(6).

O. Outpatient Hospital Service has the same meaning as set forth in 42 C.F.R. § 440.20. 42 C.F.R. § 440.20 (2024) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This regulation is available for public inspection at the Department of Health Care Policy and Financing, 303 E. 17th Ave, Denver, CO 80203. Pursuant to C.R.S § 24-4-410(12.5)(V)(b), the Department shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule.

P. Patient Contact Best Efforts means the process of communication efforts completed by the Provider to contact a patient. This includes phone calls, SMS messages, emails, and portal messages.

Q. Permissible Extraordinary Collection Action means an action other than an Impermissible Extraordinary Collection Action that requires a legal or judicial process, including but not limited to placing a lien on an individual’s real property, attaching or seizing an individual’s bank account or any other personal property, or garnishing an individual’s wages. A Permissible Extraordinary Collection Action does not include the attachment of a hospital lien pursuant to section 38-27- 101, C.R.S.

R. Provider means any Health Care Facility or Licensed Health Care Professional subject to Title 25.5, Article 3, Part 5, C.R.S.

S. Qualified Patient means an individual who attests to residing in Colorado, whose household income is not more than two hundred fifty percent of the Federal Poverty Guidelines and who received an Inpatient Hospital Service or Outpatient Hospital Service at a Health Care Facility.

T. Screen or Screening means a process identified in rule by the Department whereby Health Care Facilities assess a patient’s circumstances related to eligibility criteria and determine whether the patient is likely to qualify for public health care coverage or Discounted Care, inform the patient of the Health Care Facility’s determination, and provide information to the patient about how the patient can enroll in public health care coverage.

U. SMS means short messaging service messages, commonly referred to as text messages.

V. Uninsured means an uninsured individual, as defined in section 10-22-113(5)(d), C.R.S.

8.922 SCREENING AND APPLICATION

A. Screening, Application, and Determination Notice 1. Beginning September 1, 2022, using the single uniform application developed and distributed by the Department, a Health Care Facility shall screen each uninsured patient and any insured patients who request to be screened for:

a. Public health insurance programs including but not limited to Medicare, Medicaid, Emergency Medicaid, and the Children’s Basic Health Plan.

b. Discounted Care, as described in section 25.5-3-503, C.R.S.

2. Uninsured Patients a. Health Care Facilities must complete the screening process using the uniform application within 45 days from the uninsured patient’s date of service or date of discharge, whichever is later.

b. The screening process consists of completing the first page of the uniform application using self-attested information provided by the patient or their guardian.

c. If the self-attested screening process results in a determination that the patient may be eligible for Discounted Care, then, at the time of the screening, the Health Care Facility must provide the patient or their guardian with a list of information and documents required to complete the application process. The patient is permitted 45 days to provide the documentation required to complete the application. When all necessary documentation has been received from the patient, the Health Care Facility must determine the patient’s eligibility for Discounted Care and send written notice of the determination to the patient or guardian within 21 days.

d. If the self-attested screening process results in a determination that a patient likely is ineligible for Discounted Care, the patient must be informed that the screening results are not an official determination and that they have the right to complete the application and receive an official determination of eligibility for Discounted Care if they choose. If the patient requests to complete the application process for Discounted Care, the Health Care Facility must complete the application process and provide an official determination of eligibility for Discounted Care.

e. If the self-attested screening process results in a determination that the patient may be eligible for one or more public health coverage options, the Health Care Facility must inform the patient of those options and provide information on how the patient may apply for them, including any application deadlines the patient should be aware of.

3. Insured Patients a. If the insured patient or their guardian requests to be screened for public health insurance programs and Discounted Care, Health Care Facilities must screen insured patients within 45 days of their date of service or date of discharge, or within 45 days of the date of their first bill after their insurance adjustment, whichever is later.

b. The request to be screened may be made in person, by telephone, email, or by using the portal, if available. Health Care Facilities must contact the insured patient or their guardian to schedule the screening within three business days after receiving the insured patient’s request.

c. Patients believed to have health insurance coverage when services were rendered and who are subsequently determined to be uninsured on their date of service are considered Uninsured. Within 45 days from the date of the notification that the patient was not insured on the date of service, the Health Care Facility must complete the screening.

4. Health Care Facility Determination Notice a. The Health Care Facility must provide the patient written notice of the determination within 21 days of receiving all required documentation to complete the patient’s application for Discounted Care. A copy of the determination must be sent to any and all applicable Licensed Health Care Professionals.

b. The determination shall be written in plain language and in the patient or their guardian’s preferred language.

c. If a Health Care Facility fails to issue written notice of the determination to the patient within 21 days of receiving all required documentation to complete the patient’s application, the patient may file an appeal. If the appeal is filed within 60 calendar days of the patient submitting all required documentation, the Health Care Facility must review the appeal and respond to the patient or their guardian and the Department within 15 calendar days of the date of the appeal.

d. For patients determined to be eligible for Discounted Care, the determination notice must include but is not limited to:

1. The programs and discounts for which the patient was determined likely eligible for, including but not limited to Medicaid, Emergency Medicaid, CHP+, Medicare, and Hospital Discounted Care, and the availability of subsidies through Connect for Health Colorado. This must also include where to find additional information and how to apply for each program the patient was determined potentially eligible for.

i. If the patient appears likely eligible for a program, and there is a deadline by which the patient must apply for that program for their services to be covered, that date must be included in the determination notice.

2. The dates for which the Discounted Care determination is valid.

3. The household size and income used to determine eligibility and the household calculated FPG.

4. The patient’s monthly installment amounts calculated on their gross household income pursuant to Section 8.923.A.2.

5. Information on how to file a complaint and how to file an appeal with the Health Care Facility and the Department.

e. The determination notice for patients determined not eligible for Discounted Care must include but is not limited to:

1. The basis for denial of Discounted Care.

2. The programs and discounts for which the patient was determined likely eligible for, including but not limited to Medicaid, Emergency Medicaid, CHP+, Medicare, and the availability of subsidies through Connect for Health Colorado. This must also include where to find additional information and how to apply for each program the patient was determined potentially eligible for.

i. If the patient appears likely eligible for a program, and there is a deadline by which the patient must apply to that program for their services to be covered, that date must be included in the determination notice.

3. The service date the Discounted Care denial covers and an explanation that the household may qualify for coverage of future services if there is a change in household size or income.

4. The household size and income used to determine eligibility and the household calculated FPG.

5. Information on how to file a complaint and how to file an appeal with the Health Care Facility and the Department.

5. A Health Care Facility is no longer obligated to screen an uninsured patient for past dates of service if the patient or their guardian signs the decline screening form developed by the Department that notes those specific dates of service or a past date range that includes those specific dates of service except when a patient or guardian who opted out of screening subsequently requests to complete the screening, if the subsequent request is made prior to starting Permissible Extraordinary Collections Actions.

a. The Health Care Facility must keep on file a decline screening form signed by the patient, or their guardian until June 30 of the seventh state fiscal year after the patient’s date of service or date of discharge, whichever is later.

6. For patients who are discharged without being screened or signing the decline screening form, the Health Care Facility must attempt to contact the patient by at least one method of contact that the patient indicates is their preferred method, which can include phone call, SMS message, email, and portal message at least once a month for six months after the patient’s date of discharge with the first contact sent prior to the expiration of 45 days after screening. The Health Care Facility may commence billing 46 days after the patient’s date of service or date of discharge, whichever is later. If the patient requests that the Health Care Facility cease contacting them by phone, SMS message, or email, the provider may consider those requirements as fulfilled. The Health Care Facility must document the patient’s request and maintain the request as part of the patient record.

7. If a Health Care Facility has attempted to contact the patient in accordance with Patient Contact Best Efforts, and the patient does not respond within 182 days of their date of service or date of discharge, whichever is later, the Facility may conclude that the patient has made an informed decision to decline screening. Patient Contact Best Efforts, at a minimum, must include:

a. Notice that the failure to respond may result in the loss of their right to be screened for cost saving options.

b. Calling any phone numbers provided by the patient and leaving voice messages with allowable information under the Health Insurance Portability and Accountability Act as defined at 45 C.F.R. sec. 164.502 and the Telephone Consumer Protection Act as defined at 47 U.S.C. sec. 227 if the calls are unanswered, 1. 45 C.F.R. § 164.502 (2024) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. This regulation is available for public inspection at the Department of Health Care Policy and Financing, 303 E. 17th Ave, Denver, CO 80203. Pursuant to C.R.S § 24-4- 410(12.5)(V)(b), the Department shall provide certified copies of the material incorporated at cost upon request or shall provide the requestor with information on how to obtain a certified copy of the material incorporated by reference from the agency of the United States, this state, another state, or the organization or association originally issuing the code, standard, guideline or rule.

c. SMS messages to any of the patient’s phone numbers identified by the patient as a mobile number if the Health Care Facility has the ability to send SMS messages, d. Sending emails to any email address provided by the patient, and e. Sending messages through any appropriate patient portal.

8. If a patient does not indicate their preferred method of contact, the Provider shall contact patients in accordance with their internal patient communication policies. Documentation of the communication attempts for patients must be kept in their patient records and the communication policy must be kept on file until the June 30 of the seventh state fiscal year past the patient’s date of service.

9. Documentation of the attempts to contact the patient or guardian to complete the screening must be maintained as part of the patient record. This may include call logs, message logs, copies of sent emails, portal messages sent, and copies of bills.

10. Providers shall maintain all Discounted Care-related records, including but not limited to, documentation to support screenings and determinations, service data including dates of service for Qualified Patients and services provided to them on those dates, and expenditures until June 30 of the seventh state fiscal year following the creation of the documentation.

B. Patients 1. Any patient or patient’s guardian aged 18 and older may apply to receive Discounted Care.

2. The decision regarding eligibility for Discounted Care applies to both the patient and the members of the patient’s household.

3. If a patient is deceased, the personal representative of the estate or a family member may complete the screening and application on behalf of the patient.

4. The application to receive Discounted Care shall include the names, birth dates, and relationship to the patient of all members of the patient’s household who are included on the application.

a. A patient must include their spouse or civil union partner in their household for the application.

b. Any additional person living at the same address as the patient may also be included in the household.

c. A patient may include household members who live in other states or countries if the patient attests to the fact that they provide at least 50% of the household member’s support.

5. A minor shall not be screened separately from his or her parents or guardians unless they are emancipated or there exists a special circumstance. A minor is an individual under the age of 18.

C. Household Income 1. Using the information submitted by a patient or patient’s guardian, the Health Care Facility shall determine whether the patient meets all requirements to receive Discounted Care. Health Care Facilities must follow the income counting methodology determined by the Department. Health Care Facilities shall determine Qualified Patient financial eligibility based on income from each household member 18 and older and household size. The Health Care Facility may not consider assets in determining eligibility.

2. Eligibility shall be determined at the time of application, unless required documentation is not available, in which case the patient or patient’s guardian will be notified of the missing documentation within three business days after receipt of the application. An eligibility determination shall be made within 21 calendar days after the application is complete.

3. Patients may establish household income by providing documents that satisfy documentation guidelines established by the Department. Acceptable forms of documentation may include but is not limited to pay stubs, employer letter, tax returns, and business financial statements. The Health Care Facility may not require more than the minimum amount of documentation to substantiate declared income.

a. Patients who are experiencing homelessness are exempt from the documentation requirements related to establishing income and may self-attest to their household income.

8.923 HEALTH CARE SERVICE DISCOUNTS

A. Beginning September 1, 2022, if a patient screened pursuant to Section 8.922 is determined to be a Qualified Patient, a Health Care Facility and a Licensed Health Care Professional shall for Emergency Hospital and other Health Care Services:

1. Limit the amounts billed for Health Care Services to no more than the rate established in Department rule pursuant to Section 8.929.

2. Enter into a payment plan with the Qualified Patient in which the Qualified Patient pays for care in monthly installments. For services provided by a Health Care Facility, monthly installments shall not exceed four percent of the patient’s gross monthly household income on a bill from a Health Care Facility that contains only facility charges and shall not exceed six percent of the patient’s gross monthly household income on a bill from a Health Care Facility containing both facility and Licensed Health Care Professional charges. For services provided by each Licensed Health Care Professional who bills separately from the Health Care Facility, monthly installments shall not exceed two percent of the patient’s gross monthly household income; and 3. After a cumulative thirty-six months of payments, the Health Care Facility shall treat the Qualified Patient’s bill as paid in full and must permanently cease collection activities on any balance that remains unpaid.

4. Providers shall not suggest or require that patients obtain loans that include fees, interest, or payment plans that exceed 36 payments to pay for services in lieu of setting up a payment plan directly with the Health Care Facility or Licensed Health Care Professional.

a. If a patient defaults on a loan from the Provider, the same rules apply related to any collection actions taken by the Provider as apply for payment plans under this section. If a patient defaults on a loan from the Provider, the same rules apply related to any collection actions taken by the Provider as apply for payment plans under this section..

B. A Health Care Facility shall not:

1. Deny Discounted Care on the basis that the patient has not applied for any public benefits program; or 2. Adopt or maintain any policies that result in the denial of admission or treatment of a patient because the patient may qualify for Discounted Care.

8.924 PATIENT RIGHTS

A. Beginning September 1, 2022, a Health Care Facility shall make available to the public and to each patient information developed by the Department about patient’s rights pursuant to Part 5 of Article 3 of Title 25.5 C.R.S. (2021) and the uniform application developed by the Department pursuant to section 25.5-3-505 (2)(i), C.R.S.

B. At a minimum, the Health Care Facility shall:

1. Post the information in all languages spoken by ten percent or more of the population in any Colorado county conspicuously on the Health Care Facility’s website, including a link to the information on the Health Care Facility’s main landing page;

2. Make the information available in patient waiting areas;

3. Make the information available to each patient, or the patient’s legal guardian, before the patient is discharged from the Health Care Facility, verbally or in writing in the patient’s or legal guardian’s preferred language, which may include using professional interpretation and/or translation services; and 4. Inform each patient on the patient’s Billing Statement of the patient’s rights pursuant to Part 5 of Article 3 of Title 25.5, C.R.S. (2021) including the right to apply for Discounted Care, and provide the website, email address, and telephone number where the information may be obtained in the patient’s preferred language.

C. Providers shall not present the patient’s rights in a format that differs from the format in which the material is distributed by the Department without Department approval.

1. Providers may not make any part of the patient’s rights information part of a footnote or use any other format that may minimize its importance.

8.925 REPORTING REQUIREMENTS

A. Beginning September 1, 2023 for Health Care Facilities and beginning September 1, 2025 for Licensed Health Care Professionals, and each September 1 thereafter, each Health Care Facility and Licensed Health Care Professional shall report to the Department data that the Department determines is necessary to evaluate compliance across race, ethnicity, age, and primary- language-spoken patient groups with the screening, Discounted Care, payment plan, and collections practices required by Title 25.5, Article 3, Part 5, C.R.S. . The Department shall distribute a compliance data reporting template to each Health Care Facility.

1. If a Health Care Facility or Licensed Health Care Professional is not capable of disaggregating the required data by race, ethnicity, age, and primary language spoken, the Health Care Facility or Licensed Health Care Professional shall report to the Department the steps the Health Care Facility or Licensed Health Care Professional is taking to improve race, ethnicity, age, and primary language spoken data collection and the date by which the facility or Licensed Health Care Professional will be able to disaggregate the reported data.

B. Beginning September 1, 2023 for Health Care Facilities and beginning September 1, 2025 for Licensed Health Care Professionals, and each September 1 thereafter, each Health Care Facility and Licensed Health Care Professional shall submit Discounted Care utilization and charge data in a format and timeline determined by the Department.

8.926 COLLECTIONS

A. Beginning September 1, 2022, before assigning or selling patient debt to a collection agency or a debt buyer, or before pursuing, either directly or indirectly, any Permissible Extraordinary Collection Action:

1. A Health Care Facility shall meet the screening requirements in Section 8.922;

2. A Provider shall provide Discounted Care to a Qualified Patient pursuant to Section 8.920;

3. A Provider shall provide a plain language explanation of the health care services and fees and notify the patient or their guardian of potential collection actions in their preferred language on the timeline developed by the Department; and 4. A Provider shall bill any third-party payer that is responsible for providing health care coverage to the patient. If a Licensed Health Care Professional is an out-of-network provider under a Qualified Patient’s health insurance plan, the Licensed Health Care Professional and health insurance carrier shall comply with the out-of-network billing requirements described in sections 10-16-704 (3) and 12-30-113, C.R.S.

B. A Health Care Facility must complete the Patient Contact Best Efforts in their attempts to contact a patient who has not signed a Decline Screening Form or who has not been screened as described in Section 8.922 prior to starting Permissible Extraordinary Collections Actions.

C. Documentation of Patient Contact Best Efforts communication attempts with the patient as outlined in Section 8.922 satisfies the screening requirements for Health Care Facilities.

D. For a Qualified Patient with an established payment plan, Permissible Extraordinary Collections Actions may not be started until the patient has failed to remit three consecutive payments and has not communicated with the Provider asking for a deferment or to be redetermined prior to or during those three months of missed payments. Providers must notify Qualified Patients with established payment plans at least 30 days prior to the commencement of Permissible Extraordinary Collections Actions.

E. Providers shall not commence collection proceedings against a patient for any amount in excess of the rates established at Section 8.923.A.2, and must reduce the amount owed by the amount of any payments received from the patient or a third-party payer.

8.927 APPEALS AND COMPLAINTS

A. If a patient is determined ineligible for Discounted Care after the uniform application has been completed, the patient may appeal the decision as follows:

1. No later than 30 calendar days from the date on the Health Care Facility’s eligibility determination letter, the patient or their guardian may submit an appeal in writing via U.S. Mail, email, or patient portal message if available to the Health Care Facility that made the determination.

2. Within 15 calendar days from the date of the appeal, the Health Care Facility shall complete a redetermination of eligibility and respond to the patient or guardian and the Department.

3. If the Health Care Facility upholds its initial eligibility determination, the patient or guardian may proceed to the next step of the appeals process as described in Section 8.927.A.4.

4. No later than 15 calendar days from the date of the Health Care Facility’s initial appeal decision, the patient shall submit a written appeal to the Department. Email submissions must be addressed to hcpf_HospDiscountCare@state.co.us. Letters must be mailed to: Department of Health Care Policy and Financing Attention: State Programs Unit, Special Financing Division c/o Hospital Discounted Care 303 E. 17th Avenue Suite 1100 Denver, CO 80203 5. Within 15 calendar days from date of receipt of the appeal, the Department shall issue a final determination letter to both the patient and the Health Care Facility. If the Department deems that the redetermination was inaccurate, the Health Care Facility must resend a determination letter to the patient and the Department stating the patient is/was eligible for Discounted Care on the date of service.

B. A patient or guardian who believes a Health Care Facility has improperly calculated a payment plan based on inaccurate income information may appeal the payment plan offered by the Facility to the Department using the process described in Section 8.927.A.1.

C. The Department shall maintain records of all appeals and its final determinations for each Health Care Facility. If the Department determines a Health Care Facility has a repeated pattern of errors in patient eligibility determinations, the Department will require the Health Care Facility to attend training with the Department. The Health Care Facility may be subject to random application checks for 12 months following the training to ensure that the errors have been corrected.

D. Patients and their guardians may file complaints against Providers directly with the Department. Patients are not required to file a complaint with the Provider prior to filing a complaint with the Department.

1. Patients may submit complaints via U.S. Mail, email, or phone as follows: Phone: 303-866-2580 Email: hcpf_HospDiscountCare@state.co.us U.S. Mail: Department of Health Care Policy and Financing Attention: State Programs Unit, Special Financing Division c/o Hospital Discounted Care 303 E. 17th Avenue Suite 1100 Denver, CO 80203 2. The Department shall review complaints within 30 calendar days of receipt.

3. The Department shall maintain records of all complaints for each Provider. If the Department determines there is a repeated pattern in the complaints filed against the Provider, the Provider may be subject to a corrective action plan.

a. Providers will have 90 days to submit a corrective action plan. Extensions may be made at the Department’s discretion up to no more than 120 days.

8.928 HOSPITAL DISCOUNTED CARE PROGRAM STRUCTURE

8.928.1 REVIEW OF PROVIDERS FOR NONCOMPLIANCE

A. The Department will periodically review Providers to ensure compliance with Part 5 of Article 3 of Title 25.5, C.R.S. (2024) and these rules. If the Department finds that a Provider is not in compliance with these rules, the Department will notify the Provider.

B. The Provider will have 90 days to file a corrective action plan with the Department that must include measures to inform impacted patients about the noncompliance and provide financial corrections consistent with these rules.

1. At the Department’s discretion, a Provider may be permitted up to 120 days to submit a corrective action plan upon request.

2. The Department may require a Provider that is not in compliance with Title 25.5, Article 3, Part 5, C.R.S. or these rules to develop and operate under a corrective action plan until the Department determines the Provider is in compliance.

C. If a Provider’s noncompliance with these rules is determined by the Department to be knowing or willful or there is a repeated pattern of noncompliance, the Department may fine the Provider no more than $5,000. If the Provider fails to take corrective action or fails to file a corrective action plan with the Department pursuant to this section, the Department may fine the Provider no more than $5,000 per week until the Provider takes corrective action. The Department will consider the size of the Health Care Facility and the seriousness of the violation in setting the fine amount.

D. The Department will make the information reported pursuant to this section and any corrective action plans for which fines were imposed pursuant to this section available to the public and shall annually report the information as part of its presentation to its committees of reference at a hearing held pursuant to section 2-7-203 (2)(a), C.R.S. of the “State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act.” E. For audit purposes, Providers shall maintain all Discounted Care related records, including but not limited to, documentation to support screenings and determinations, service data including dates of service for Qualified Patients and services provided to them on those dates, and expenditures until June 30 of the seventh state fiscal year following the screening or determination.

8.928.2 RATES

The Department will annually establish rates for Discounted Care. The rates will approximate and not be less than one hundred percent of the Medicare rate or one hundred percent of the Medicaid rate, whichever is greater. The Department will publicly post the established rates on the Department’s website pursuant to section 25.5-3-505, C.R.S.

8.928.3 ADVISORY COMMITTEE

A. Committee Makeup. The Department will create a Hospital Discounted Care Advisory Committee, effective July 1, 2025. The Executive Director of the Department will appoint 11 members to the Hospital Discounted Care Advisory Committee. Committee members will include:

1. A member representing the Department;

2. Three members who are health care consumers, of whom no more than two members may be employed by a health care consumer advocacy organization;

3. A member who is a representative of a safety net hospital for which the percent of Medicaid-eligible inpatient days relative to the hospital’s total inpatient days is equal to or greater than one standard deviation above the mean;

4. A member who is a representative of a hospital in a rural area;

5. A member who is a representative of a hospital in an urban area;

6. A member who is a representative of a statewide organization of hospitals;

7. A member who is a representative of licensed health care professionals who provide services to patients in a hospital setting;

8. A member who is a representative of an organization of Colorado community health centers or a representative of a Colorado community health center, as defined in 42 U.S.C. § 254b;

9. A member who is a representative of an organization of safety net health providers or a safety net health provider that is not a community health center. Members shall serve without compensation or reimbursement of expenses. The Executive Director of the Department will designate a member to serve as chair of the committee and the appointment will be valid until the seat is vacated, the chair steps down, or a new chair is selected by the Executive Director. The council shall convene at least twice every state fiscal year according to a schedule set by the chair. Members of the council shall serve three-year terms. Of the members initially appointed to the advisory committee, the Executive Director will appoint six members for two-year terms and five members for three-year terms. In the event of a vacancy on the advisory committee, the Executive Director will appoint a successor to fill the unexpired portion of the term for the member.

B. Committee Duties. The advisory committee shall:

1. Advise the Department on the operations and policies for Hospital Discounted Care, and 2. Make recommendations to the Medical Services Board regarding rules for Hospital Discounted Care.

8.930 [Repealed effective 8/12/2011.]

8.940 OLD AGE PENSION HEALTH CARE PROGRAM

8.941 EXTENT AND LIMITATIONS OF MEDICAL CARE

8.941.1 GENERAL DESCRIPTION - OLD AGE PENSION HEALTH CARE PROGRAM

In accordance with the Constitution of Colorado, Article XXIV, Section 7, and the Colorado Public Assistance Act, an Old Age Pension Health Care Program is established to provide necessary medical care for the Old Age Pension (OAP) recipients who do not qualify for Medicaid under Title XIX of the Social Security Act and Colorado statutes. The State Department is designated as the single State agency to administer the program.

A. The Old Age Pension Health Care Program provides optional benefits to clients who qualify for (State only) OAP pensions who do not qualify for Federal Financial Participation (FFP) in the Colorado Medicaid Program. These cases are coded with Supplemental Income Status Code (SISC) C.

B. Under the Old Age Pension Health Care Program, only the following State funded benefits are provided:

1. Physician and practitioner services 2. Inpatient hospital 3. Outpatient services 4. Lab and x-ray 5. Emergency transportation 6. Emergency services 7. Dental 8. Pharmacy i. Medicare Part D prescription drugs provided pursuant to the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (defined at 42 U.S.C. sections 1395w-102 and 141 and 42 C.F.R. Part 423, et seq.) are not a benefit for those individuals who are eligible for both Medicare and the Old Age Pension Health Care Program. The pharmacy drug benefit under the Old Age Pension Health Care Program is subject to the requirements set forth at s Section 8.800.

9. Home health services and supplies 10. Medicare cost sharing i. If Medicare pays for a medical service that is a non-benefit under the Old Age Pension Health Care Program, the co-insurance and deductible will not be paid by the Old Age Pension Health Care Program.

C. For the benefits listed above, the Old Age Pension Health Care Program shall only be used to provide clients with health care services determined to be medically necessary by a qualified health care provider.

D. All other medical benefits not listed in paragraph B are excluded under the Old Age Pension Health Care Program. Inpatient care in an institution for tuberculosis or mental diseases, skilled and intermediate nursing facility services, and home and community-based services are also excluded.

E. Eligibility shall not be retroactive and shall begin on the date of application or date eligibility is established, whichever is later.

F. Counties shall provide information to Old Age Pension Health Care Program clients regarding the disposal of excess resources in order to qualify for the Medicaid program. Such information shall include advisements concerning the prohibition of transfer of assets without fair consideration.

8.941.2 DEFINITIONS

A. Aid to the Needy Disabled-Colorado Supplement (AND-CS) – Program that provides a supplemental payment for individuals age zero (0) to fifty-nine (59) who are receiving Social Security Income (SSI) due to a disability or blindness, but are not receiving the full SSI benefit standard, as defined in 9 CCR 2503-5 3.510.

B. Aid to the Needy Disabled-State Only (AND-SO) – Program that provides interim assistance to individuals age eighteen (18) through fifty-nine (59) years of age (unless diagnosed with blindness, then age zero [0] through fifty-nine [59] years of age) who are disabled or blind but have not been approved for SSI or Social Security Disability Insurance (SSDI). Individuals are required to meet the total disability requirements of the program in addition to the non-financial and financial eligibility requirements. Individuals who are partially disabled or have a short-term disability are not eligible.

C. Federal Financial Participation (FFP) – The portion paid by the federal government to states for their share of expenditures for providing Medicaid services and for administering the Medicaid program and certain other human services programs.

D. Medical ID Card – The card issued to members and used by providers to verify member eligibility.

E. Old Age Pension (OAP) – Program that provides financial assistance for low-income Colorado residents who are sixty (60) years of age or older who meet all financial and non-financial eligibility requirements.

F. Old Age Pension-C (OAP-C) – Program for individuals who are sixty (60) years of age or older who have been committed to the Colorado Mental Health Institute or to a Regional Center by order of the district or probate court.

G. State Department or Department – The Colorado Department of Health Care Policy and Financing.

H. Supplemental Income Status Code (SISC) – System codes used to distinguish the different types of state supplementary benefits (such as OAP) a recipient may receive. Supplemental Income Status Codes determine the FFP for benefits paid on behalf of groups covered under the Medical Assistance program.

I. Supplemental Security Income (SSI) – A Federal income supplement program funded by general tax revenues (not Social Security taxes) that provides income to aged, blind, or disabled individuals with little or no income and resources.

8.941.3 GROUPS ASSISTED UNDER THE OLD AGE PENSION HEALTH CARE PROGRAM

Old Age Pension Health Care Program benefits are provided to persons receiving OAP who do not meet SSI eligibility criteria but do meet the State eligibility criteria for the Old Age Pension Health Care Program. These persons qualify for a SISC C..

A. SISC C – this code is for persons eligible to receive financial assistance under OAP who do not receive an SSI payment, and do not otherwise qualify for the Colorado Medicaid Program. SISC C signifies that no FFP is available in medical assistance program expenditures.

B. Recipients of financial assistance under AND-CS, AND-SO, or OAP-C are not eligible for assistance under the Old Age Pension Health Care Program.

8.941.4 FINANCIAL ASSISTANCE

All rules applicable to Old Age Pension financial assistance program payments (as set forth in the Department of Human Services rules at 9 CCR 2503-5) shall apply to the Old Age Pension Health Care Program.

8.941.5 CERTIFICATION OF PAYMENT FOR PROVIDERS

When submitting a claim for medical services to the Old Age Pension Health Care Program providers must submit a certification that states the following: “I will accept as payment in full, payment made under the Old Age Pension Health Care Program, and certify that no supplemental charges have been, or will be, billed to the patient, except for those non-covered items, or services, if any, which are not reimbursable under the Old Age Pension Health Care Program.”

8.941.6 OUT-OF-STATE MEDICAL CARE

All requirements for out-of-state medical care as defined by Section 8.013 apply to the Old Age Pension Health Care Program for covered services with the exception that any reduction, suspension or elimination of benefits must be applied.

8.941.7 SUBMISSION OF CLAIMS

Rules governing the submission or payment of claims, provider or recipient appeals, third party liability, overpayment, fraud and abuse, and State identification numbers as defined in Section 8.100, apply to the Old Age Pension Health Care Program for covered services with the exception that any reduction, suspension or elimination of benefits provided must also be applied.

8.941.8 REIMBURSEMENT TO PROVIDERS

When reimbursement rates are modified, notifications shall be published on the Department’s website and will be published in the Provider Bulletin.

8.941.9 CLIENT CO-PAYMENT

Clients are responsible for paying directly to providers a co-payment according to the regulations and fee schedule as set forth under Section 8.754.1.

Clients whose co-payments reach a limit of $300 within a January 1 through December 31 calendar year will be exempted from further co-payments during that year. The exemption will begin on the date of payment that the $300 limit cumulative maximum has been reached. A client must present the Medical ID Card to the provider at the time a service is rendered in order to claim exemption from copayment for that service.

8.942 CHANGE OF SUPPLEMENTAL INCOME STATUS CODE (SISC) TO MEDICAID

8.942.1 MEDICAID QUALIFICATION

When a recipient of the Old Age Pension Health Care Program subsequently qualifies for Medicaid, their SISC must be changed to indicate Medicaid benefits. Additionally, the county must backdate the Medicaid benefits to the date the individual became eligible for Medicaid even if the recipient was eligible for the Old Age Pension Health Care Program at the time.

8.950 PRIMARY CARE FUND

8.950.1 GENERAL DESCRIPTION

8.950.1.A. In accordance with Section 21 of Article X (Tobacco Taxes for Health Related Purposes) of the State Constitution, an increase in Colorado’s tax on cigarettes and tobacco products became effective January 1, 2005, and created a cash fund that was designated for health related purposes. House Bill 05-1262 divided the tobacco tax cash fund into separate funds, assigning 19% of the moneys to establish the Primary Care Fund, set forth how the funds will be allocated and designated the Department of Health Care Policy and Financing (the Department) as the administrator of the Primary Care Fund.

8.950.1.B. The Primary Care Fund provides an allocation of moneys to health care providers that make basic health care services available in an outpatient setting to residents of Colorado who are considered low-income and uninsured. Moneys shall be allocated based on the number of eligible patients in an amount proportionate to the total number of eligible patients served by all health care providers who qualify for moneys from this fund.

8.950.2 DEFINITIONS

8.950.2.A. Arranges For - Demonstrating Established Referral Relationships with health care providers for any of the Comprehensive Primary Care services not directly provided by the provider.

8.950.2.B. Children’s Basic Health Plan also known as Child Health Plan Plus (CHP+) - As specified in Article 8 of Title 25.5, C.R.S.

8.950.2.C. Comprehensive Primary Care - Basic, entry-level health care provided by health care practitioners or non-physician health care practitioners that is generally provided in an outpatient setting. At a minimum, this includes providing or arranging for the provision of the following services on a Year-Round Basis: primary health care; maternity care, including prenatal care; preventive, developmental, and diagnostic services for infants and children; adult preventive services, diagnostic laboratory and radiology services; emergency care for minor trauma; Pharmaceutical Services; and coordination and follow-up for hospital care. It may also include optional services based on a patient’s needs such as dental, behavioral health and eyeglasses. 8.950.2.D. Cost-Effective Care - Provides or Arranges for Comprehensive Primary Care that is appropriate and at a reasonable average cost per patient Visit and/or Encounter. 8.950.2.E. Eligible Patient is a patient receiving medical services from a Qualified Provider:

1. Whose yearly family income is at or below two hundred percent (200%) of the Federal Poverty Guideline (FPG);

2. Who is not eligible for the Medical Assistance Program, the Children’s Basic Health Plan, Medicare or any other governmental health care coverage such as through Social Security, the Veterans Administration, Military Dependency (TRICARE or CHAMPUS), or the United States Public Health Service; and 3. There is no Third Party Payer.

8.950.2.F Eligible Qualified Provider - A Qualified Provider who is identified by the Department to receive funding from the Primary Care Fund.

8.950.2.G. Established Referral Relationship - A formal, written agreement in the form of a letter, a memorandum of agreement or a contract between two entities which includes:

1. The Comprehensive Primary Care and/or products (e.g., pharmaceuticals, radiology) to be provided by one entity on behalf of the other entity;

2. Any applicable policies, processes or procedures;

3. The guarantee that referred Eligible Patients shall receive services on a Sliding Fee Schedule or at no charge; and 4. Signatures by representatives of both entities.

8.950.2.H. Medical Assistance Program (Medicaid) - As specified in Article 4 of Title 25.5, C.R.S. 8.950.2.I. Medically Underserved Area - A federal government designation given to a geographical area based on the ratio of medical personnel (physicians, dentists, behavioral health workers, etc.) to the population. These areas have fewer than a generally accepted minimum number of medical personnel per thousand population resulting in insufficient health resources (personnel and/or facilities) to meet the medical needs of the resident population. Such areas are also defined by measuring the health status of the resident population; an area with an unhealthy population being considered underserved.

8.950.2.J. Medically Underserved Population - A federal government designation given to a human population that does not receive adequate medical attention or have access to health care facilities.

8.950.2.K. Outside Entity - A business or professional that is not classified as an employee of the provider or the Department and does not have a direct or indirect financial interest with the provider, but has auditing experience or experience working directly with the Medical Assistance Program or similar services or grants for Eligible Patients. 8.950.2.L. Pharmaceutical Services - Services that provide prescription drugs, or coordinate access to or Arranges for Eligible Patients to receive prescription drugs prescribed by the Qualified Provider on a Sliding Fee Schedule or at no charge.

8.950.2.M. Qualified Provider - An entity that provides Comprehensive Primary Care in Colorado and that:

1. Accepts all patients regardless of their ability to pay and uses a Sliding Fee Schedule for payments or does not charge Eligible Patients for services;

2. Serves a designated Medically Underserved Area or Medically Underserved Population as provided in section 330(b) of the federal “Public Health Service Act”, 42 U.S.C. sec. 254b, or demonstrates to the Department that the entity serves a population or area that lacks adequate health care services for low-income, uninsured persons;

3. Has a demonstrated Track Record of providing Cost-Effective Care;

4. Provides or Arranges For the provision of Comprehensive Primary Care to persons of all ages. An entity in a rural area may be exempt from this requirement if they can demonstrate that there are no providers in the community to provide one or more of the Comprehensive Primary Care services;

5. Completes a screening that evaluates eligibility for the Medical Assistance Program and the Children’s Basic Health Plan and refers patients potentially eligible for one of the programs to the appropriate agency (e.g., county departments of human/social services) for eligibility determination if they are not qualified to make eligibility determinations; and 6. Is a community health center, as defined in Section 330 of the federal “Public Health Services Act”, 42 U.S.C. Section 254b; or at least 50% of the patients served by the provider are Eligible Patients or patients who are enrolled in the Medical Assistance Program, the Children’s Basic Health Plan, or any combination thereof. 8.950.2.N. Quality Assurance Program - Formalized plan and processes designed to ensure the delivery of quality and appropriate Comprehensive Primary Care in a defined medical setting. This can be demonstrated by obtaining a certification or accreditation through the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC). If such certification or accreditation is not available, then at a minimum, the Quality Assurance Program shall be comprised of elements that meet or exceed the following components:

1. Establishment of credentialing/re-credentialing requirements for medical personnel;

2. Surveying and monitoring of patient satisfaction;

3. Establishment of a grievance process for patients, including documentation of grievances and resolutions;

4. Development of clinic operating policies and scheduled performance monitoring;

5. Review of medical records to check for compliance with established policies and to monitor quality of care;

6. Assessment of state and federal regulations to ensure compliance;

7. Establishment of patient safety procedures; and 8. Establishment of infection control practices.

8.950.2.O. Sliding Fee Schedule - A tiered co-payment system that determines the level of patient’s financial participation and guarantees that the patient financial participation is below usual and customary charges. Factors considered in establishing the tiered co-payment system shall only be financial status and the number of members in the patient’s family unit. 8.950.2.P. Third Party Payments or Third Party Payer - Any individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient. Examples include the Medical Assistance Program; the Children’s Basic Health Plan; Medicare; commercial, individual or employment-related health insurance; court-ordered health insurance (such as that required by non-custodial parents); workers' compensation; automobile insurance; and long-term care insurance.

8.950.2.Q. Track Record - Evidence of providing Comprehensive Primary Care covering at least a consecutive 52-week period prior to the submission of the application. 8.950.2.R. Unduplicated User/Patient Count - The sum of patients who have had at least one Visit/Encounter and received at least one of the services under the Comprehensive Primary Care definition during the applicable calendar year, but does not include the same patient more than once. The sum shall be calculated on a specific point-in-time occurring between the end of the applicable calendar year and prior to the submission of the application. Each patient shall be counted once under only one payment source designation (Third Party Payer or Eligible Patient). The patient’s payment source designation shall be the payment source designation listed for the patient at the specific point-in-time in which the calculation is made. The sum shall not include:

1. Counting a patient more than once if the same patient returns for additional services (e.g., medical or dental) and/or products (e.g., pharmaceuticals) during the applicable calendar year;

2. Counting a patient more than once if the payment source designation changed during the applicable calendar year;

3. Persons who have only received services through an outreach event, community education program, nurse hotline, or other types of community-based events or programs and were not documented on an individual basis;

4. Persons who have only received services from large-scale efforts such as mass immunization programs, screening programs, and health fairs; or 5. Persons whose only contact with the provider is to receive Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program) counseling and vouchers are not users and the contact does not generate an encounter. 8.950.2.S. Visit/Encounter - An appointment with medical personnel (physicians, physician assistants, dentists, behavioral health workers, etc.) in which the patient received health related services and/or products (e.g., pharmaceuticals or radiology) and the appointment is customarily billable to a Third Party Payer.

8.950.2.T. Year-Round Basis - Comprehensive Primary Care provided in a consecutive 52-week period directly by the provider and/or through an established referral relationship with other providers. If an organization is closed for four consecutive weeks or longer in a calendar year on a regularly scheduled basis, it is not considered to directly provide services on a year-round basis.

8.950.3 PROVIDER ELIGIBILITY

8.950.3.A. Providers who provide Comprehensive Primary Care to Eligible Patients and who meet all of the requirements established for the Primary Care Fund as of the date the application form is submitted to the Department shall receive moneys appropriated to the Primary Care Fund. Specifically, the provider shall:

1. Meet all of the requirements of a Qualified Provider as specified in Section 8.950.2.M;

2. Have a Quality Assurance Program in place as specified in Section 8.950.2.N; and 3. Submit a completed application form according to stated guidelines as specified under Section 8.950.4.

8.950.4 APPLICATION

8.950.4.A. The application form shall be available to providers annually and posted for public access on the Department's website at least 30 calendar days prior to the response due date. 8.950.4.B. At a minimum, the application form shall require responses that:

1. Demonstrate how the provider meets the criteria of a Qualified Provider as defined in Section 8.950.2.M;

2. Provide an Unduplicated User/Patient Count covering the applicable calendar year which, at a minimum, shall include the number of patients eligible for the Medical Assistance Program and the Children’s Basic Health Plan and the number of patients considered to be Eligible Patients;

3. Provide certification that the Unduplicated User/Patient Count identified in Section 8.950.4.B.2 has been verified by an Outside Entity; and 4. Provide documentation that the provider has a Quality Assurance Program as defined in Section 8.950.2.N.

8.950.4.C. Providers shall complete and provide a response annually. The response shall be made in compliance with all specifications in the application form, including format, data and documentation. Responses to the application form shall be submitted directly to the Department by the required response deadline.

8.950.4.D. All providers who submit a response to the application form shall be notified within 45 days of the response deadline if the provider met or did not meet the requirements to become an Eligible Qualified Provider.

8.950.5 DISBURSEMENT

8.950.5.A. Eligible Qualified Providers are determined on a state fiscal year basis and shall receive only those moneys appropriated to the Primary Care Fund for that same state fiscal year, subject to the tax amount actually collected for that state fiscal year. 8.950.5.B. Payments shall be based on the number of Eligible Patients in each Eligible Qualified Provider’s Unduplicated User/Patient Count in an amount proportionate to the total number of Eligible Patients from all Eligible Qualified Providers’ Unduplicated User/Patient Counts. 8.950.5.C. The schedule for the disbursement of moneys to all Eligible Qualified Providers shall be dependent on actual tax collections allocated to the Primary Care Fund such that:

1. Tax collections for sales in July, August, and September shall be distributed to Eligible Qualified Providers prior to the end of October.

2. Tax collections for sales in October, November, and December shall be distributed to Eligible Qualified Providers prior to the end of January.

3. Tax collections for sales in January, February, and March shall be distributed to Eligible Qualified Providers prior to the end of April.

4. Tax collections for sales in April, May, and June shall be distributed to Eligible Qualified Providers prior to the end of July.

5. For State Fiscal Year 2005-06 only, tax collections for sales in January 2005 through December 2005, shall be distributed to Eligible Qualified Providers prior to the end of February 2006.

8.960 COLORADO DENTAL HEALTH CARE PROGRAM FOR LOW-INCOME SENIORS

8.960.A Definitions 1. Arrange For or Arranging For means demonstrating established relations with Qualified Providers for any of the Covered Dental Care Services not directly provided by the applicant.

2. Covered Dental Care Services include Diagnostic Imaging, Emergency Services, Endodontic Services, Evaluation, Oral and Maxillofacial Surgery, Palliative Treatment, Periodontal Treatment, Preventive Services, Prophylaxis, Removable Prosthesis, and Restorative Services as listed by alphanumeric procedure code in Schedule A.

3. C.R.S. means the Colorado Revised Statutes.

4. Dental Health Professional Shortage Area or Dental HPSA means a geographic area, population group, or facility so designated by the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

5. Dental Prosthesis means any device or appliance replacing one or more missing teeth and associated structures if required.

6. Department means the Colorado Department of Health Care Policy and Financing established pursuant to title 25.5, C.R.S.

7. Diagnostic Imaging means a visual display of structural or functional patterns for the purpose of diagnostic evaluation.

8. Economically Disadvantaged means a person whose Income is at or below 250% of the most recently published federal poverty level for a household of that size.

9. Eligible Senior or patient means an adult who is 60 years of age or older, who is Economically Disadvantaged, who is not eligible for dental services under Medicaid or the Old Age Pension Health and Medical Care Program, and who does not have private dental insurance. An Eligible Senior or patient is not ineligible solely because he/she is receiving dental benefits under Medicare or Medicare Advantage Plans.

10. Emergency Services means the need for immediate intervention by a Qualified Provider to stabilize an oral cavity condition.

11. Endodontic Services means services which are concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues, including pulpectomy.

12. Evaluation means an assessment that may include gathering of information through interview, observation, examination, and use of specific tests that allows a dentist to diagnose existing conditions.

13. Federally Qualified Health Center means a federally funded nonprofit health center or clinic that serves medically underserved areas and populations as defined in 42 U.S.C. section 1395x (aa)(4).

14. Income means any cash, payments, wages, in-kind receipt, inheritance, gift, prize, rents, dividends, or interest that are received by an individual or family. Income may be self-declared. Resources are not included in Income.

15. Max Allowable Fee means the total reimbursement listed by procedure for Covered Dental Care Services under the Colorado Dental Health Care Program for Low-Income Seniors in Schedule A. The Max Allowable Fee is the sum of the Program Payment and the Max Patient Co-Pay.

16. Max Patient Co-Pay means the maximum amount that a Qualified Provider may collect from an Eligible Senior listed by procedure in Schedule A for Covered Dental Services under the Colorado Dental Health Care Program for Low-Income Seniors.

17. Medicaid means the Colorado medical assistance program as defined in article 4 of title 25.5, C.R.S.

18. Medicare means the federal health insurance program for people who are 65 or older; certain younger people with disabilities; or people with End-Stage Renal Disease.

19. Medicare Advantage Plans mean the plans offered by Medicare-approved private companies that must follow rules set by Medicare and may provide benefits for services Medicare does not, such as vision, hearing, and dental care.

20. Old Age Pension Health and Medical Care Program means the program described at Section

8.940 et. seq. and as defined in sections 25.5-2-101 and 26-2-111(2), C.R.S.

21. Oral and Maxillofacial Surgery means the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.

22. Palliative Treatment for dental pain means emergency treatment to relieve the patient of pain; it is not a mechanism for addressing chronic pain.

23. Periodontal Treatment means the therapeutic plan intended to stop or slow periodontal disease progression.

24. Preventive Services means services concerned with promoting good oral health and function by preventing or reducing the onset and/or development of oral diseases or deformities and the occurrence of oro-facial injuries.

25. Program Payment means the maximum amount by procedure listed in Schedule A for Covered Dental Care Services for which a Qualified Grantee may invoice the Department under the Colorado Dental Health Care Program for Low-Income Seniors. Program Payment must not be less than the reimbursement schedule for fee-for-service dental fees under the medical assistance program established in Articles 4, 5, and 6 of 10 CCR 2505-10.

26. Prophylaxis means the removal of dental plaque and calculus from teeth, in order to prevent dental caries, gingivitis and periodontitis.

27. Qualified Grantee means an entity that can demonstrate that it can provide or Arrange For the provision of Covered Dental Care Services and may include but is not limited to:

a. An Area Agency on Aging, as defined in section 26-11-201, C.R.S.;

b. A community-based organization or foundation;

c. A Federally Qualified Health Center, safety-net clinic, or health district;

d. A local public health agency; or e. A private dental practice.

28. Qualified Provider means a licensed dentist or dental hygienist in good standing in Colorado or a person who employs a licensed dentist or dental hygienist in good standing in Colorado and who is willing to accept reimbursement for Covered Dental Services. A Qualified Provider may also be a Qualified Grantee if the person meets the qualifications of a Qualified Grantee.

29. Removable Prosthesis means complete or partial Dental Prosthesis, which after an initial fitting by a dentist, can be removed and reinserted by the eligible senior.

30. Restorative Services means services rendered for the purpose of rehabilitation of dentition to functional or aesthetic needs of the patient.

31. Senior Dental Advisory Committee means the advisory committee established pursuant to section 25.5-3-406, C.R.S..

8.960.B Legal Basis 8.960.B.1 The Colorado Dental Health Care Program for Low-Income Seniors is authorized by state law at part 4 of article 3 of title 25.5, C.R.S..

8.960.C Request of Grant Proposals and Grant Award Procedures 8.960.C.1. Request for Grant Proposals 8.960.C.1.a Grant awards shall be made through an application process. The request for grant proposals form shall be issued by the Department and posted for public access on the Department’s website at https://www.colorado.gov/hcpf/research-data-and-grants at least 30 days prior to the due date.

8.960.C.2 Evaluation of Grant Proposals 8.960.C.2.a Proposals submitted for the Colorado Dental Health Care Program for Low-Income Seniors will be evaluated by a review panel in accordance with the following criteria developed under the advice of the Senior Dental Advisory Committee.

1) The review panel will be comprised of individuals who are deemed qualified by reason of training and/or experience and who have no personal or financial interest in the selection of any particular applicant.

2) The sole objective of the review panel is to recommend to the Department’s executive director those proposals which most accurately and effectively meet the goals of the program within the available funding.

3) Preference will be given to grant proposals that clearly demonstrate the applicant’s ability to:

a) Outreach to and identify Eligible Seniors;

b) Collaborate with community-based organizations; and c) Serve a greater number of Eligible Seniors or serve Eligible Seniors who reside in a geographic area designated as a Dental HPSA.

4) The review panel shall consider the distribution of funds across the state in recommending grant proposals for awards. The distribution of funds should be based on the estimated percentage of Eligible Seniors in the state by Area Agency on Aging region as provided by the Department.

8.960.C.3 Grant Awards 8.960.C.3.a The Department’s executive director, or his or her designee, shall make the final grant awards to selected Qualified Grantees for the Colorado Dental Health Care Program for Low- Income Seniors.

8.960.C.4 Qualified Grantee Responsibilities 8.960.C.4.a A Qualified Grantee that is awarded a grant under the Colorado Dental Health Care Program for Low-Income Seniors is required to:

1) Identify and outreach to Eligible Seniors and Qualified Providers;

2) Demonstrate collaboration with community-based organizations;

3) Ensure that Eligible Seniors receive Covered Dental Care Services efficiently without duplication of services;

4) Maintain records of Eligible Seniors serviced, Covered Dental Care Services provided, and moneys spent for a minimum of six (6) years;

5) For Eligible Seniors with dental coverage through a Medicare Advantage Plan, bill the Medicare Advantage Plan for dental procedures covered by the Medicare Advantage Plan prior to seeking payment from the Department. The Colorado Dental Health Care Program is secondary to the Medicare Advantage Plan dental coverage;

6) Distribute grant funds to Qualified Providers in its service area or directly provide Covered Dental Care Services to Eligible Seniors;

7) Expend no more than seven (7) percent of the amount of its grant award for administrative purposes; and 8) Submit an annual report as specified under section 8.960.3.F. 8.960.C.5 Invoicing 8.960.C.5.a A Qualified Grantee that is awarded a grant under the Colorado Dental Health Care Program for Low-Income Seniors shall submit invoices on a form and schedule specified by the Department. Covered Dental Care Services shall be provided before a Qualified Grantee may submit an invoice to the Department.

1) Invoices shall include the number of Eligible Seniors served, the alphanumeric code and procedure description as listed in Schedule A, and any other information required by the Department.

2) The Department will pay no more than the established Program Payment per procedure rendered, as listed in Schedule A.

3) Eligible Seniors shall not be charged more than the Max Patient Co-Pay as listed in Schedule A.

4) Qualified Grantees shall not bill the Department for any procedures covered by Medicare Advantage Plans that have been billed and paid by the Medicare Advantage Plans;

5) Qualified Grantees shall indicate on the invoice if the Eligible Senior has dental coverage through a Medicare Advantage Plan and any claim to the Medicare Advantage Plan was adjudicated prior to billing the Department;

6) Qualified Grantees may invoice for no more than seven (7) percent of the Program Payment for administrative costs.

8.960.C.6 Annual Report 8.960.C.6.a On or before September 1, 2016, and each September 1 thereafter, each Qualified Grantee receiving funds from the Colorado Dental Health Care Program for Low-Income Seniors shall submit a report to the Department following the state fiscal year contract period. 8.960.C.6.b The annual report shall be completed in a format specified by the Department and shall include:

1) The number of Eligible Seniors served;

2) The types of Covered Dental Care Services provided;

3) An itemization of administrative expenditures;

4) The procedures and amounts billed to Medicare Advantage Plans for Eligible Seniors; and 5) Any other information deemed relevant by the Department. 10 CCR 2505-10 § 8.960 SCHEDULE A: COLORADO DENTAL HEALTH CARE PROGRAM FOR LOW-INCOME SENIORS COVERED SERVICES AND PROCEDURE CODES Capitalized terms within this schedule shall have the meaning specified in the Definitions section. Evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation, periodontal Periodic oral screening where indicated, and evaluation - D0120 $46.00 $46.00 $0.00 may require interpretation of established information acquired through patient additional diagnostic procedures. The findings are discussed with the patient.

Report additional diagnostic procedures separately.

Frequency: Two of D0120, D0150, D0180 per 12 months per patient.

An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Definitive procedures may be required on the same date as the Limited oral evaluation. Typically, patients evaluation - D0140 $63.99 $53.99 $10.00 receiving this type of evaluation problem focused present with a specific problem and/or dental emergencies, trauma, acute infections, etc.

Frequency: Two of D0140 per 12 months per grantee per patient. Not reimbursable on the same date as D0120, D0150, or D0180. Dental hygienists may only provide for an established patient of record.

Evaluation used by general dentist and/or a specialist when evaluating a patient comprehensively. Applicable to new patients; established patients with significant health changes or other unusual circumstances by report; or established patients who have been absent from active treatment for three or more years. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional Comprehensive diagnostic procedures.

oral evaluation - Additional diagnostic new or D0150 $81.00 $81.00 $0.00 procedures should be reported established separately. This includes an patient evaluation for oral cancer, the evaluation and recording of the patient's dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occulusal relationships, periodontal conditions (including periodontal screening and/or charting), hard and soft tissue anomalies, etc.

Frequency: One of D0150 per 36 months per grantee per patient. Two of D0120, D0150, D0180 per 12 months per grantee per patient.

This procedure is indicated for patients showing signs & symptoms of periodontal disease & patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, an Comprehensive evaluation for oral cancer, periodontal evaluation and recording of the evaluation - new D0180 $88.00 $88.00 $0.00 patient’s dental and medical or established history and general health patient assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, and occlusal relationships.

Frequency: One of D0180 per 36 months per patient. Two of D0120, D0150, D0180 per 12 months per patient.

Radiographic survey of whole mouth, intended to display the crowns & roots of all teeth, periapical areas, interproximal areas and alveolar bone including edentulous areas.

Panoramic radiographic image D0330 & bitewing radiographic images D0270-D0277 taken on the same date of service shall not be billed as a D0210.

Intraoral - Minimum of 12-20 films is comprehensive required. Payment for additional series of D0210 $125.00 $125.00 $0.00 periapical radiographs within 60 radiographic days of a full mouth series images D0277 or a panoramic film D0330 is not covered unless there is evidence of trauma.

Frequency: One of D0210, D0277, D0330 per 60 months per patient. Any combination of x-rays taken on the same date of service that equals or exceeds the max allowable fee for D0210 must be billed and reimbursed as D0210.

Six of D0220 per 12 months per patient. Report additional radiographs as D0230. Working and final endodontic treatment films are not covered. Not Intraoral - covered if billed with D3310, periapical first D3320, D3330. Any combination D0220 $25.00 $25.00 $0.00 radiographic of D0220 through D0277 taken image on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. Not allowed on the same day as D0210.

D0230 must be utilized for additional films taken beyond D0220. Working and final endodontic treatment films are included in the endo codes. Not Intraoral - covered if billed with D3310, periapical each D3320, or D3330. Not allowed additional D0230 $23.00 $23.00 $0.00 on the same day as D0210. Any radiographic combination of D0220 through image D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: One of D0270, D0272, D0273, D0274 per 12 months per patient. Any Bitewing - single combination of D0220 through radiographic D0270 $26.52 $26.52 $0.00 D0277 taken on the same date image of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: One of D0270, D0272, D0273, D0274 per 12 months per patient. Any Bitewings - two combination of D0220 through radiographic D0272 $42.00 $42.00 $0.00 D0277 taken on the same date images of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: One of D0270, D0272, D0273, D0274 per 12 months per patient. Any Bitewings - three combination of D0220 through radiographic D0273 $52.00 $52.00 $0.00 D0277 taken on the same date images of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: One of D0270, D0272, D0273, D0274 per 12 months per patient. Any Bitewings - four combination of D0220 through radiographic D0274 $60.00 $60.00 $0.00 D0277 taken on the same date images of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: One of D0210, D0277, D0330 per 60 months per patient. Counts as a full mouth series. Counts as an Vertical bitewings intraoral complete series.

– seven to eight Counts as an intraoral complete D0277 $68.32 $68.32 $0.00 radiographic series. Any combination of images D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: One of D0210, Panoramic D0277, D0330 per 60 months radiographic D0330 $63.00 $63.00 $0.00 per grantee per patient. Counts image as a full mouth series.

Removal of plaque, calculus and stains from the tooth structures and implants in the permanent and transitional dentition. It is intended to control local irritational factors.

Frequency:

● Two of D1110, D4346, D4910 per 12 months per patient.

● Prophylaxis - adult D1110 $99.06 $99.06 $0.00 ● ● May be alternated with D4910 for maintenance of periodontally-involved individuals.

● D1110 cannot be billed on the same day as D4341 – D4910.

● Only allowed for cases with a history of surgical or non- surgical periodontal treatment, excluding D4355.

Topical fluoride application is to be used in conjunction with prophylaxis or preventive Topical application appointment. Should be applied D1206 $52.00 $52.00 $0.00 of fluoride varnish to whole mouth. Frequency: up to four times per 12 calendar months. Cannot be used with D1208.

Any fluoride application, including swishing, trays or paint on variety, to be used in conjunction with prophylaxis or Topical application preventive appointment.

of fluoride - D1208 $52.00 $52.00 $0.00 Frequency: one time per 12 excluding varnish calendar months. Cannot be used with D1206. D1206 varnish should be utilized in lieu of D1208 whenever possible.

Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound Application of tooth structure. Frequency: Two caries arresting Teeth 1- of D1354 per 12 months per D1354 $55.40 $55.40 $0.00 medicament – per 32 patient per tooth for permanent tooth teeth. Not to exceed 4 times per tooth in a lifetime. Cannot be billed on the same day as D1355 or D3110 or D3120 or any D2000 series code (D2140– D2954). Must Report tooth number.

For primary prevention or remineralization. Medicaments applied do not include topical fluorides. Medicaments that may be applied during the delivery of D1355 procedure include Silver Diamine Fluoride (SDF), Silver Caries preventive Nitrate (SN), thymol-CHX medicament Teeth 1- varnish, and topical povidone D1355 $5.83 $5.83 $0.00 application – per 32 iodine (PVP-I). Cannot be billed tooth on the same day as: D1206, D1208, D1354, D0140, D9110, or any restoration codes on the same day or within 12 months of D2140 thru D2954. Maximum of four D1355 per tooth per lifetime. Must report tooth number.

Amalgam - one Frequency: One of D2140 – Teeth 1- surface, primary D2140 $121.78 $111.78 $10.00 D2394 per 36 months per or permanent patient per tooth per surface.

Amalgam - two Frequency: One of D2140 – Teeth 1- surfaces, primary D2150 $152.84 $142.84 $10.00 D2394 per 36 months per or permanent patient per tooth per surface.

Amalgam - three Frequency: One of D2140 – Teeth 1- surfaces, primary D2160 $185.16 $175.16 $10.00 D2394 per 36 months per or permanent patient per tooth per surface.

Amalgam - four or Frequency: One of D2140 – more surfaces, Teeth 1- D2161 $222.27 $212.27 $10.00 D2394 per 36 months per primary or 32 patient per tooth per surface.

permanent Frequency: One of D2140 – Resin-based Teeth 6 - D2394 per 36 months per composite - one D2330 $118.53 $108.53 $10.00 11, 22 - patient per tooth per surface. surface, anterior 27 See Explanation of Restorations.

Frequency: One of D2140 – Resin-based Teeth 6 - D2394 per 36 months per composite - two D2331 $146.00 $136.00 $10.00 11, 22 - patient per tooth per surface. surfaces, anterior 27 See Explanation of Restorations.

Frequency: One of D2140 – Resin-based Teeth 6 - D2394 per 36 months per composite - three D2332 $179.00 $169.00 $10.00 11, 22 – patient per tooth per surface. surfaces, anterior 27 See Explanation of Restorations.

. Frequency: One of D2140 – Resin-based Teeth 6 - D2394 per 36 months per composite - four D2335 $212.00 $202.00 $10.00 11, 22 - patient per tooth per surface. or more surfaces 27 See Explanation of (anterior)

Restorations.

Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not Teeth 1 - Resin-based a preventive procedure.

5, 12 - composite - one D2391 $134.00 $124.00 $10.00 Frequency: One of D2140 – 21, 28 - surface, posterior D2394 per 36 months per patient per tooth per surface.

See Explanation of Restorations.

Frequency: One of D2140 – Teeth 1 - Resin-based D2394 per 36 months per 5, 12 - composite -two D2392 $176.00 $166.00 $10.00 patient per tooth per surface. 21, 28 - surfaces, posterior See Explanation of Restorations.

Frequency: One of D2140 – Teeth 1 - Resin-based D2394 per 36 months per 5, 12 - composite - three D2393 $218.00 $208.00 $10.00 patient per tooth per surface. 21, 28 - surfaces, posterior See Explanation of Restorations.

Frequency: One of D2140 – Resin-based Teeth 1 - D2394 per 36 months per composite - four 5, 12 - D2394 $268.00 $258.00 $10.00 patient per tooth per surface. or more surfaces, 21, 28 - See Explanation of posterior 32 Restorations.

Frequency: One of D2740 – D2794 per 84 months per patient per tooth. Second Teeth 2 - Crown - molars are only covered if it D2740 $912.75 $862.75 $50.00 15, 18 - porcelain/ceramic meets criteria and is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Frequency: One of D2740 – D2794 per 84 months per patient per tooth. Second Crown - porcelain Teeth 2 - molars are only covered if it fused to high D2750 $904.52 $854.52 $50.00 15, 18 - meets criteria and is necessary noble metal 31 to support a partial denture or to maintain eight posterior teeth in occlusion.

Frequency: One of D2740 – D2794 per 84 months per Crown - porcelain patient per tooth. Second Teeth 2 - fused to molars are only covered if it D2751 $829.30 $779.30 $50.00 15, 18 - predominantly meets criteria and is necessary base metal to support a partial denture or to maintain eight posterior teeth in occlusion.

Frequency: One of D2740 – D2794 per 84 months per patient per tooth. Second Crown - porcelain Teeth 2 - molars are only covered if it fused to noble D2752 $861.06 $811.06 $50.00 15, 18 - meets criteria and is necessary metal 31 to support a partial denture or to maintain eight posterior teeth in occlusion.

Frequency: One of D2740 – D2794 per 84 months per patient per tooth. Second Crown - 3/4 cast Teeth 2 - molars are only covered if it predominantly D2781 $780.00 $730.00 $50.00 15, 18 - meets criteria and is necessary base metal 31 to support a partial denture or to maintain eight posterior teeth in occlusion.

Frequency: One of D2740 – D2794 per 84 months per patient per tooth. Second Teeth 2 - Crown - 3/4 cast molars are only covered if it D2782 $780.00 $730.00 $50.00 15, 18 - noble metal meets criteria and is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

This procedure does not include facial veneers. Frequency: One of D2740 – D2794 per 84 months per patient per tooth.

Crown - 3/4 Teeth 1 - D2783 $780.00 $730.00 $50.00 Second molars are only covered porcelain/ceramic 32 if it meets criteria and is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Frequency: One of D2740 – D2794 per 84 months per patient per tooth. Second Teeth 2 - Crown - full cast molars are only covered if it D2790 $932.52 $882.52 $50.00 15, 18 - high noble metal meets criteria and is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Frequency: One of D2740 – D2794 per 84 months per patient per tooth. Second Crown - full cast Teeth 2 - molars are only covered if it predominantly D2791 $780.00 $730.00 $50.00 15, 18 - meets criteria and is necessary base metal 31 to support a partial denture or to maintain eight posterior teeth in occlusion.

Frequency: One of D2740 – D2794 per 84 months per patient per tooth. Second Teeth 2 - Crown - full cast molars are only covered if it D2792 $780.00 $730.00 $50.00 15, 18 - noble metal meets criteria and is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Frequency: One of D2740 – D2794 per 84 months per patient per tooth. Second Teeth 2 - Crown titanium molars are only covered if it D2794 $900.27 $850.27 $50.00 15, 18 - and titanium alloys meets criteria and is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Re-cement or re- bond inlay, onlay, Teeth 1 - Not allowed within 6 months of veneer or partial D2910 $87.00 $77.00 $10.00 32 placement.

coverage restoration Re-cement or re- Teeth 1 - Not allowed within 6 months of D2920 $89.00 $79.00 $10.00 bond crown 32 placement.

Direct placement of a restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, manage caries, create a seal for endodontic isolation, or prevent further deterioration Placement of Teeth 1 - until definitive treatment can be Interim Direct D2940 $66.09 $56.09 $10.00 32 rendered. Not to be used for Restoration endodontic access closure, or as a base or liner under restoration. One of D2940 per lifetime per tooth. RDH's will receive reimbursement when used for telehealth dentistry in partnership with treating dentist.

. Refers to building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box form, or Core buildup, Teeth 2 - concave irregularity in a including any pins D2950 $225.00 $200.00 $25.00 15, 18 - preparation. Frequency: One of when required 31 D2950, D2952, D2954 per 84 months per patient per tooth.

Refers to building up of anatomical crown when restorative crown will be placed.

Not payable on the same tooth and same day as D2951.

Pins placed to aid in retention of Pin retention - per Teeth 2 - restoration. Can only be used in tooth, in addition D2951 $50.00 $40.00 $10.00 15, 18 - combination with a multi-surface to restoration 31 amalgam.

Post and core are custom fabricated as a single unit.

Frequency: One of D2950, Post and core in D2952, D2954 per 84 months Teeth 2 - addition to crown, per patient per tooth. Refers to D2952 $332.00 $307.00 $25.00 15, 18 - indirectly building up of anatomical crown fabricated when restorative crown will be placed. Not payable on the same tooth and same day as D2951.

Core is built around a prefabricated post. This procedure includes the core material. Frequency: One of Prefabricated post Teeth 2 - D2950, D2952, D2954 per 84 and core in D2954 $269.00 $244.00 $25.00 15, 18 - months per patient per tooth. addition to crown 31 Refers to building up of anatomical crown when restorative crown will be placed.

Not payable on the same tooth and same day as D2951.

Preparation of tooth surfaces and topical application of a Application of scaffold to guide hydroxyapatite Hydroxyapatite Teeth 1 - regeneration. One of D2991 per Regeneration D2991 $67.20 $57.20 $10.00 32 lifetime per patient per tooth.

Medicament - per Cannot be billed on the same tooth day/same tooth as any other D2000's codes or D1354.

Endodontic Teeth 6 - Frequency: One D3310 per therapy, anterior D3310 $862.56 $812.56 $50.00 11, 22 - lifetime per patient per tooth. tooth (excluding 27 Teeth covered: 6-11 and 22-27.

final restoration)

Teeth 4, Endodontic Frequency: One D3320 per 5, 12, therapy, premolar lifetime per patient per tooth.

D3320 $982.39 $932.39 $50.00 13, 20, tooth (excluding Teeth covered: 4, 5, 12, 13, 20, 21, 28, final restoration) 21, 28, and 29.

Frequency: One D3330 per lifetime per patient per tooth.

Teeth 2, Second molars are only covered Endodontic 3, 14, if it meets criteria and is therapy, molar $1,127.0 D3330 $1,177.06 $50.00 15, 18, necessary to support a partial tooth (excluding 6 19, 30, denture or to maintain eight final restoration)

31 posterior teeth in occlusion.

Teeth covered: 2, 3, 14, 15, 18, 19, 30, and 31.

Includes all appointments necessary to complete treatment; also includes intra- operative radiographs. Does not Retreatment of include diagnostic evaluation Teeth 6 - Previous Root and necessary D3346 $976.20 $926.20 $50.00 11, 22 - Canal Therapy- radiographs/diagnostic images.

Anterior One of D3346 per lifetime per patient per tooth. Only reimbursable if original treatment not paid by Senior Dental Program.

Includes all appointments necessary to complete treatment; also includes intra- operative radiographs. Does not Teeth 4, Retreatment of include diagnostic evaluation 5, 12, Previous Root $1,060.8 and necessary D3347 $1,110.83 $50.00 13, 20, Canal Therapy- 3 radiographs/diagnostic images.

21, 28, Premolar One of D3347 per lifetime per patient per tooth. Only reimbursable if original treatment not paid by Senior Dental Program Includes all appointments necessary to complete treatment; also includes intra- operative radiographs. Does not include diagnostic evaluation and necessary Teeth 2, radiographs/diagnostic images.

Retreatment of 3, 14, One of D3348 per lifetime per Previous Root $1,266.0 D3348 $1,316.00 $50.00 15, 18, patient per tooth. Only Canal Therapy- 0 19, 30, reimbursable if original Molar 31 treatment not paid by Senior Dental Program. Second molars are only covered if it meets criteria and is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a Periodontal Per definitive treatment in some scaling & root Quadran stages of periodontal disease planing - four or D4341 $280.77 $270.77 $10.00 t LL, LR, and/or as part of pre-surgical more teeth per UL, or procedures in others.

quadrant UR Frequency:

● One of D4341, D4342 per 36 months per patient per quadrant. A minimum of four affected teeth in the quadrant.

● Maximum of two quadrants per date of service in a non- hospital setting.

● Cannot be charged on same date as D1110.

● Any follow-up and re- evaluation are included in the initial reimbursement.

This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as part of pre-surgical Periodontal Per procedures in others. Current scaling & root Quadran periodontal charting must be planing - one to D4342 $192.71 $192.71 $0.00 t LL, LR, present in patient chart three teeth per UL, or documenting active periodontal quadrant UR disease. Frequency:

● One of D4341, D4342 per 36 months per patient per quadrant. A maximum of three teeth in the affected quadrant.

● Maximum of two quadrants per date of service in a non- hospital setting..

1. Documentation of other treatment provided at same time will be requested.

● Cannot be charged on same date as D1110.

● Any follow-up and re- evaluation are included in the initial reimbursement.

The removal of plaque, calculus, and stains from supra- and sub- gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, Scaling in and moderate to severe presence of bleeding on probing. Should not generalized be reported in conjunction with moderate or prophylaxis, scaling and root D4346 $102.00 $92.00 $10.00 severe gingival planing, or debridement inflammation – full procedures. Frequency: Two of mouth, after oral D1110, D4346 per 12 months evaluation per patient. Not reimbursed when billed on the same date of service as D1110, D4341, D4342, D4355, D4910.

● Any follow-up and re- evaluation are included in the initial reimbursement.

● One of (D4335) per 36 months per patient. D0150, D0160, D0180 D1110 is not Full mouth reimbursable when provided on debridement to the same day of service as enable a D4355. D4355 is not comprehensive reimbursable if patient record D4355 $101.48 $91.48 $10.00 periodontal indicates D1110 or D4910 have evaluation and been provided in the previous diagnosis on a 12 month period. Other D4000 subsequent visit series codes are not reimbursable when provided on the same date of service as D4355.

This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated and polishing the teeth. If new Periodontal or recurring periodontal disease D4910 $151.39 $151.39 $0.00 maintenance appears, additional diagnostic and treatment procedures must be considered. Frequency:

● Up to four times per fiscal year per patient.

● Cannot be charged on the same date as D4346.

● Cannot be charged within the first three months following active periodontal treatment.

Reimbursement made upon delivery of a complete maxillary denture to the patient. D5110 or D5120 cannot be used to report an immediate denture, D5130 or D5140. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement. A complete denture is made after teeth have Complete denture D5110 $945.03 $865.03 $80.00 been removed and the gum and - maxillary bone tissues have healed - or to replace an existing denture.

This can vary greatly depending upon patient, oral health, overall health, and other confounding factors. Frequency: Program will only pay for one per every 60 months - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of a complete mandibular denture to the patient. D5110 or D5120 cannot be used to report an immediate denture, D5130, D5140. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement. A complete denture is made after Complete denture D5120 $946.59 $866.59 $80.00 teeth have been removed and - mandibular the gum and bone tissues have healed - or to replace an existing denture. This can vary greatly depending upon patient, oral health, overall health, and other confounding factors.

Frequency: Program will only pay for one per every 60 months - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of an immediate maxillary denture to the patient.

Routine follow-up adjustments/soft tissue condition relines within 6 months are to be anticipated and are included in the initial reimbursement. An immediate denture is made prior to teeth being extracted and is inserted Immediate same day of extraction of denture – D5130 $945.03 $865.03 $80.00 remaining natural teeth.

maxillary Frequency: D5130 can be reimbursed only once per lifetime per patient. Complete denture, D5110, may be considered 60 months after immediate denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file.

Reimbursement made upon delivery of an immediate mandibular denture to the patient. Routine follow-up adjustments/soft tissue condition relines within 6 months are to be anticipated and are included in the initial reimbursement. An immediate denture is made prior to teeth being extracted and is inserted Immediate same day of extraction of denture – D5140 $946.59 $866.59 $80.00 remaining natural teeth.

mandibular Frequency: D5140 can be reimbursed only once per lifetime per patient. Complete dentures, D5120, may be considered 60 months after immediate denture was reimbursed – documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file.

Reimbursement made upon delivery of a complete partial maxillary denture to the patient.

D5211 and D5212 are considered definitive treatments.

Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial resin base denture can be made right after having teeth Maxillary partial extracted (healing from only a denture - resin few teeth is not as extensive as base (including healing from multiple). A partial D5211 $700.00 $640.00 $60.00 retentive/clasping resin base denture can also be materials, rests, made before having teeth and teeth) extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and “try-in” appointments may be necessary and are included in the cost. Frequency: Program will only pay for one resin maxillary per every 36 months - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of a complete partial mandibular denture to the patient. D5211 and D5212 are considered definitive treatment.

Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial resin base denture can be made right Mandibular partial after having teeth extracted denture - resin (healing from only a few teeth is base (including not as extensive as healing from D5212 $778.00 $718.00 $60.00 retentive/clasping multiple). A partial resin base materials, rests, denture can also be made and teeth) before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and “try-in”

appointments may be necessary and are included in the cost.

Frequency: Program will only pay for one every 36 months - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of a complete partial maxillary denture to the patient.

D5213 and D5214 are considered definitive treatment.

Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial cast metal base can also Maxillary partial be made right after having teeth denture – cast extracted (healing from only a metal framework few teeth is not as extensive as with resin denture healing from multiple). A partial D5213 $913.93 $853.93 $60.00 bases (including cast metal base denture can be retentive/clasping made before having teeth materials, rests extracted if the teeth being and teeth) removed are in the front or necessary healing will be minimal. Several impressions and “try-in” appointments may be necessary and are included in the cost. Frequency: Program will only pay for one maxillary per every 60 months - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of a complete partial mandibular denture to the patient. D5213 and D5214 are considered definitive treatment.

Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial cast metal base can be Mandibular partial made right after having teeth denture – cast extracted (healing from only a metal framework few teeth is not as extensive as with resin denture healing from multiple). A partial D5214 $913.93 $853.93 $60.00 bases (including cast metal base denture can retentive/clasping also be made before having materials, rests teeth extracted if the teeth being and teeth) removed are in the front or necessary healing will be minimal. Several impressions and “try-in” appointments may be necessary and are included in the cost. Frequency: Program will only pay for one mandibular per every 60 months - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of an immediate partial maxillary denture to the patient.

D5221 can be reimbursed only once per lifetime per patient and must be on the same date of service as the extraction.

Routine follow-up adjustments or relines within 6 months is to be anticipated and are included in the initial reimbursement. An Immediate immediate partial resin base maxillary partial denture can be made before denture – resin having teeth extracted if the base (including D5221 $656.22 $596.22 $60.00 teeth being removed are in the retentive/clasping front or necessary healing will materials, rests be minimal. Several impressions and teeth)

and “try-in” appointments may be necessary and are included in the cost. Frequency: A maxillary partial denture may be considered 36 months after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file.

Reimbursement made upon delivery of an immediate partial mandibular denture to the patient. D5222 can be reimbursed only once per lifetime per patient and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 months is to be anticipated and are included in the initial Immediate reimbursement. An immediate mandibular partial partial resin base denture can denture – resin be made before having teeth base (including D5222 $656.22 $596.22 $60.00 extracted if the teeth being retentive/clasping removed are in the front or materials, rests necessary healing will be and teeth) minimal. Several impressions and “try-in” appointments may be necessary and are included in the cost. Frequency: A mandibular partial denture may be considered 36 months after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file.

Reimbursement made upon delivery of an immediate partial maxillary denture to the patient.

D5223 can be reimbursed only once per lifetime per patient and must be on the same date of service as the extraction.

Routine follow-up adjustments or relines within 6 months is to be anticipated and are included Immediate in the initial reimbursement. An maxillary partial immediate partial cast metal denture – cast framework with resin base metal framework denture can be made before with resin denture D5223 $913.93 $853.93 $60.00 having teeth extracted if the bases (including teeth being removed are in the retentive/clasping front or necessary healing will materials, rests be minimal. Several impressions and teeth) and “try-in” appointments may be necessary and are included in the cost. Frequency: A maxillary partial denture may be considered 60 months after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file.

Reimbursement made upon delivery of an immediate partial mandibular denture to the patient. D5224 can be reimbursed only once per lifetime per patient and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial Immediate reimbursement. An immediate mandibular partial partial cast metal framework denture – cast with resin base denture can be metal framework made before having teeth with resin denture D5224 $913.93 $853.93 $60.00 extracted if the teeth being bases (including removed are in the front or retentive/clasping necessary healing will be materials, rests minimal. Several impressions and teeth)

and “try-in” appointments may be necessary and are included in the cost. Frequency: A mandibular partial denture may be considered 60 months after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file.

Reimbursement made upon delivery of a partial maxillary denture to the patient. D5225 and D5226 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial flexible base can be made right after having teeth Maxillary partial extracted (healing from only a denture – flexible few teeth is not as extensive as base (including healing from multiple). A partial D5225 $810.65 $750.65 $60.00 retentive/clasping flexible base denture can also materials, rests, be made before having teeth and teeth) extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and “try-in” appointments may be necessary and are included in the cost. Frequency: Program will only pay for one maxillary per every 36 months - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of a partial mandibular denture to the patient. D5225 and D5226 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial flexible base can be made right after having teeth Mandibular partial extracted (healing from only a denture – flexible few teeth is not as extensive as base (including healing from multiple). A partial D5226 $810.65 $750.65 $60.00 retentive/clasping flexible base denture can also materials, rests, be made before having teeth and teeth) extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and “try-in” appointments may be necessary and are included in the cost. Frequency: Program will only pay for one mandibular per every 36 months - documentation that existing prosthesis cannot be made serviceable must be maintained.

Adjust complete maxillary denture. Frequency: two of D5410 per 12 months per client.

Adjust Complete Cannot be charged on a denture Denture - D5410 $55.12 $45.12 $10.00 provided in last six months.

maxillary Cannot be charged in addition to a rebase or reline in a 12 month period.

Adjust complete maxillary denture. Frequency: two of D5411 per 12 months per client.

Adjust Complete Cannot be charged on a denture Denture - D5411 $55.12 $45.12 $10.00 provided in last six months.

mandibular Cannot be charged in addition to a rebase or reline in a 12 month period.

Adjust complete maxillary denture. Frequency: two of D5421 per 12 months per client.

Adjust Partial Cannot be charged on a denture Denture - D5421 $55.12 45.12 $10.00 provided in last six months.

maxillary Cannot be charged in addition to a rebase or reline in a 12 month period.

Adjust complete maxillary denture. Frequency: two of D5422 per 12 months per client.

Adjust Partial Cannot be charged on a denture Denture - D5422 $55.12 $45.12 $10.00 provided in last six months.

mandibular Cannot be charged in addition to a rebase or reline in a 12 month period.

Repair broken complete Repair broken mandibular denture base.

complete denture D5511 $133.79 $123.79 $10.00 Frequency: Two of D5511 per base, mandibular 12 months per patient.

Repair broken complete Repair broken maxillary denture base.

complete denture D5512 $133.79 $123.79 $10.00 Frequency: Two of D5512 per base, maxillary 12 months per patient.

Replace missing Replacement/repair of missing or broken teeth - Teeth 1 - D5520 $100.27 $90.27 $10.00 or broken teeth. Teeth 1 – 32 complete denture 32 and must report tooth number.

- per tooth Repair resin partial mandibular Repair resin denture base. Frequency: Two partial denture D5611 $100.98 $90.98 $10.00 D5611 per 12 months per base, mandibular patient.

Repair resin partial maxillary Repair resin denture base. Frequency: Two partial denture D5612 $100.98 $90.98 $10.00 D5612 per 12 months per base, maxillary patient.

Repair cast partial mandibular Repair cast partial framework. Frequency: Two of framework, D5621 $131.18 $121.18 $10.00 D5621 per 12 months per mandibular patient.

Repair cast partial maxillary Repair cast partial framework. Frequency: Two of framework, D5622 $131.18 $121.18 $10.00 D5622 per 12 months per maxillary patient.

Repair or replace Repair of broken clasp on partial broken denture base – per tooth. Teeth Teeth 1 - retentive/clasping D5630 $141.73 $131.73 $10.00 1 – 32, report tooth number(s). materials – per Frequency: One of D5630 per tooth 12 months per patient per tooth.

Repair/replacement of missing Replace missing tooth. Teeth 1 – 32, report tooth Teeth 1 - or broken teeth- D5640 $101.48 $91.48 $10.00 number(s). Frequency: One of per tooth D5640 per 12 months per patient per tooth.

Adding tooth to partial denture base. Frequency: One of D5650 Add tooth to per 12 months per patient per existing partial Teeth 1 - tooth. Documentation may be D5650 $109.00 $99.00 $10.00 denture – per 32 requested when charged on tooth partial delivered in last 12 months. Teeth 1 – 32, report tooth number(s).

Adding clasp to partial denture base – per tooth. Frequency:

One of D5660 per 12 months Add clasp to per patient per tooth.

existing partial Teeth 1 - D5660 $147.24 $137.24 $10.00 Documentation may be denture – per 32 requested when charged on tooth partial delivered in last 12 months. Teeth 1 – 32, report tooth number(s).

Frequency: One time per 12 months. Completed at laboratory. Cannot be charged Rebase complete D5710 $322.00 $297.00 $25.00 on denture provided in the last 6 maxillary denture months. Cannot be charged in addition to a reline in a 12 month period.

Frequency: One time per 12 months. Completed at Rebase complete laboratory. Cannot be charged mandibular D5711 $322.00 $297.00 $25.00 on denture provided in the last 6 denture months. Cannot be charged in addition to a reline in a 12 month period.

Frequency: One time per 12 months. Completed at laboratory. Cannot be charged Rebase maxillary D5720 $304.00 $279.00 $25.00 on denture provided in the last 6 partial denture months. Cannot be charged in addition to a reline in a 12 month period.

Frequency: One time per 12 months. Completed at Rebase laboratory. Cannot be charged mandibular partial D5721 $304.00 $279.00 $25.00 on denture provided in the last 6 denture months. Cannot be charged in addition to a reline in a 12 month period.

Frequency: One time per 12 months. Cannot be charged on Reline complete denture provided in the last 6 maxillary denture D5730 $192.96 $182.96 $10.00 months. Cannot be charged in (chairside/direct)

addition to a rebase in a 12 month period.

Frequency: One time per 12 Reline complete months. Cannot be charged on mandibular denture provided in the last 6 D5731 $192.96 $182.96 $10.00 denture months. Cannot be charged in (chairside/direct) addition to a rebase in a 12 month period.

Frequency: One time per 12 months. Cannot be charged on Reline maxillary denture provided in the last 6 partial denture D5740 $190.53 $180.53 $10.00 months. Cannot be charged in (chairside/direct)

addition to a rebase in a 12 month period.

Frequency: One time per 12 months. Cannot be charged on Reline mandibular denture provided in the last 6 partial denture D5741 $192.36 $182.36 $10.00 months. Cannot be charged in (chairside/direct)

addition to a rebase in a 12 month period.

Frequency: One time per 12 Reline complete months. Cannot be charged on maxillary denture denture provided in the last 6 D5750 $256.78 $231.78 $25.00 (laboratory/indirect months. Cannot be charged in ) addition to a rebase in a 12 month period.

Frequency: One time per 12 Reline complete months. Cannot be charged on mandibular denture provided in the last 6 denture D5751 $257.98 $232.98 $25.00 months. Cannot be charged in (laboratory/indirect addition to a rebase in a 12 )

month period.

Frequency: One time per 12 Reline maxillary months. Cannot be charged on partial denture denture provided in the last 6 D5760 $254.95 $229.95 $25.00 (laboratory/indirect months. Cannot be charged in ) addition to a rebase in a 12 month period.

Frequency: One time per 12 Reline mandibular months. Cannot be charged on partial denture denture provided in the last 6 D5761 $254.95 $229.95 $25.00 (laboratory/indirect months. Cannot be charged in ) addition to a rebase in a 12 month period.

Includes removal of tooth Extraction, structure, minor smoothing of erupted tooth or Teeth 1 - socket bone, and closure as exposed root D7140 $120.82 $110.82 $10.00 32 necessary. Frequency: One of (elevation and/or D7140 per lifetime per patient forceps removal)

per tooth. Teeth 1 – 32.

Extraction, erupted tooth Includes related cutting of requiring removal gingiva and bone, removal of of bone and/or tooth structure, minor smoothing Teeth 1 - sectioning of D7210 $187.33 $177.33 $10.00 of socket bone and closure. tooth, and Frequency: One of D7210 per including elevation lifetime per patient per tooth.

of mucoperiosteal Teeth 1 - 32 flap if indicated Occlusal surface of tooth covered by soft tissue; requires Removal of Teeth 1 - mucoperiosteal flap elevation.

impacted tooth- D7220 $223.87 $203.87 $20.00 32 Teeth 1-32. Frequency: One of soft tissue D7220 per lifetime per patient per tooth.

Part of crown covered by bone;

requires mucoperiosteal flap Removal of Teeth 1 - elevation and bone removal.

impacted tooth- D7230 $276.44 $256.44 $20.00 32 Teeth 1-32. Frequency: One of partially bony D7230 per lifetime per patient per tooth Most or all of crown covered by bone; requires mucoperiosteal Removal of Teeth 1 - flap elevation and bone impacted tooth- D7240 $320.92 $300.92 $20.00 32 removal. Teeth 1-32.

completely bony Frequency: One of D7240 per lifetime per patient per tooth.

Most or all of crown covered by bone; unusually difficult or Removal of complicated due to factors such impacted tooth- as nerve dissection required, completely boney, Teeth 1 - D7241 $421.97 $401.97 $20.00 separate closure of maxillary with unusual 32 sinus required or aberrant tooth surgical position. Teeth 1-32. Frequency:

complications One of D7241 per lifetime per patient per tooth.

Includes cutting of soft tissue and bone, removal of tooth structure, and closure. Cannot Removal of be charged for removal of residual tooth Teeth 1 - broken off roots for recently D7250 $197.59 $187.59 $10.00 roots (cutting 32 extracted tooth. Teeth 1 – 32 procedure) Frequency: One of D7250 per lifetime per patient per tooth.

Will not be paid to the dentists or group that removed the tooth.

Subsequent to surgical removal of tooth, exposure of sinus requiring repair, or immediate closure of oroantral or oralnasal communication in absence of Primary closure of D7261 $492.96 $482.96 $10.00 fisulous tract. Narrative of a sinus perforation medical necessity may be required and if the sinus perforation was caused by a current grantee or provider of the program.

For partial removal of specimen only. This procedure involves biopsy of osseous lesions and is not used for Incisional biopsy apicectomy/periradicular of oral tissue - D7285 $199.66 $189.66 $10.00 surgery. This procedure does hard (bone, tooth)

not entail an excision. Only covered if there is a suspicious lesion. Must have a pathology report in file.

For partial removal of an architecturally intact specimen only. This procedure is not used at the same time as codes for apicoectomy/periradicular Incisional biopsy curettage. This procedure does D7286 $391.00 $381.00 $10.00 of oral tissue-soft not entail an excision.

Treatment notes must include documentation and proof that biopsy was sent for evaluation.

Only covered if there is a suspicious legion.

The alveoloplasty is distinct (separate procedure) from extractions. Usually in Alveoloplasty in preparation for prosthesis or conjunction with Per other treatments such as extractions - four Quadran D7310 $150.91 $140.91 $10.00 radiation therapy and transplant or more teeth or t LL, LR, surgery. Frequency: One of tooth spaces, per UL, UR D7310 or D7311 per lifetime per quadrant patient per quadrant. Minimum of 4 extractions in the affected quadrant.

The alveoloplasty is distinct (separate procedure) from extractions. Usually in Alveoloplasty in preparation for a prosthesis or conjunction with Per other treatments such as extractions - one Quadran D7311 $150.91 $140.91 $10.00 radiation therapy and transplant to three teeth or t LL, LR, surgery. Frequency: One of tooth spaces, per UL, UR D7311 or D7310 per lifetime per quadrant patient per quadrant. Maximum of 3 extractions in the affected quadrant.

No extractions performed in an edentulous area. See D7310 if teeth are being extracted Alveoloplasty not concurrently with the in conjunction with Per alveoloplasty. Usually in extractions - four Quadran D7320 $217.38 $207.38 $10.00 preparation for prosthesis or or more teeth or t LL, LR, other treatments such as tooth spaces, per UL, UR radiation therapy and transplant quadrant surgery. Frequency: One of D7320 or D7321 per lifetime per patient per quadrant.

No extractions performed in an edentulous area. See D7311 if teeth are being extracted Alveoloplasty not concurrently with the in conjunction with Per alveoloplasty. Usually in extractions - one Quadran D7321 $217.38 $207.38 $10.00 preparation for prosthesis or to three teeth or t LL, LR, other treatments such as tooth spaces, per UL, UR radiation therapy and transplant quadrant surgery. Frequency: One of D7320 or D7321 per lifetime per patient per quadrant.

Excision of benign Must have a pathology report in Lesion up to 1.25 D7410 203.95 193.95 $10.00 file.

cm Removal of benign nonodontogenic Must have a pathology report in D7460 $257.37 $247.37 $10.00 cyst or tumor- file.

lesion diameter up to 1.25 cm Limited to the removal of exostosis, including the removal Removal of lateral of tori, osseous tuberosities, and Per Arch exostosis (maxilla D7471 $314.97 $304.97 $10.00 other osseous protuberances, LA, UA or mandible) when the mass prevents the seating of denture and does not allow denture seal.

Limited to the removal of exostosis, including the removal Per of tori, osseous tuberosities, and Removal of torus Quadran other osseous protuberances, D7472 $370.47 $360.47 $10.00 palatinus t LL, LR, when the mass prevents the UL, UR seating of denture and does not allow denture seal.

Limited to the removal of exostosis, including the removal Per of tori, osseous tuberosities, and Removal of torus Quadran other osseous protuberances, D7473 $361.32 $351.32 $10.00 mandibularis t LL, LR, when the mass prevents the UL, UR seating of denture and does not allow denture seal.

Incision & Incision through mucosa, drainage of Teeth 1 - including periodontal origins.

D7510 $196.66 $186.66 $10.00 abscess - intraoral 32 One of D7510 per lifetime per soft tissue patient per tooth.

Treatment that relieves pain but is not curative; services Palliative provided do not have distinct treatment of procedure codes. Not allowed D9110 $82.95 $57.95 $25.00 dental pain – per with any other services other visit than radiographs. Cannot be billed when the only other service is writing a prescription.

Evaluation for moderate sedation, deep One of D9219 per 12 months D9219 $44.53 $44.53 $0.00 sedation or per grantee per patient.

general anesthesia Deep sedation/general One of D9222 per 1 day per D9222 $126.60 $116.60 $10.00 anesthesia - first patient.

15 minutes Deep sedation/general anesthesia-each D9223 $111.69 $101.69 $10.00 Not allowed with D9243 subsequent 15 minute increment Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non- invasive monitoring protocol and remains in continuous attendance of the patient.

Anesthesia services are considered completed when the Intravenous patient may be safely left under moderate the observation of trained (conscious) D9239 $126.60 $116.60 $10.00 personnel and the doctor may sedation/analgesi safely leave the room to attend a-first 15 minutes to other patients or duties. The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetic effects upon the central nervous system and not dependent upon the route of administration. One of D9239 per 1 day per patient.

Intravenous moderate (conscious)

Thirteen of D9243 per 1 day per sedation/analgesi D9243 $111.69 $101.69 $10.00 patient. Not allowed with D9223 a-each subsequent 15 minute increment EXPLANATION OF RESTORATIONS Location Number Characteristics of Surfaces Anterior - 1 Placed on one of the five surface classifications. . Mesial, Distal, 2 Placed, without interruption, on two of the surface classifications. Incisal, 3 Placed, without interruption, on three of the surface classifications. Lingual, or 4 or more Placed, without interruption, on four or more of the surface classifications. Facial (or Labial)

Posterior – 1 Placed on one of the five surface classifications. Mesial, Distal, 2 Placed, without interruption, on two of the surface classifications. Occlusal, 3 Placed, without interruption, on three of the surface classifications. Lingual, or 4 or more Placed, without interruption, on four or more of the surface classifications. Buccal NOTE: Tooth surfaces are reported using the letters in the following table. Surface Code Buccal B Distal D Facial (or Labial) F Incisal I Lingual L Mesial M Occlusal O

8.970 PROVIDER STABILIZATION FUND

8.970.1 GENERAL DESCRIPTION

8.970.1.A In accordance with Colorado Senate Bill (SB) 25-290 Stabilization Payments for Safety Net Providers, the Provider Stabilization Fund was created to make stabilization payments to eligible safety net providers. The bill directed the state treasury to establish a Provider Stabilization Fund to collect the monies to be used for payments and set forth how the funds will be allocated and designated the Department of Health Care Policy & Financing (the Department) as the administrator of the payments.

8.970.1.B The Provider Stabilization Fund provides an allocation of monies to safety net providers that serve individuals who are considered low-income and uninsured. Monies shall be allocated based on the number of eligible patients in an amount proportional to the total number of eligible patients served by all safety net providers who qualify for monies from this fund.

8.970.2 DEFINITIONS

8.970.2.A Advisory Board means The Provider stabilization fund advisory board created pursuant to C.R.S. § 25.5-3-605, 8.970.2.B. Children’s Basic Health Plan also known as Child Health Plan Plus (CHP+) means the program as specified in Article 8 of Title 25.5, C.R.S. 8.970.2.C. Comprehensive Behavioral Health Provider has the same meaning as defined at C.R.S. § 27-50-101(11).

8.970.2.D. Eligible Patient means a low-income, uninsured individual who is a patient receiving medical services from a Qualified Provider:

1. Whose annual household income is at or below two hundred percent (200%) of the Federal Poverty Guideline (FPG);

2. Who is not enrolled in the Medical Assistance Program, the Children’s Basic Health Plan, Medicare or any other governmental health care coverage such as through Social Security, the Veterans Administration, Military Dependency (TRICARE or CHAMPUS), or the United States Public Health Service; and 3. For whom there is no Third Party Payer paying or reimbursing the safety net provider for all or a portion of the amount charged for the services provided to the individual. 8.970.2.E. Eligible Safety Net Provider - A Safety Net Provider who is identified by the Department to receive funding from the Provider Stabilization Fund. 8.970.2.G. Monies means funds appropriated, transferred, or credited to the Provider Stabilization Fund created in the State Treasury consisting of:

1. Money credited to the fund as a loan from the unclaimed property trust fund pursuant to C.R.S. § 38-13-801(6) ;

2. Money appropriated, transferred, or credited to the fund by the general assembly;

3. Gifts, grants, or donations the Department may receive from public or private sources for the fund.

8.970.2.H. Outside Entity means a business or professional that is not classified as an employee of the provider or the Department and does not have a direct or indirect financial interest with the provider, but has auditing experience or experience working directly with the Medical Assistance Program or similar services or grants for Eligible Patients. 8.970.2.I. Primary Care means health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with patients and treat a range of health-related issues. These providers may also coordinate a patient’s care with specialists and may include other services based on a patient’s needs including dental, comprehensive behavioral health, and vision.

1. 8.970.2.J. Safety Net Provider means a provider as defined at C.R.S. § 25.5-3-602(8). A comprehensive Community Behavioral Health provider as defined at C.R.S. § 27-50-101(11);

2. A Rural Health Clinic as defined at 42 U.S.C § 1395x(aa)(2);

3. A Federally Qualified Health Center as defined at 42 U.S.C. § 1395x(aa)(4); or 4. A health-care provider that is delivering primary care services and at least 50% of whose client caseload is individuals who are enrolled in Medicaid, Medicare, or the Children’s Basic Health Plan or who are Low-Income, Uninsured Individuals. 8.970.2.K. Sliding Fee Schedule meansa tiered co-payment system that determines the level of a patient’s financial participation and guarantees that the patient financial participation is below usual and customary charges. Factors considered in establishing the tiered co-payment system are limited to financial status and the number of members in the patient’s family unit. 8.970.2.L. Third Party Payments or Third Party Payer meansany individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient. Examples include the Medical Assistance Program; the Children’s Basic Health Plan; Medicare; commercial, individual or employment-related health insurance; court-ordered health insurance (such as that required by non-custodial parents); workers' compensation; automobile insurance; and long-term care insurance.

8.970.2.M. Unduplicated User/Patient Count meansthe sum of patients who have had at least one Visit/Encounter with an eligible safety net provider during the applicable calendar year, but does not include the same patient more than once. The sum shall be calculated on a specific point-in- time occurring between the end of the applicable calendar year and prior to the submission of the application. Each patient shall be counted once under only one payment source designation (Third Party Payer or Eligible Patient). The patient’s payment source designation shall be the payment source designation listed for the patient at the specific point-in-time in which the calculation is made. The sum shall not include:

1. Counting a patient more than once if the same patient returns for additional services (e.g., medical or dental) and/or products (e.g., pharmaceuticals) during the applicable calendar year;

2. Counting a patient more than once if the payment source designation changed during the applicable calendar year;

3. Persons who have only received services through an outreach event, community education program, nurse hotline, or other types of community-based events or programs and services were not recorded on an individual basis;

4. Persons who have only received services from large-scale efforts such as mass immunization programs, screening programs, and health fairs; or 5. Persons whose only contact with the provider is to receive Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program) counseling and vouchers are not users and the contact does not generate an encounter. 8.970.2.N. Visit/Encounter meansan appointment with medical personnel (physicians, physician assistants, nurse practitioners, dentists, behavioral health workers, etc.) in which the patient received health related services and/or products (e.g., pharmaceuticals or radiology) and the appointment included primary care that is customarily billable by a safety net provider..

8.970.3 PROVIDER ELIGIBILITY

8.970.3.A. Safety Net Providers who provide Primary Care to Eligible Patients and who meet all the requirements established for the Provider Stabilization Fund as of the date the application form is submitted to the Department shall receive monies appropriated to the Provider Stabilization Fund. Specifically, the provider shall:

1. Meet one of the conditions of a Safety Net Provider as specified in Section 8.970.2.K.; and 2. Submit a completed application form according to stated guidelines as specified under Section 8.970.4.

8.970.4 APPLICATION

8.970.4.A. The application form shall be available to providers annually and posted for public access on the Department's website at least 30 calendar days prior to the application due date. 8.970.4.B. At a minimum, the application form shall require responses that:

1. Demonstrate how the provider meets the criteria of a Safety Net Provider as defined in Section 8.970.2.K.;

2. Provide an Unduplicated User/Patient Count covering the applicable calendar year which, at a minimum, includes the number of patients enrolled in the Medical Assistance Program and the Children’s Basic Health Plan and the number of patients considered to be Eligible Patients; and 3. Provide certification that the Unduplicated User/Patient Count identified in Section 8.970.4.B.2 has been verified by an Outside Entity.

8.970.4.C. Providers must complete and provide an application annually. The application must be made in compliance with all specifications in the application form, including format, data and documentation. Applications must be submitted directly to the Department by the required deadline.

8.970.4.D. All providers who submit an application will be notified within 45 days of the applicationdeadline if the provider has met or did not meet the requirements to be a Eligible Qualified Provider.

8.970.4.E. Safety Net Providers who are eligible for the Primary Care Fund are able to use their Primary Care Fund application for the Provider Stabilization Fund. Such providers must submit the Provider Stabilization Fund Attestation Form to the Department. The attestation form shall:

1. Be available to providers annually and posted for public access on the Department’s website at least 30 calendar days prior to the application due date;

2. Provide attestation that the Safety Net Provider wishes to use the data from their Primary Care Fund application for the Provider Stabilization Fund application;

3. Provide Safety Net Provider contact information and be signed by a representative of the Safety Net Provider.

8.970.5 DISBURSEMENT

8.970.5.A. Eligible Safety Net Providers are determined on a state fiscal year basis and shall receive only those monies received by the Provider Stabilization Fund during that same state fiscal year. Monies disbursed shall include all monies defined in 8.970.2.G. 8.970.5.B. Payments shall be based on the number of Eligible Patients in each Eligible Safety Net Provider’s Unduplicated User/Patient Count in an amount proportionate to the total number of Eligible Patients from all Eligible Safety Net Providers’ Unduplicated User/Patient Counts. 8.970.5.C. The schedule for the disbursement of monies to all Eligible Safety Net Providers shall be dependent on the source and when the funds are available to the Department, with a schedule as follows:

1. Money received by the Department as a loan from the unclaimed property trust or money appropriated, credited, or transferred by the general assembly shall be distributed to eligible providers no later than March 31 in State Fiscal Year 2025-26 and by September 30 in following State Fiscal Years.

2. Money received as a gift, grant, or donation shall be distributed in the first month of the quarter following the quarter the money was received. (Example: Money gifted, granted, or donated between July 1 and September 30 would be distributed by October 3. Money received as a gift, grant, or donation during State Fiscal Year 2025-26 Quarters One and Two (July 1, 2025 - December 31, 2025) would be distributed no later than March 31, 2026.

8.970.6 ADVISORY BOARD

8.970.6.A. Advisory Board function and duties 1. Collaborate with the Department to seek, accept and expend gifts, grants or donations from private or public sources.

2. Collaborate with the Department to annually allocate money appropriated by the general assembly to the Provider Stabilization Fund.

3. Assist the Department with the annual Provider Stabilization Fund report as defined in C.R.S. § 25.5-3-606.

4. Act as consultation to the Department on obtaining federal matching money to the funds in the Provider Stabilization fund.

5. Support the Department with the implementation of the Safety Net Stabilization fund program.

8.970.6.B. Advisory Board appointment details. The advisory board was created by 25.5-3-605 to support the Department with the implementation of the Provider Stabilization Fund. Board members shall be appointed by the Governor with initial appointments being made no later than August 1, 2025. The Advisory Board shall elect a Chair and Vice-Chair from the provider and consumer members.

8.970.6.C. Advisory Board Membership Tenure, Compensation and Frequency of meetings shall be the following:

1. Advisory Board members shall serve a three-year term.

2. Advisory Board members shall serve without compensation or expense reimbursement.

3. Advisory board meetings shall be held quarterly or as determined necessary by the Chair.

8.970.6.D. Sunset Provisions. The Provider Stabilization Fund Advisory Board will be repealed, effective September 1, 2031, subject to review under the Colorado “Sunset” law. _________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 03/04/2007, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]