DEPARTMENT OF HEALTH CARE POLICY AND FINANCING Medical Services Board MEDICAL ASSISTANCE - SECTION 8.700 10 CCR 2505-10 8.700 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _______________________________________________________________________________

8.700 FEDERALLY QUALIFIED HEALTH CENTERS

8.700.1 DEFINITIONS

Federally Qualified Health Center (FQHC) means a hospital-based or free standing center that meets the FQHC definition found in Section 1905(1)(2)(B) of the Social Security Act. Section 1905(1)(2)(B) of the Social Security Act is incorporated by reference. This rule does not include any later amendments to or editions of the incorporated material. A copy of Section 1905(1)(2)(B) of the Social Security Act is available for public inspection for a reasonable charge at the Colorado Department of Health Care Policy and Financing, 1570 Grant St, Denver, Colorado 80203. A copy of the incorporated material is also available for a reasonable charge from the U.S. Government Printing Office, P.O. Box 371954, Pittsburgh, Pennsylvania 15250-7954. The incorporated material may also be examined at any state publications depository library:

Visit means a face-to-face encounter between a center client and physician, dentist, dental hygienist, physician assistant, nurse practitioner, nurse-midwife, visiting nurse, clinical psychologist, podiatrist or clinical social worker providing the services set forth in 8.700.3.

8.700.2 CLIENT CARE POLICIES

8.700.2.A The FQHCs health care services shall be furnished in accordance with written policies that are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member of the group shall not be a member of the FQHC staff.

8.700.2.B The policies shall include:

1. 1. A description of the services the FQHC furnishes directly and those furnished through agreement or arrangement. See section 8.700.3.A.3.
2. 2. Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or client referral, the maintenance of health care records and procedures for the periodic review and evaluation of the services furnished by the FQHC.
3. 3. Rules for the storage, handling and administration of drugs and biologicals.

8.700.3 SERVICES

8.700.3.A The following services may be provided by a certified FQHC:

1. 1. General services Code of Colorado Regulations 1
   1. a. Outpatient primary care services that are furnished by a physician, dentist, dental hygienist, physician assistant, nurse practitioner, nurse midwife visiting nurse, clinical psychologist, podiatrist or clinical social worker as defined in their respective practice acts.
   2. b. Part-time or intermittent visiting nurse care.
   3. c. Services and medical supplies, other than pharmaceuticals, that are furnished as a result of professional services provided under 8.700.3.A.1.a and b.
2. 2. Emergency services. FQHCs furnish medical emergency procedures as a first response to common life-threatening injuries and acute illness and must have available the drugs and biologicals commonly used in life saving procedures.
3. 3. Services provided through agreements or arrangements. The FQHC has agreements or arrangements with one or more providers or suppliers participating under Medicare or Medicaid to furnish other services to clients, including inpatient hospital care; physician services (whether furnished in the hospital, the office, the client’s home, a skilled nursing facility, or elsewhere) and additional and specialized diagnostic and laboratory services that are not available at the FQHC.

8.700.4 PHYSICIAN RESPONSIBILITIES

8.700.4.A A physician shall provide medical supervision and guidance for physician assistants and nurse practitioners, prepare medical orders, and periodically review the services furnished by the clinic. A physician shall be present at the clinic for sufficient periods of time to fulfill these responsibilities and must be available at all times by direct means of communications for advice and assistance on patient referrals and medical emergencies. A clinic operated by a nurse practitioner or physician assistant may satisfy these requirements through agreements with one or more physicians.

8.700.5 ALLOWABLE COST

8.700.5.A The following types and items of cost for primary care services are included in allowable costs to the extent that they are covered and reasonable:

1. 1. Compensation for the services of a physician, dentist, dental hygienist, physician assistant, nurse practitioner, nurse-midwife, visiting nurse, qualified clinical psychologist, podiatrist and clinical social worker who owns, is employed by, or furnishes services under contract to an FQHC.
2. 2. Compensation for the duties that a supervising physician is required to perform.
3. 3. Costs of services and supplies related to the services of a physician, dentist, dental hygienist, physician assistant, nurse practitioner, nurse-midwife, visiting nurse, qualified clinical psychologist, podiatrist or clinical social worker.
4. 4. Overhead cost, including clinic or center administration, costs applicable to use and maintenance of the entity, and depreciation costs.
5. 5. Costs of services purchased by the clinic or center. Code of Colorado Regulations 2 8.700.5.B Unallowable costs include but are not limited to expenses that are incurred by an FQHC and that are not for the provision of covered services, according to applicable laws, rules, and standards applicable to the Medical Assistance Program in Colorado. An FQHC may expend funds on unallowable cost items, but these costs may not be used in calculating the per visit encounter rate for Medicaid clients.

   Unallowable costs, include, but are not necessarily limited to, the following:

6. 1. Offsite Laboratory/X-Ray;
7. 2. Costs associated with services paid by a contracted Behavioral Health Organization (BHO) are costs for provision of covered services but not allowed in the FQHC costs; and, 3. Costs associated with clinics or cost centers which do not provide services to Medicaid clients.

8.700.6 REIMBURSEMENT

8.700.6.A FQHCs shall be reimbursed a per visit encounter rate based on 100% of reasonable cost. An FQHC may be reimbursed for up to three separate encounters occurring in one day and at the same location, so long as the encounters submitted for reimbursement are any combination of the following: medical encounter, dental encounter, or mental health encounter. Duplicate encounters of the same service category occurring on the same day and at the same location are prohibited unless it is a distinct mental health encounter, which is allowable only when rendered services are covered and paid by a contracted BHO.

8.700.6.B A medical encounter, a dental encounter, and a mental health encounter on the same day and at the same location shall count as three separate visits.

1. 1. Encounters with more than one health professional, and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except when the client, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment.
2. 2. Distinct mental health encounters are allowable only when rendered services are covered and paid by a contracted BHO.

8.700.6.C Encounter rate calculation Effective September 1, 2009, the encounter rate shall be the average of the Prospective Payment System (PPS) rate and the alternative payment rate. Effective July 1, 2013, encounter rates will be raised by 2% with the encounter rate not to exceed the higher of the alternative payment rate or the PPS rate.

1. 1. The PPS rate is defined by Section 702 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) included in the Consolidated Appropriations Act of 2000, Public Law 106-554. BIPA is incorporated herein by reference. No amendments or later editions are incorporated.
   1. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Any material that has been incorporated by reference in this rule may be examined at any state publications depository library.
2. 2. The alternative payment rate shall be the lower of the annual rate or the base rate. The annual rate and the base rate shall be calculated as follows:

Code of Colorado Regulations 3

1. a) Annual rates shall be the FQHCs current year’s calculated inflated rate, after audit.
   1. b) The new base rate shall be the calculated, inflated weighted average encounter rate, after audit, for the past three years. Beginning July 1, 2004 the base encounter rate shall be inflated annually using the Medicare Economic Index to coincide with the federal reimbursement methodology for FQHCs. Base rates shall be recalculated (rebased) every three years.
2. 3. If the PPS rate is higher than the alternative payment rate, the FQHC encounter rate shall be the PPS rate.
3. 4. New FQHCs shall file a preliminary FQHC Cost Report with the Department. Data from the preliminary report shall be used to set a reimbursement base rate for the first year. The base rate shall be calculated using the audited cost report showing actual data from the first fiscal year of operations as a FQHC. This shall be the FQHCs base rate until the next rebasing period.
   1. New base rates may be calculated using the most recent audited Medicaid FQHC cost report for those FQHCs that have received their first federal Public Health Service grant with the three years prior to rebasing, rather than using the inflated weighted average of the most recent three years audited encounter rates.
4. 5. The Department shall audit the FQHC cost report and calculate the new annual and base reimbursement rates. If the cost report does not contain adequate supporting documentation, the FQHC shall provide requested documentation within ten (10) business days of request. Unsupported costs shall be unallowable for the calculation of the FQHCs new encounter rate.
   1. Freestanding FQHCs shall file the Medicaid cost reports with the Department on or before the 90th day after the end of the FQHCs’ fiscal year. Freestanding FQHCs shall use the Medicaid FQHC Cost Report developed by the Department to report annual costs and encounters. Failure to submit a cost report within 180 days after the end of a freestanding FQHCs’ fiscal year shall result in suspension of payments. The new reimbursement rate for freestanding FQHCs shall be effective 120 days after the FQHCs fiscal year end. The old reimbursement rate (if less than the new audited rate) shall remain in effect for an additional day above the 120 day limit for each day the required information is late; if the old reimbursement rate is more than the new rate, the new rate shall be effective the 120th day after the freestanding FQHCs fiscal year end. The new reimbursement rate for hospital-based FQHCs shall be effective January 1 of each year.

      If a hospital-based FQHC fails to provide the requested documentation, the costs associated with those activities shall be presumed to be non-primary care services and shall be settled using the Outpatient Hospital reimbursement rate. All hospital-based FQHCs shall submit separate cost centers and settlement worksheets for primary care services and non-primary care services on the Medicare Cost Report for their facilities. Non-primary care services shall be reimbursed according to Section 8.332. Code of Colorado Regulations 4

5. 6. The performance of physician and mid-level medical staff shall be evaluated through application of productivity standards established by the Centers for Medicare and Medicaid Services (CMS) in CMS Publication 27, Section 503; "Medicare Rural Health Clinic and FQHC Manual". If a FQHC does not meet the minimum productivity standards, the productivity standards established by CMS shall be used in the FQHCs’ rate calculation.

8.700.6.D The Department shall notify the FQHC of its rate.

8.700.8 REIMBURSEMENT FOR OUTSTATIONING ADMINISTRATIVE COSTS

8.700.8.A The Department shall reimburse freestanding FQHCs for reasonable costs associated with assisting clients in the Medicaid application process. This outstationing payment shall be made based upon actual cost with a reasonable cost-per-application limit to be established by the Department. The reasonable cost-per application limit shall be based upon the lower of the amount allocated to county departments of social services for comparable functions or a provider- specific workload standard. In no case shall the outstationing payment for FQHCs exceed a maximum cap of $60,000 per facility per year for all administrative costs associated with outstationing activities.

8.700.8.B

1. 1. Hospitals with hospital-based FQHCs shall receive federal financial participation for reasonable costs associated with assisting potential beneficiaries in the Medicaid application process. For any hospital-based FQHC Medicaid cost report audited and finalized after July 1, 2005, Denver Health Medical Center shall receive federal financial participation for eligible expenditures. To receive the federal financial participation, Denver Health Medical Center shall provide the state’s share of the outstationing payment by certifying that the audited administrative costs associated with outstationing activities are eligible Medicaid public expenditures. Such certifications shall be sent to the Safety Net Programs Manager.
2. 2. Hospitals with hospital-based FQHCs shall receive federal financial participation for reasonable costs associated with assisting potential beneficiaries in the Medicaid application process. Effective with the hospital cost report year 2010 and forward, the Department will make an interim payment to Denver Health Medical Center for estimated reasonable costs associated with outstationing activities based on the costs included in the as-filed Medicare cost report. This interim payment will be reconciled to actual costs after the cost report is audited. Denver Health Medical Center shall receive federal financial participation for eligible expenditures. To receive the federal financial participation, Denver Health Medical Center shall provide the state’s share of the outstationing payment by certifying that the interim estimated administrative costs and the final audited administrative costs associated with outstationing activities are eligible Medicaid public expenditures. Such certifications shall be sent to the Safety Net Programs Manager.

8.700.8.C To receive payment, FQHCs shall submit annual logs of applicant information to the Department with their cost report. Applicant logs shall include the applicant’s name, date of application, and social security number if available.

8.700.8.D Reimbursement for outstationing administrative costs shall be determined according to the following guidelines:

Code of Colorado Regulations 5

1. 1. Freestanding FQHCs shall report on a supplementary schedule the administrative and general direct pass-through costs associated with outstationing activities. The Department shall allocate appropriate overhead costs (not separately identified) to calculate the total facility outstationing administrative expenses incurred. Freestanding FQHCs shall receive an annual lump sum retrospective payment based on the audited cost report.
2. 2. Hospitals with hospital-based FQHCs shall submit the administrative and general pass through direct and indirect costs associated with outstationing activities on an extra line on the Medicaid Cost Report and submit all other source documentation to compute allowable outstationing costs. Hospitals with hospital-based FQHCs shall receive payment in accordance with 8.700.8.B. The reimbursement shall be separately identified on the Medicaid Settlement Sheet.

8.711.1 through 8.712 Repealed, effective June 30, 2005

8.715 BREAST AND CERVICAL CANCER PROGRAM

8.715.1 DEFINITIONS

Breast and Cervical Cancer Program (BCCP) means the Medicaid program established, operated and monitored by the Department.

Colorado Women's Cancer Control Initiative (CWCCI) means the program administered by the Colorado Department of Public Health and Environment and funded by the Centers for Disease Control and the National Breast and Cervical Cancer Early Detection Program. In Need of Treatment means services necessary to determine the extent and proper course of cancer or precancerous treatment as well as definitive cancer treatment itself. Treatment can include surgery, radiation, chemotherapy and approved medications following treatment as determined by the client's physician and the Department.

National Breast and Cervical Cancer Early Detection Program (NBCCEDP) means the program where the Centers for Disease Control (CDC) provides breast and cervical screening services to underserved women. In Colorado, the CDC provider is the Department of Public Health and Environment's Colorado Women's Cancer Control Initiative.

Presumptive Eligibility for BCCP means the temporary eligibility for benefits that begin on the date a Qualified Entity determines the client meets eligibility requirements for the BCCP and the client signs the presumptive eligibility form. Women identified by the CWCCI as being In Need of Treatment for breast or cervical cancer or a precancerous condition shall apply for presumptive eligibility on a simplified Medicaid application.

Qualified Entity means a provider contracted with the Department of Public Health and Environment under a cooperative agreement with the CDC to support activities related to the NBCCEDP. A qualified entity shall provide breast and cervical cancer assessment services for the CWCCI. State Designated Entity means an agency acting on behalf of and at the direction of the Department and whose function may include, but is not limited to, processing eligibility determinations and assisting clients with the application process.

8.715.2 ELIGIBILITY REQUIREMENTS

8.715.2.A. Clients shall meet all requirements of the CWCCI program. Code of Colorado Regulations 6 8.715.2.B. Clients shall enroll for screening at participating Breast and Cervical Cancer assessment sites through the CWCCI.

8.715.2.C. Clients shall:

1. 1. Be a woman who has not yet attained the age of 65.
2. 2. Be a resident of Colorado.
3. 3. Be a citizen of the United States or a qualified alien as described in 8.100.53(A)(2) through 8.100.53(A)(4).
4. 4. Have been screened by a Qualified Entity and found to be In Need of Treatment for breast or cervical cancer, including precancerous conditions as determined through pathological tests.
5. 5. Not have creditable coverage as described in 8.715.3.
6. 6. Not be eligible under another Medicaid program.
7. 7. Be a client who has previously qualified and enrolled in a NBCCED program in another state and chooses to transfer her enrollment to CWCCI.

8.715.2.D. Clients shall not have been previously screened or received treatment for breast or cervical cancer prior to July 1, 2002.

8.715.2.E. Clients shall not be considered to be In Need of Treatment if it is determined she only requires routine follow-up monitoring services.

8.715.2.F. Clients shall be willing to seek Medicaid approved breast or cervical cancer or precancerous treatment within three months of the date of eligibility. If a client does not seek such treatment within three months of the date of presumptive eligibility, the client shall be removed from the program on the last day of the third month. The client will be re-entered in the BCCP program at such time as treatment is scheduled to begin. If treatment has not been started within one month of the scheduled date, the client will be disenrolled.

8.715.3 CREDITABLE COVERAGE

8.715.3.A. Creditable coverage shall include coverage of any individual as defined at 10-16-102, C.R.S. (2002).

8.715.3.B. The following are not considered creditable coverage:

1. 1. Limited scope coverage such as that which covers only dental, vision or long term care;
2. 2. Coverage only for a specific disease or illness (unless the specific disease or illness includes breast or cervical cancer); or 3. A medical care program run by the Indian Health Services or a tribal organization. 8.715.3.C. An individual who otherwise has creditable coverage may qualify for the program if:
3. 1. The individual is in a period of exclusion for treatment of breast or cervical cancer; or Code of Colorado Regulations 7 2. The individual has exhausted her lifetime limits on benefits under the plan for breast or cervical cancer.

8.715.3.D. Individuals who have coverage that contains yearly limited drug benefits, yearly limits on outpatient visits or high deductibles shall be considered to have creditable coverage.

8.715.4 PRESUMPTIVE ELIGIBILITY

8.715.4.A. Presumptive eligibility shall be determined by Qualified Entities. 8.715.4.B. The Department shall make available to Qualified Entities:

1. 1. Information on the BCCP presumptive eligibility form and card;
2. 2. Information on how to obtain the Medicaid application; and 3. Information on how to assist CWCCI personnel and individuals on application completion and filing.

8.715.4.C. Qualified Entities shall determine presumptive eligibility based on verbal confirmation by the potential client that she meets CWCCI criteria and shall enroll the clients who appear to be eligible.

8.715.4.D. Presumptive eligibility shall begin on the date the client completes the BCCP presumptive eligibility form and the Qualified Entity determines the client meets all eligibility criteria. 8.715.4.E. All potential clients shall be required to complete the BCCP presumptive eligibility form and the Medicaid application at the same time.

8.715.4.F. The Qualified Entity shall submit the presumptive eligibility form, a copy of the presumptive eligibility card, the CWCCI history and physical, the diagnosis pathology report and the signed consent form to the Department.

8.715.4.G. The Designated Entity shall process the Medicaid application within thirty calendar days of receipt.

8.715.4.H. The presumptive eligibility period shall end on the following:

1. 1. The date on which a formal determination is made on the client's Medicaid application; or 2. If a full determination cannot be made on the basis of the BCCP presumptive eligibility form and the client fails to complete the Medicaid application, then eligibility will end on last day of the month following the month in which the client was determined to be presumptively eligible.

8.715.5 ELIBILITY PERIOD

8.715.5.A. Eligibility shall begin on the date the client is determined to be presumptively eligible. 8.715.5.B. The client shall be eligible to receive services for up to one year from the date of initial eligibility unless she is no longer In Need of Treatment or no longer meets program eligibility requirements.

8.715.5.C. If the client remains in treatment beyond one year, renewed eligibility shall be determined consistent with BCCP and Medicaid requirements.

Code of Colorado Regulations 8 8.715.5.D. A period of renewed eligibility begins each time the client is screened under the CWCCI program and is found to be In Need of Treatment for breast or cervical cancer and meets all other eligibility criteria.

8.715.5.E. A client may be determined no longer eligible for the program if:

1. 1. She does not complete the Medicaid application; or 2. She is no longer In Need of Treatment for breast or cervical cancer or qualified precancerous conditions when the client's provider notifies the Department; or 3. She reaches the age of 65; or 4. She obtains other creditable coverage describe in 8.715.3. 8.715.5.F. Clients who are determined no longer eligible shall be notified in writing as described in 8.715.6(B).

8.715.6 NOTIFICATION

8.715.6.A. The BCCP presumptive eligibility form shall include a statement of the applicant's rights and responsibilities.

8.715.6.B. .The Department shall notify clients who are no longer In Need of Treatment for the BCCP in writing thirty days prior to their disenrollment date. This notice will be provided only to those clients who have completed their course of treatment per their provider.

1. 1. Copies of the notice shall be sent to the client, her designated representative if applicable, the CWCCI site, the State Designated Entity and the client's provider.
2. 2. The notification shall include information regarding appeal rights described in 10 C.C.R. 2505- 10, Section 8.057.

8.715.6.C. The Department shall notify clients who no longer meet the BCCP eligibility criteria at least ten days prior to program termination.

8.715.7 BENEFITS

8.715.7.A. Eligible clients shall receive all Medicaid benefits included in the State Plan. 8.715.7.B. Breast reconstructive surgery shall be a covered benefit when completed up to seven months following a mastectomy.

8.715.7.C. Breast or cervical cancer or precancerous treatment provided prior to the NBCCED program implementation or client enrollment into the BCCP is not a covered benefit. 8.715.7.D. Clients eligible for this program shall receive all mental health services through the Mental Health Assessment Service Agency of the county in which the client resides.

8.715.8 ROLES/RESPONSIBILITIES

8.715.8.A. County Departments of Human/Social Services shall:

1. 1. Assist in providing information to the client about services and benefits available through the program;

Code of Colorado Regulations 9

1. 2. Assist the client in accessing health care services or contact the appropriate agencies for services, such as the enrollment broker, mental health provider and transportation provider;
2. 3. Assist the client in applying for and accessing other benefits for which she may qualify, such as home care allowance, food stamps and financial assistance; and 4. Assist the Department by notifying the Department when a client's eligibility status changes. 8.715.8.B. Clients shall notify the Department and healthcare providers if the client receives creditable coverage or if a third party is responsible for illness or injury to the client. 8.715.8.C. Providers shall respond to inquiries from the Department and provide information required to verify the client's In Need of Treatment status within ten calendar days of the Department's request.

8.715.8.D. Provider's shall follow Medicaid billing instructions and obtain prior authorizations when necessary.

8.715.8.E. The State Designated Entities shall have the following responsibilities:

1. 1. To determine whether a client is eligible for Medicaid in any other eligibility group;
2. 2. To complete review of the Medicaid application form within fifteen days of receipt;
3. 3. To notify the client she has thirty days to submit addition information if needed and if the information is not received the client will be found ineligible;
4. 4. To inform the client of her appeal rights if eligibility is denied; and 5. To disenroll the client from the BCCP when notified the client is no longer in Need of Treatment.

8.726 TEEN PREGNANCY PREVENTION PILOT PROGRAM

8.726.1 DEFINITIONS

At Risk Teenager means a person under nineteen years of age who resides in a neighborhood in which there is a preponderance of poverty, unemployment and underemployment, substance abuse, crime, school dropouts, a significant public assistance population, teen pregnancies and teen parents or other conditions that put families at risk.

Support Services means individual or group counseling, which includes a component on delayed parenting, health guidance and health services such as home visits or visiting nurse services.

8.726.2 CLIENT ELIGIBILITY

The client shall be identified as an At Risk Teenager by a school, health care provider, social service or other community agency.

8.726.3 PROVIDER ELIGIBILITY

Eligible providers shall meet all the following criteria;

1. 1. Be enrolled as a participating provider.

Code of Colorado Regulations 10

1. 2. Submit an application to the Department and be approved as a Teen Pregnancy Prevention Pilot Program provider. The provider application shall include at a minimum:
   1. a. A method of identifying and targeting At Risk Teenagers.
   2. b. An overview of strategies and principles to promote self-sufficiency, self-reliance and the ability to make appropriate family planning decisions.
   3. c. A method of securing a minimum of 10% local funds that will be reviewed by the Department for compliance with federal Medicaid matching requirements.
   4. d. A specific package of Support Services.
   5. e. A methodology for tracking teens to determine success in preventing pregnancy.
   6. f. A description of established community support and collaboration to provide educational, vocational and other services that are not inclusive in the provider's package of Support Services.

8.726.4 REIMBURSABLE SERVICES

The Teen Pregnancy Prevention Pilot Program includes a package of support services developed to reduce teen pregnancy. The support service package may include, but shall not be limited to:

1. 1. Intensive individual or group counseling, which includes a component on delayed parenting.
2. 2. Guidance promoting self-sufficiency, self-reliance and the ability to make appropriate family planning decisions.
3. 3. Home visits or visiting nurse services.

The service package must be specified in the Teen Pregnancy Prevention Pilot Program provider application and provided as approved. Teen Pregnancy Prevention Pilot Program services are in addition to the currently reimbursed family planning services available to clients.

8.726.5 REIMBURSEMENT

Reimbursement is dependent upon receipt of 90% federal financial funds under the family planning provision. Reimbursement shall be the lower of:

1. 1. Submitted charges; or 2. Fee schedule as determined by the Department.

8.730 FAMILY PLANNING SERVICES

8.730.1 DEFINITIONS

Family Planning Services means physical examinations, diagnoses, treatments, supplies, prescriptions and follow-up services provided to individuals of child-bearing age, including minors who can be considered to be sexually active, in a physician's office, physician's clinic, outpatient or inpatient hospital setting, family planning provider, Federally Qualified Health Center, Rural Health Clinic or a Colorado Department of Health and Environment facility.

Code of Colorado Regulations 11 Institutionalized Individual means an individual who is (a) involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of a mental illness; or (b) confined, under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness. Life-Endangering Circumstance means:

1. 1. The presence of a medical condition, other than a psychiatric condition, as determined by the attending physician, which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term; or 2. The presence of a psychiatric condition, which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term. In such cases, unless the pregnant woman has been receiving prolonged psychiatric care, the attending physician shall obtain consultation from a licensed physician specializing in psychiatry confirming the presence of such a psychiatric condition. Mentally Incompetent Individual means an individual who has been declared mentally incompetent by a federal, state or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes that include the ability to consent to sterilization. Sterilization means any medical procedure, treatment or operation (except for a hysterectomy) for the purpose of rendering an individual permanently incapable of reproducing and requires informed consent.

8.730.2 STERILIZATION

8.730.2.A. Sterilization may be provided as a benefit of the Colorado Medical Assistance Family Planning benefit when the individual has voluntarily given written informed consent and at least 30 days, but no more than 180 days have passed between the date of informed consent and the date of sterilization.

8.730.2.B. The time limitations in 8.730.2A do not apply in the case of premature delivery or emergency abdominal surgery, if at least 72 hours have passed since the date of consent. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery.

8.730.2.C. Sterilization is not a Colorado Medical Assistance Family Planning benefit for an individual who is under the age of 21, mentally incompetent, or institutionalized. 8.730.2.D. An individual shall have given informed consent for sterilization when the person to whom consent was given offered to answer any questions concerning the procedure, provided a copy of the consent form, obtained a signed copy of the consent form and orally provided the following information:

1. 1. The individual is free to withhold or withdraw consent to the procedure at any time before the sterilization without affecting the right to future care or treatment and without loss or withdrawal of any federally funded program benefits to which the individual might otherwise be entitled.
2. 2. A description of available alternative methods of family planning and birth control.
3. 3. The sterilization procedure is considered to be irreversible.
4. 4. An explanation of the specific sterilization procedure to be performed. Code of Colorado Regulations 12 5. A description of the discomforts and risks that may accompany or follow the sterilization procedure including an explanation of the type and possible effects of any anesthetic to be used.
5. 6. A description of the benefits or advantages that may be expected as a result of the sterilization.
6. 7. The sterilization will not be performed for at least 30 days from consent except under the circumstances specified in 8.730.2.B.

8.730.2.E. Arrangements shall be made to ensure the information specified in 8.730.2.D is effectively communicated to any individual who is blind, deaf or otherwise handicapped. 8.730.2.F. An interpreter shall be provided if the individual to be sterilized does not understand the language used on the consent form or the language used by the person obtaining consent. 8.730.2.G. The individual to be sterilized may have a witness of his or her choice present when consenting to the procedure.

8.730.2.H. The consent form requirements of 8.730.2.J shall be met. 8.730.2.I. Informed consent for sterilization cannot be obtained when an individual is:

1. 1. In labor or childbirth;
2. 2. Seeking to obtain or obtaining an abortion; or 3. Under the influence of substances that impair the individual's decision making capabilities. 8.730.2.J. A sterilization consent form shall be signed and dated by:
3. 1. The individual to be sterilized;
4. 2. The interpreter, if one was provided;
5. 3. The person who obtained the consent; and 4. The physician who will perform the sterilization procedure. 8.730.2.K. If an interpreter is provided, the interpreter shall, by signing the consent form, certify that he or she translated the information presented orally, read the consent form and explained its contents to the individual and that to the best of the interpreter's knowledge the individual understood the information provided.

8.730.2.L. The person who obtained the consent shall, by signing the consent form, certify that he or she provided the individual with all of the information set forth in 8.730.2.D above and to the best of best or her knowledge, the individual appeared mentally competent, and knowingly and voluntarily consented to be sterilized.

8.730.2.M. The physician performing the sterilization shall, by signing the consent form, certify that:

1. 1. He or she provided the individual with all of the information set forth in 8.730.2.D above.
2. 2. To the best of his or her knowledge the individual appeared mentally competent, and knowingly and voluntarily consented to be sterilized.

Code of Colorado Regulations 13

1. 3. Except in the case of premature delivery or emergency abdominal surgery, the physician shall further certify that at least 30 days have passed between the date of the individual's signature on the consent form and the date upon which the sterilization was performed.
   1. a. In the case of premature delivery or emergency abdominal surgery performed within 30 days of consent, the physician shall certify that the sterilization was performed less than 30 days, but more than 72 hours after informed consent was obtained because of premature delivery or emergency abdominal surgery, and b. In the case of premature delivery, shall state the expected date of delivery, or c. In the case of abdominal surgery, shall describe the emergency.

8.730.3 HYSTERECTOMIES

8.730.3.A. A hysterectomy is a benefit of the Colorado Medical Assistance Program when performed solely for medical reasons and when the following conditions are met:

1. 1. The person who secures the authorization to perform the hysterectomy has informed the individual or her representative if any, orally and in writing that the hysterectomy will render the individual permanently incapable of reproducing; and;
2. 2. The individual or her representative, if any, has acknowledged in writing receiving that information.

8.730.3.B. The fiscal agent for the Medical Assistance Program shall be provided with a copy of that written acknowledgment. The acknowledgement must be received before reimbursement for any services related to the procedure will be made.

8.730.3.C. Hysterectomy is not a benefit of the Medical Assistance Program when:

1. 1. It is performed solely for the purpose of rendering an individual permanently incapable of reproducing; or 2. There was more man one purpose to the procedure and the hysterectomy would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing.

8.730.3.D. A written acknowledgment of sterility from the recipient is not required if the following circumstances exist:

1. 1. The individual is already sterile at the time of the hysterectomy; or 2. The individual requires a hysterectomy because of a life-threatening emergency in which the physician determines prior acknowledgement is not possible. 8.730.3.E. If an acknowledgement of sterility is not required because of the above exceptions, the physician who performs the hysterectomy must certify in writing either 1. The individual was already sterile, stating the cause of that sterility; or 2. The hysterectomy was performed under a life-threatening emergency situation in which the physician determined prior acknowledgement was not possible. The physician must include a description of the emergency.

Code of Colorado Regulations 14 8.730.3 F. The fiscal agent must receive the physician's certification before reimbursement for the services will be made.

8.730.4 ABORTION SERVICES

8.730.4.A. Abortion services shall only be a benefit of the Colorado Medical Assistance Program when the pregnancy is causing a life-endangering circumstance or in cases of sexual assault or incest. 8.730.4.B. In cases of a life-endangering circumstance, the physician must make every reasonable effort to preserve the lives of the pregnant woman and the unborn child. A licensed physician shall perform the procedure in a licensed health care facility. Such services may be performed in other than a licensed health care facility if, in the medical judgment of the physician, the life of the pregnant woman is substantially threatened and a transfer to a licensed health care facility would further endanger the life of the pregnant woman. Such medical services may be performed in other than a licensed health care facility if the medical services are necessitated by a life- endangering circumstance and if there is no licensed health care facility within a thirty-mile radius of the place where such medical services are performed. 8.730.4.C. Any claim for payment must be accompanied by a case summary which includes the following information:

1. 1. Name, address and age of the pregnant woman;
2. 2. Gestational age of the unborn child;
3. 3. Description of the medical condition which necessitated the abortion;
4. 4. Services performed;
5. 5. Facility in which the abortion was performed; and 6. Date of service.

8.730.4D. A claim for payment must also be accompanied by at least one of the following forms with additional supporting documentation that confirms the life-endangering circumstances:

1. 1. Hospital admission summary.
2. 2. Hospital discharge summary.
3. 3. Consultant findings and reports.
4. 4. Laboratory results and findings.
5. 5. Office visit notes.
6. 6. Hospital progress notes.

8.730.4.E. An evaluation by a licensed physician specializing in psychiatry must accompany the claim for reimbursement for the abortion if a psychiatric condition represents a serious and substantial threat to the pregnant woman's life if the pregnancy continues to term.

8.740 RURAL HEALTH CLINICS

8.740.1 DEFINITIONS

Code of Colorado Regulations 15 Rural Health Clinic means a clinic or center that:

1. 1. Has been certified as a Rural Health Clinic under Medicare.
2. 2. Is located in a rural area, which is an area that is not delineated as an urbanized area by the Bureau of the Census.
3. 3. Has been designated by the Secretary of Health and Human Services as a Health Professional Shortage Area (HPSA) through the Colorado Department of Public Health and Environment.
4. 4. Is not a rehabilitation facility or a facility primarily for the care and treatment of mental diseases.

   Visit means a face-to-face encounter between a clinic client and any health professional providing the services set forth in 8.740.4.

8.740.2 REQUIREMENTS FOR PARTICIPATION

8.740.2.A. A Rural Health Clinic shall be certified under Medicare. 8.740.2.B. A Rural Health Clinic providing laboratory services shall be certified as a clinical laboratory in accordance with 10 C.C.R 2505-10, Section 8.660.

8.740.3 CLIENT CARE POLICIES

8.740.3.A. The Rural Health Clinic’s health care services shall be furnished in accordance with written policies that are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member of the group shall not be a member of the Rural Health Clinic staff. 8.740.3.B. The policies shall include:

1. 1. A description of the services the Rural Health Clinic furnishes directly and those furnished through agreement or arrangement. See section 8.740.4.A.4.
2. 2. Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or client referral, the maintenance of health care records and procedures for the periodic review and evaluation of the services furnished by the Rural Health Clinic.
3. 3. Rules for the storage, handling and administration of drugs and biologicals.

8.740.4 SERVICES

8.740.4.A. The following services may be provided by a certified Rural Health Clinic:

1. 1. General services
   1. a. Outpatient primary care services that are furnished by a physician assistant, clinical psychologist, clinical social worker, nurse practitioner or nurse midwife as defined in their respective practice acts.
   2. b. Part-time or intermittent visiting nurse care.

Code of Colorado Regulations 16

1. c. Services and medical supplies, other than pharmaceuticals, that are furnished as a result of professional services provided under 8.740.4.A.1.a and b.
2. 2. Laboratory services. Rural Health Clinics furnish basic laboratory services essential to the immediate diagnosis and treatment of the client.
3. 3. Emergency services. Rural Health Clinics furnish medical emergency procedures as a first response to common life-threatening injuries and acute illness and must have available the drugs and biologicals commonly used in life saving procedures.
4. 4. Services provided through agreements or arrangements. The Rural Health Clinic has agreements or arrangements with one or more providers or suppliers participating under Medicare or Medicaid to furnish other services to clients, including inpatient hospital care; physician services (whether furnished in the hospital, the office, the client’s home, a skilled nursing facility, or elsewhere) and additional and specialized diagnostic and laboratory services that are not available at the Rural Health Clinic.

8.740.5 PHYSICIAN RESPONSIBILITIES

8.740.5.A. A physician shall provide medical supervision and guidance for physician assistants and nurse practitioners, prepare medical orders, and periodically review the services furnished by the clinic. A physician shall be present at the clinic for sufficient periods of time to fulfill these responsibilities and must be available at all times by direct means of communications for advice and assistance on client referrals and medical emergencies. A clinic operated by a nurse practitioner or physician assistant may satisfy these requirements through agreements with one or more physicians.

8.740.6 ALLOWABLE COSTS

8.740.6.A. The following types and items of cost shall be included in allowable costs to the extent that they are covered and reasonable:

1. 1. Compensation for the services of a physician who owns, is employed by, or furnishes services under contract to a Rural Health Clinic.
2. 2. Compensation for the duties that a supervising physician is required to perform.
3. 3. Costs of services and supplies incident to the services of a physician, physician assistant, clinical psychologist, clinical social worker, nurse practitioner, or nurse-midwife.
4. 4. Overhead costs, including clinic or center administration, costs applicable to use and maintenance of the entity and depreciation costs.
5. 5. Costs of services purchased by the Rural Health Clinic.

8.740.7 REIMBURSEMENT

8.740.7.A. The Department shall reimburse Rural Health Clinics a per visit encounter rate. Encounters with more than one health professional, and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except when the client, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment.

8.740.7.B. The encounter rate shall be the higher of:

Code of Colorado Regulations 17

1. 1. The Prospective Payment System (PPS), as defined by Section 702 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) included in the Consolidated Appropriations Act of 2000, Public Law 106-554, BIPA is incorporated herein by reference. No amendments or later editions are incorporated. The Acute Care Benefits Section Manager at the Colorado Department of Health Care Policy and Financing may be contacted at 1570 Grant Street, Denver, Colorado 80203, for a copy of BIPA, or the materials may be examined at any publications depository library.
2. 2. The Medicare rate.
   1. a. The Medicare rate for hospital based Rural Health Clinics with less than 50 beds shall be based on actual costs.
   2. b. The Medicare rate for all other Rural Health Clinics is the Medicare upper payment limit for Rural Health Clinics.

8.745 SPECIAL CONNECTIONS

8.745.1 DEFINITIONS

Assessment means an evaluation by a certified drug/alcohol treatment counselor that is designed to determine the level of drug/alcohol abuse or dependence and the comprehensive treatment needs of a drug/alcohol abusing pregnant client.

Case Management means services provided by a certified drug/alcohol treatment counselor to include Medicaid and non-Medicaid service planning, linkage to other service agencies and monitoring, and those actions necessary to obtain both Medicaid and non-Medicaid reimbursable services for the eligible client with multiple treatment needs.

Drug/Alcohol Individual Therapy means substance abuse counseling services provided by a certified drag/alcohol treatment counselor to a client in a licensed drug and alcohol treatment program. Drug/Alcohol Group Therapy means substance abuse counseling services provided by a certified drug/alcohol treatment counselor to a group of not more than twelve clients in a licensed drug and alcohol treatment program.

Health Maintenance Group means services facilitated by a certified drug/alcohol treatment counselor to help a client develop health and life management skills.

8.745.2 DETERMINATION OF CLIENT ELIGIBILITY

8.745.2.A. To receive an Assessment, the client shall be:

1. 1. Medically verified to be pregnant.
2. 2. Determined either presumptively eligible or eligible for Medicaid.
3. 3. Self referred or referred by a health care practitioner as being at risk of a poor birth outcome due to substance abuse during the prenatal period and in need of special assistance in order to reduce such risk.

8.745.2.B. To receive drug/alcohol treatment services, the client shall meet the following conditions:

1. 1. Received an Assessment and met the screening criteria as determined by the Alcohol and Drug Abuse Division of the Colorado Department of Human Services. Code of Colorado Regulations 18 2. Be prior authorized by the Alcohol and Drug Abuse Division of the Colorado Department of Human Services to receive services.

8.745.3 PROVIDER ELIGIBILITY

8.745.3.A. The Alcohol and Drug Abuse Division of the Colorado Department of Human Services shall be the only provider to receive reimbursement for Assessments and drug/alcohol treatment services provided to Program enrolled clients.

8.745.3.B. The Alcohol and Drug Abuse Division of the Colorado Department of Human Services shall contract with certified and approved drug/alcohol treatment programs for the delivery of services.

8.745.4 REIMBURSABLE SERVICES

8.745.4.A. Special Connections Program services are limited to:

1. 1. One Assessment per pregnancy.
2. 2. Drug/alcohol treatment services including Case Management, Drug/Alcohol Individual Therapy, Drug/Alcohol Group Therapy and/or Health Maintenance Group Services.
3. 3. Urine screening and monitoring.

8.745.4.B. All services must be prior approved by the Alcohol and Drug Abuse Division of the Colorado Department of Human Services. Services may be provided as outpatient or residential. Room and board are not covered services.

8.745.5 REIMBURSEMENT

Reimbursement for services provided shall be the lowest of:

1. 1. Submitted charges; or 2. Fee schedule as determined by the Department.

8.746 OUTPATIENT SUBSTANCE ABUSE TREATMENT

8.746.1 DEFINITIONS [Emer. Rule eff 9/ 8 /06; Perm. Rule eff 10/1/06]

Alcohol and/or drug screening means the collection of urine to test for the presence of alcohol and/or drugs.

Group Therapy means therapeutic substance abuse counseling and treatment services with more then one client.

Individual and Family Therapy means therapeutic substance abuse counseling services with one client per session. Family therapy shall be directly related to the client’s treatment for substance abuse and/or dependence.

Social/Ambulatory Detoxification means services provided on a residential basis by a facility licensed by the Alcohol and Drug Abuse Division (ADAD) of the Department of Human Services based on American Society of Addiction Medicine (ASAM) criteria.

Substance Abuse Assessment means an evaluation designed to determine the level of drug/alcohol abuse or dependence and the comprehensive treatment needs of a client. Code of Colorado Regulations 19 Targeted Case Management means medically necessary coordination and planning services provided with or on behalf of a client with a substance abuse diagnosis.

8.746.2 Client Eligibility [Emer. Rule eff 9/8/06; Perm. Rule eff 10/1/06]

8.746.2.A. Clients identified as being appropriate for the Substance Abuse Treatment program shall be assessed as having drug/alcohol abuse or dependence.

8.746.3 Provider Requirements [Emer. Rule eff 9/8/06; Perm. Rule eff 10/1/06]

8.746.3.A. Outpatient substance abuse services shall be provided in an approved facility or by certain licensed health care practitioners with certification in addiction counseling. 8.746.3.B. Providers shall be one of the following:

1. a. Facilities licensed by ADAD to offer outpatient services.
2. b. Licensed physicians who are also:
   1. i) Certified in Addiction Medicine by the American Society of Addiction Medicine (ASAM), or ii) Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction Counselors
      1. (LAC) by Department of Regulatory Agencies (DORA), or
   2. iii) Certified by the National Association of Alcohol and Drug Abuse Counselors (NAADAC) as an NCAC II or MAC.
   3. iv) Certified in Addiction Psychiatry by the American Board of Psychiatry and Neurology (ABPN).
3. c. Licensed non-physician practitioners are any of the following:
   1. i) Psychologist, PhD.
   2. ii) Nurse Practitioner.
   3. iii) Licensed Clinical Social Worker (LCSW).
   4. iv) Marriage and Family Therapist.
   5. v) Licensed Professional Counselor (LPC).
   6. vi) Licensed Addiction Counselor (LAC).
4. d. The above licensed non-physician practitioners shall also be certified addiction counselors with one of the following credentials:
   1. i) Certified by DORA as a CAC II, CAC III.
   2. ii) Certified by NAADAC as an NCAC II or MAC.

8.746.4 Covered Services [Emer. Rule eff 9/8/06; Perm. Rule eff 10/1/06]

1. Outpatient Substance Abuse Treatment services are limited to: Code of Colorado Regulations 20

1. a. Substance Abuse Assessment, which shall be limited to three sessions per state fiscal year.
2. b. Individual and Family Therapy, which shall be limited to 25 sessions at 15 minutes per unit, up to four units per session per state fiscal year.
3. c. Group Therapy sessions, which shall be up to an including three hours per session and limited to 36 sessions per state fiscal year.
4. d. Alcohol/Drug Screening, which shall be limited to 36 specimen collections per state fiscal year. Substance abuse counseling services shall be provided along with screening to discuss results with client.
5. e. Targeted Case Management, which shall be limited to 36 contacts per state fiscal year. Services may include service planning, advocacy and linkage to other medical services related to substance abuse diagnosis, monitoring, and care coordination.
6. f. Social/Ambulatory Detoxification, which shall be limited to seven days per state fiscal year and includes supervision, observation and support for individuals whose intoxication/withdrawal signs and symptoms are severe enough to require a 24 hour structured program but do not require hospitalization.

8.747 SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT SERVICES

8.747.1 DEFINITIONS

Brief Intervention means a provider interaction with a client that is intended to induce a positive change in a health-related behavior. Brief intervention may include an initial intervention, a follow-up intervention and/or a referral.

Brief Screen or Pre-screen means several short questions related to the client’s substance use. A brief screen or pre-screen is designed to determine if a full screen is necessary. Follow-up Intervention means services to reassess a client’s status, assess progress and promote or sustain a reduction in substance use. Follow-up services may also be used to assess a client’s need for additional services.

Full Screen means the use of a Colorado Medicaid approved evidence-based screening tool to identify clients at risk for substance abuse problems.

Screening, Brief Intervention and Referral to Treatment (SBIRT) means comprehensive, integrated public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.

8.747.2 CLIENT ELIGIBILITY

8.747.2.A. All clients 12 years of age and older are eligible to receive this service.

8.747.3 PROVIDER REQUIREMENTS

8.747.3.A. Screening, Brief Intervention and Referral to Treatment services must be provided by, or under the supervision of, a licensed health care professional. Code of Colorado Regulations 21 8.747.3.B. The following licensed professionals are eligible to provide services or supervise staff that are providing services:

1. 1. Licensed Physician 2. Physician Assistant 3. Nurse Practitioner 4. Dentist 5. Psychologist with PhD. or PsyD.
2. 6. Licensed Clinical Social Worker (LCSW)
3. 7. Marriage and Family Therapist 8. Licensed Professional Counselor (LPC)
4. 9. Licensed Addiction Counselor (LAC)
5. 10. Certified Addictions Counselor III 8.747.3.C. All licensed individuals must be trained in order to provide or supervise individuals providing Screening, Brief Intervention and Referral to Treatment services.
6. 1. A minimum of four (4) hours Screening, Brief Intervention and Referral to Treatment training is required.

8.747.3.D. All non-licensed individuals must be trained in Screening, Brief Intervention and Referral to Treatment services in order to provide services; including the following requirements:

1. 1. Be under the supervision of a licensed and trained Screening, Brief Intervention and Referral to Treatment services provider.
2. 2. Complete a minimum of 60 hours professional experience such as coursework, internship, practicum, education or professional work within their respective field. This experience should include a minimum of 4 hours of training that is directly related to Screening, Brief Intervention and Referral to Treatment services.
3. 3. Complete a minimum of 30 hours of face-to-face client contact within their respective field. This may include internships, on the job training, or professional experience. This contact may include, but does not have to be directly related to Screening, Brief Intervention and Referral to Treatment services training.

8.747.4 COVERED SERVICES

8.747.4.A Screening, Brief Intervention and Referral to Treatment services are covered for risky substance use or abuse including alcohol and drugs.

1. 1. A full screen, using a Colorado Medicaid approved screening tool, shall be limited to two (2) per client per state fiscal year.

8.747.4.B. Brief intervention services may be provided on the same date of service as the full screen, or on subsequent days.

Code of Colorado Regulations 22

1. 1. The Brief Intervention shall be limited to two (2) sessions per client per state fiscal year. Each session is limited to two (2) units per session, at 15 minutes per unit.

8.747.5 NON-COVERED SERVICES

8.747.5.A Non-covered services include:

1. 1. Pre-screen or brief screen.

8.747.6 REIMBURSEMENT

8.747.6.A Providers may submit for reimbursement under either CPT or HCPC codes, but not both. 8.747.6.B Screening, Brief Intervention and Referral to Treatment services provided by Federally Qualified Health Centers under supervision, as defined in Section 8.700.1, will be reimbursed in the encounter rate.

8.747.6.C Screening, Brief Intervention and Referral to Treatment services may be provided on the same day as other Evaluation & Management services.

8.747.6.D Any claims reimbursed for more than the maximum units per year are subject to recovery by the Department.

8.748 PRENATAL PLUS PROGRAM

8.748.1 DEFINITIONS

Initial Assessment Form means the Prenatal Plus Program risk assessment tool that must be used by all Prenatal Plus Program Providers to further assess and document a client’s needs. Program Eligibility Screening Form means the Prenatal Plus Program eligibility tool that must be used by all Prenatal Plus Program Providers to determine if a client is eligible for Prenatal Plus Program services. Prenatal Plus Program Provider means an entity or agency that meets the qualifications described in Section 8.748.4 and has been accepted as such by the Department of Health Care Policy and Financing (the Department).

8.748.2 PROGRAM PURPOSE

The purpose of the Prenatal Plus Program is to improve the maternal and infant health outcomes of at- risk Medicaid clients by providing comprehensive and coordinated prenatal and early postpartum support services that complement traditional clinical prenatal care. The primary goal of the program is to reduce the incidence of low birth weight babies while also addressing other lifestyle, behavioral, and non-medical aspects of a woman’s life that may affect her and/or her baby’s health and well-being. By focusing on case management, nutrition counseling and support, psychosocial counseling and support, client education and health promotion, the Prenatal Plus Program seeks to ensure that women have access to the services and information needed to have healthy pregnancies and healthy babies.

8.748.3 CLIENT ELIGIBILITY

8.748.3.A To be eligible for services provided through the Prenatal Plus Program, a Colorado Medicaid client shall:

1. 1. Be pregnant (self-declared or medically verified) or in the postpartum period (but participated in the Prenatal Plus Program during the prenatal period); and Code of Colorado Regulations 23 2. Be determined by a Prenatal Plus Program Provider using the Program Eligibility Screening Form to be at risk of having a negative maternal and/or infant health outcome(s) due to identified risk factors which shall be further assessed and documented using the Initial Assessment Form.

8.748.4 PROVIDER ELIGIBILITY AND QUALIFICATIONS

8.748.4.A Providers wishing to render and be reimbursed for Prenatal Plus Program services, as a condition of being a Prenatal Plus Program Provider, shall:

1. 1. Be a Colorado Medicaid provider enrolled as one of the following Colorado Medicaid Billing Provider Types: Clinic, Federally Qualified Health Center, Rural Health Center, Non- Physician Practitioner Group, Physician, Nurse Practitioner, Certified Nurse-Midwife, or Physician’s Assistant;
2. 2. Execute and submit a Prenatal Plus Program addendum to the Colorado Medical Assistance Program Provider Participation Agreement for review and acceptance by the Department; and 3. Manage a Prenatal Plus Program multidisciplinary team(s) of personnel. The multidisciplinary team shall include:
   1. a. A care coordinator(s) who acts as the hub of the multidisciplinary team and is the person primarily responsible for organizing resources and assisting clients in accessing services to meet their individual needs. The care coordinator(s) shall, at minimum, hold a bachelor’s degree in a relevant human/social services discipline or be a registered nurse;
   2. b. A registered dietitian(s) who is currently registered with the Commission on Dietetic Registration as a registered dietitian, or a dietetic intern(s) in an internship accredited by the American Dietetic Association and supervised by a registered dietitian who has agreed to serve as a preceptor for the dietetic intern;
   3. c. A mental health professional(s) who, at minimum, is a master’s level professional in the field of social work, marriage and family therapy, professional counseling, or other mental health specialty, or an intern(s) in an accredited mental health internship and supervised by a master’s level mental health professional; or the Prenatal Plus Program Provider must have a consistent, documented referral relationship with a mental health provider(s) not part of the multidisciplinary team but participating with the Colorado Medicaid Community Mental Health Services Program. Prenatal Plus Program Providers who do not include a mental health professional as part of their multidisciplinary team shall not be eligible for reimbursement of psychosocial counseling and support through the Prenatal Plus Program; and d. A Colorado Medicaid-enrolled physician, nurse practitioner, certified nurse-midwife, or physician’s assistant who is the rendering provider that delegates the provision of Prenatal Plus Program services to the multidisciplinary team.
3. 4. Retain in the record of each client to whom Prenatal Plus Program services are rendered:
   1. a. Identification of qualifying risk factors using the Program Eligibility Screening Form; and b. A client risk assessment using the Initial Assessment Form. Code of Colorado Regulations 24

8.748.5 REIMBURSABLE SERVICES

8.748.5.A Services reimbursable through the Prenatal Plus Program include:

1. 1. Nutrition counseling and support provided by the registered dietitian/dietetic intern consisting of the following components which may be provided on an individual basis or in a group setting based on client need:
   1. a. Nutrition screening;
   2. b. General nutrition education;
   3. c. Comprehensive nutrition status assessment; and d. Nutrition counseling and targeted nutrition education based on client-specific need. Nutrition counseling shall be considered inclusive of nutrition care-planning, goal- setting, monitoring, follow-up, and nutrition care plan revision.
2. 2. Psychosocial counseling and support provided by the mental health professional consisting of the following components which may be provided on an individual basis or in a group setting based on client need:
   1. a. Psychosocial health screening;
   2. b. Comprehensive psychosocial health assessment; and c. Psychosocial health counseling and support. Psychosocial counseling and support shall be considered inclusive of psychosocial care-planning, goal-setting, monitoring, follow-up, and psychosocial care plan revision.
      1. i. Psychosocial counseling and support does not include clinical psychotherapy services, traditional medication management, or other clinical services specifically related to treatment of a diagnosed mental health disorder. When clinical mental health disorders are identified, including substance use disorders, clients shall be referred to a provider who participates in the Colorado Medicaid Community Mental Health Services Program or a Medicaid-enrolled substance use disorder treatment provider.
3. 3. General client education and health promotion provided by the care coordinator which may be provided on an individual basis or in a group setting based on client need, regarding topics that may include:
   1. a. Basic understanding of the prenatal period
      1. i. Physical and emotional changes related to pregnancy including fetal development;
      2. ii. Healthy and appropriate weight gain during pregnancy;
      3. iii. Healthy prenatal diet and food precautions;
      4. iv. Physical activity precautions and appropriate exercise;
      5. v. Substance use and how it can affect maternal and infant health outcomes; Code of Colorado Regulations 25 vi. Sexually transmitted diseases/infections and how they can affect maternal and infant health outcomes;
      6. vii. Bonding with the baby before birth;

         viii. Importance of oral hygiene;

      7. ix. Warning signs of preterm labor; and x. Common terminology;
   2. b. Common concerns related to childbirth and breastfeeding
      1. i. Birth planning, hospital packing/preparation, and attending birth classes;
      2. ii. Pain management options during delivery; and iii. Benefits of breastfeeding, preparing for breastfeeding and breastfeeding basics;
   3. c. The postpartum period and healthy infancy
      1. i. Postpartum mood disorders ("baby blues" and postpartum depression);
      2. ii. Postpartum recovery issues and adjustment including body changes, self- esteem, and relationship stressors;
      3. iii. Managing stress, day-to-day problem-solving, positive communication techniques, building and using support networks;
      4. iv. Family planning and contraception;
      5. v. Comforting and stimulating infants (including education on shaken baby syndrome risk reduction, recognizing an infant’s distress cues, and bonding/attachment postpartum);
      6. vi. Appropriate expectations for infant behavior, sleeping patterns, teething and crying;
      7. vii. Infant health including newborn feeding, immunizations, pediatrician visits, and car-seat safety; and viii. Environmental risk factors including violence in the home, smoke, substance use and how they can affect infant health; and
4. 4. Targeted case management provided by the care coordinator. Targeted case management is a service provided to assist clients in gaining access to needed medical, social, educational, and other services, and includes the following components:
   1. a. Comprehensive assessment and periodic reassessment of the client’s needs to determine the necessity for any medical, educational, social, or other services; Code of Colorado Regulations 26 b. Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that specifies the goals and actions to address the medical, social, educational, and other services needed and identifies a course of action to respond to the assessed needs;
   2. c. Referral and related activities to help the client obtain needed services including activities that help link the client with medical, social, or educational providers, or other programs and services that are capable of providing needed services; and d. Monitoring and follow-up activities including activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the client’s needs, and which may be with the client, family members, providers, or other entities or individuals.
   3. e. Targeted case management provided by the care coordinator may include, but is not limited to, screening for nutrition and psychosocial risk factors.
   4. f. Note: Targeted case management does not include case management activities that are an integral component of another covered Medicaid service; the direct delivery of an underlying medical, educational, social, or other service to which a client has been referred; activities integral to the administration of foster care programs; or activities for which a client may be eligible that are integral to the administration of another non-medical program.

8.748.6 REIMBURSEMENT

8.748.6.A Reimbursement shall be the lower of:

1. 1. Submitted charges; or 2. Fee schedule for Prenatal Plus Program services as determined by the Department.

8.749 NURSE HOME VISITOR PROGRAM

8.749.1 DEFINITIONS

Nurse means a person licensed as a professional nurse pursuant to §12-38-102,C.R.S., et seq., or accredited by another state or voluntary agency that the state board of nursing has identified by rule pursuant to §12-38-108(1)(a),C.R.S., as one whose accreditation may be accepted in lieu of board approval.

Nurse Home Visitors means registered nurses who provide targeted case management services. Provider Agency means an agency that has met the Nurse Home Visiting Program provider requirements and has been certified by the Department of Public Health and Environment. Targeted Case Management means services which will assist individuals in gaining access to needed medical, social, education and other services to promote healthy first pregnancies, improve the health and development of a woman’s first child and to encourage self-sufficiency.

8.749.2 PROGRAM DESCRIPTION

Code of Colorado Regulations 27 Nurse Home Visitor Program (NHVP) means a program established pursuant to §25-31-101,C.R.S. et seq., including the provision of targeted case management services to first-time pregnant women or whose first child is less than one month old and who are at or below 200% of the Federal Poverty Level. Services are offered through the child’s second birthday plus one month.

8.749.3 CLIENT ELIGIBILITY

First-time (defined as no previous live births), pregnant women or whose first child is less than one month old and who are at or below 200% of the Federal Poverty Level are eligible for the NHVP.

8.749.4 PROVIDER REQUIREMENTS

8.749.4.A. A participating provider shall be:

1. 1. Certified by the Colorado Department of Public Health and Environment; and 2. Allowed to bill as a clinic including, but not limited to Certified Public Health Clinics, Federally Qualified Health Centers and Rural Health Centers.

8.749.5 PROVIDER RESPONSIBILITIES

8.749.5.A. Targeted Case Management Services

1. 1. Providers shall provide Targeted Case Management services including:
   1. a. Assessment of the first time pregnant woman and her first child’s needs for health, mental health, social services, education, housing, childcare and related services.
   2. b. Development of care plans to obtain the needed services.
   3. c. Referral to resources to obtain the needed services including medical providers who provide care to a first time pregnant woman and her first child.
   4. d. Routine monitoring and follow-up visits with the women where progress in obtaining the needed services is monitored, problem-solving assistance is provided and the care plans are revised to reflect the women and children’s current needs.
2. 2. Providers shall document and chart Targeted Case Management activities and complete assessment and referral forms.

8.749.6 REIMBURSEMENT

8.749.6.A. Monthly payments for Targeted Case Management shall be made for each child/family visited under the program.

1. 1. Services to the mother shall be limited to 3 units per month with a lifetime maximum limit of 30 units.
2. 2. Services to the child shall be limited to 3 units per month with a lifetime maximum of 75 units.
3. 3. A different rate shall be calculated for each provider agency based on their actual historical cost and their projected budget for the next fiscal year. Code of Colorado Regulations 28 4. At the end of the fiscal year, payments will be reconciled with the actual costs for each agency based on agency cost reports, to assure that payment was not more than the actual cost of providing services. Overages shall be recovered.

8.750 COMMUNITY MENTAL HEALTH CENTERS/CLINICS [Eff. 08/30/2007]

8.750.1 DEFINITIONS

Community Mental Health Center/Clinic means either a physical plant or health institution planned, organized, operated, and maintained to provide basic community services or a group of services under unified administration or affiliated with one another.

Outpatient means a program of care in which the client receives services in a hospital or other health care facility, but does not remain in the facility twenty four hours a day. Rehabilitative services means activities and/or services recommended by a physician or other licensed practitioner, for maximum reduction or restoration of a physical or mental disability to the best possible functional level.

8.750.2 REQUIREMENTS FOR PARTICIPATION

8.750.2.A. The center/clinic must be licensed by the Colorado Department of Public Health and Environment (CDPHE).

8.750.3 COVERED SERVICES

8.750.3.A. Services shall include but are not limited to prevention, diagnosis and treatment of emotional or mental disorders. Such services shall be rendered primarily on an outpatient and consultative basis for clients residing in a particular community in or near the facility so situated. 8.750.3.B. Community Mental Health Centers/Clinics shall provide medically necessary rehabilitation services in an outpatient setting. Covered services shall include:

1. 1. Case management services, including but not limited to:
   1. a. Service planning and program linkage.
   2. b. Referral recommendations.
   3. c. Monitoring and follow up.
   4. d. Client advocacy.
   5. e. Crisis management.
2. 2. Group psychotherapy services shall be face-to-face services that are insight-oriented, behavior modifying, and that involve emotional interactions of the group members. Group psychotherapy services shall assist in providing relief from distress and behavior issues with other clients who have similar problems and who meet regularly with a practitioner.
3. 3. Individual psychotherapy services shall be face-to-face services that are tailored to address the individual needs of the client. Services shall be insight-oriented, behavior modifying and/or supportive with the client in an office or outpatient facility setting. Individual psychotherapy services are limited to thirty-five visits per State fiscal year. Code of Colorado Regulations 29

8.750.4 REIMBURSEMENT

8.750.4.A. For the purpose of reimbursing Community Mental Health Center and Clinic providers, the Department shall establish a price schedule annually with the Department of Human Services in order to reimburse each provider for its actual or reasonable cost of services.

8.754 CLIENT CO-PAYMENT

8.754.1 CLIENT RESPONSIBILITY

Clients shall be responsible for the following co-payments: 8.754.1.A. Hospital outpatient, $3.00 per visit.

8.754.1.B. Physician (M.D. or D.O) office or home visit, $2.00 per visit. 8.754.1.C. Rural health clinic, $2.00 per visit.

8.754.1.D. Brief, individual, group and partial care community mental health center visits except services which fall under Home and Community Based Service programs, $2.00 per visit. 8.754.1.E. Pharmacy, $1.00 per prescription or refill for generic or multi-source drugs and $3.00 per prescription for single-source or brand name drugs.

8.754.1.F. Optometrist, $2.00 per visit.

8.754.1.G. Podiatrist, $2.00 per visit.

8.754.1.H. Inpatient hospital, $10.00 per day up to 50% of the Medicaid rate for the first day of care in the hospital.

8.754.1.I. Psychiatric services, $.50 per unit of service. A unit is a 15 minute segment. 8.754.1.J. Durable medical equipment/disposable supply services, $1.00 per date of service. 8.754.1.K. Laboratory services, $1.00 per date of service. 8.754.1.L. Radiology services, $1.00 per date of service. 8.754.1.M. Emergency services, $0.00 co-pay.

1. 1. It is the provider’s responsibility to identify emergency on the claim form so that the fiscal agent can exempt the service from co-payment.

8.754.2 NON-EMERGENCY SERVICES

Non-emergency services in the emergency room are considered to be outpatient hospital services and shall be subject to the same co-payment amount as a hospital outpatient visit.

8.754.3 EMERGENCY TREATMENT

Prescription drugs administered during emergency treatment shall be considered part of the treatment and are not subject to co-payment.

8.754.4 PRESCRIPTIONS

Code of Colorado Regulations 30 All prescriptions written in the emergency room or elsewhere are subject to the co-payment set forth in Paragraph 8.754.1.E. above.

8.754.5 EXEMPTIONS

The following clients and services are exempt from co-payment requirements: 8.754.5.A. Children under the age of 19.

8.754.5.B. All services to women in the maternity cycle.

1. 1. The maternity cycle means pregnancy, labor, birth and the immediate postpartum period not to exceed six weeks.
2. 2. The client must inform the provider of her pregnancy or postpartum condition at the time of service, and all providers must indicate pregnancy on the claim form in order to claim this exemption.
3. 3. In the case of prescription drugs, the prescribing physician should note pregnancy or postpartum on the prescription.
4. 4. Providers may request oral or written verification of pregnancy or postpartum condition by contacting the physician.
5. 5. If the provider questions the client’s statement that she is pregnant or postpartum and the provider is unable to obtain verification of the pregnancy or postpartum condition, then the provider may collect the co-payment amount imposed by this regulation from the recipient.
6. 6. If the recipient feels that she has been wrongly denied an exemption due to an unverified pregnancy or postpartum condition, she has the right of appeal through the recipient appeal process set forth at 10 C.C.R. 2505-10, Section 8.057. 8.754.5.C. All services to institutionalized clients, including those in skilled nursing facilities, intermediate care facilities (ICF’s), ICF’s for the mentally retarded, recipients under age 21 in inpatient psychiatric hospitals, and recipients 65 and over in institutions for mental diseases. 8.754.5.D. Family planning services and supplies furnished to clients of child-bearing age. The fiscal agent shall identify the family planning services and supplies exempted on the Medicaid claim form.

8.754.5.E. All emergency services.

1. 1. Emergency services means for all Medicaid clients care for any condition which is life threatening or requires immediate medical intervention.
2. 2. Emergency treatment can be given in the emergency room, the outpatient department, or a physician’s office.
3. 3. The attending medical personnel shall define the emergent nature of the recipient’s condition.
4. 4. For cases where it is not clear if an emergency exists, a triage of the recipient may be conducted as set forth in 10 C.C.R. 2505-10, Section 8.253.6.
5. 5. There shall be no co-payment charge for the triage.

Code of Colorado Regulations 31 8.754.5.F. All services provided under the Community Mental Health Services program and Managed Care programs.

8.754.5.G All preventive and vaccine services as required by the Affordable Care Act (42 USC § 1396d(a)(13) (2010)) and described in the United States Preventive Services Task Force (USPSTF) A and B recommendations and the Advisory Committee for Immunization Practices

1. (ACIP) recommended vaccines and their administration which are hereby incorporated by reference. The incorporation of the USPSTF A and B recommendations and the ACIP recommended vaccines excludes later amendments to, or editions of, the referenced material. The USPSTF A and B recommendations is available from the US Preventive Services Task Force web page at http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm . The ACIP recommended vaccines is available at the Centers for Disease Control and Prevention webpage at http://www.cdc.gov/vaccines/hcp/acip-recs/ . Pursuant to § 24-4-103 (12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

8.754.6 PROVIDERS

8.754.6.A. The co-payment amount charged by a provider shall not vary depending on the cost of the specific service being rendered, except in the case of pharmacy services, where a co-payment differential is established for generic or multi-source versus single-source or “brand-name” drugs. 8.754.6.B. A provider may not deny services to an individual when such clients are unable to immediately pay the co-payment amount. However, the client remains liable for the co-payment at a later date.

8.754.6.C. Providers shall bill their usual and customary charge. For any service for which a co-payment amount is imposed, the fiscal agent shall deduct the appropriate co-payment amount from the payment to the provider.

8.754.6.D. Physicians providing laboratory or radiology services in their office shall be responsible for collecting co-payments for the office visit and for the laboratory or radiology services provided.

8.760 TARGETED CASE MANAGEMENT SERVICES

8.760.1 DEFINITIONS

.11 "Child with a developmental delay" means: a person less than five years of age with delayed development or who is at risk of having a developmental disability as set forth at 2 CCR 503-1 Section 16.120, or as amended.

.12 "Community Centered Board" means a private corporation, for profit or not for profit, which, when designated pursuant to C.R.S. 27-10.5-105, as amended, is authorized to determine eligibility of persons with developmental disabilities within a specific geographic catchment area for services authorized under C.R.S. 27-10.5, as amended, provide case management services to such persons, and provide authorized services to such persons either directly or by purchasing such services from local service agencies.

1. a. Persons receiving targeted case management services may not be restricted from requesting, on a statewide basis, which community centered board will provide them with targeted case management services.

Code of Colorado Regulations 32 .13 "Developmental disability" means a disability that is manifested before the person reaches twenty-two years of age; which constitutes a substantial disability to the affected individual; and is attributable to mental retardation or related conditions which include cerebral palsy, epilepsy, autism, or other neurological conditions when such conditions result in impairment of general intellectual functioning or adaptive behavior similar to that of a person with mental retardation and as set forth in 2 CCR 503-1 Section 16.120, or as amended. Unless otherwise specifically stated, the federal definition of “developmental disability" found in 42 U.S.C. sec. 6000, et seq., shall not apply.

8.761 TARGETED CASE MANAGEMENT SERVICES FOR PERSONS WITH DEVELOPMENTAL

1. DISABILITITES .14 Targeted Case Management services for persons with developmental disabilities consists of facilitating enrollment; locating, coordinating, and monitoring needed developmental disabilities services; and coordinating with other non-developmental disabilities funded services, such as medical, social, educational, and other services to ensure non-duplication of services and monitor the effective and efficient provision of services across multiple funding sources. Targeted case management services includes the following activities:
2. a. Comprehensive assessment and periodic reassessment of individual needs to determine the need for any medical, educational, social or other services and completed annually or when the client experiences significant change in need or in level of support. These assessment activities include:
   1. 1. taking client history;
   2. 2. identifying the client's needs, completing related documentation, and gathering information from other sources such as family members, medical providers, social workers, and educators as necessary, to form a complete assessment of the client.
3. b. Development and periodic revision of a specific care plan that:
   1. 1. is based on the information collected through the assessment;
   2. 2. specifies the goals and actions to address the medical, social, educational, and other services needed by the client;
   3. 3. includes activities such as ensuring the active participation of the client, and working with the client (or the client representative as defined in 10 CCR 2505-10 Section 8.500.1) and others to develop those goals; and 4. identifies a course of action to respond to the assessed needs of the client.
4. c. Referral and related activities to help a client obtain needed services including activities that help link a client with:
   1. 1. medical, social, educational providers; or 2. other programs and services including, making referrals to providers for needed services and scheduling appointments, as needed.
5. d. Monitoring and follow-up includes activities that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual’s needs. Monitoring and follow up actions shall:

Code of Colorado Regulations 33

1. 1. be performed when necessary to address health and safety and services in the care plan.
   1. 2. include activities to ensure:
      1. A. services are being furnished in accordance with the client’s care plan;
      2. B. services in the care plan are adequate; and C. necessary adjustments in the care plan and service arrangements with providers are made if the needs of the client have changed.
   2. 3. include direct contact and observation with the client in a place where services are delivered to a client in accordance with the following frequency:
      1. A. Face to face monitoring shall be completed for a client enrolled in HCBS-DD at least once per quarter, B. Face to face monitoring shall be completed for a client enrolled in HCBS-SLS at least once per quarter, C. Face to face monitoring shall be completed for a client in HCBS-CES at least once per quarter, or D. Face to face monitoring shall be completed at least once per six month period for children in Early Intervention Services.

8.761.2 DETERMINATION OF CLIENT ELIGIBLITY

.21 To receive targeted case management services individuals must meet the following criteria:

1. a. be determined to be eligible for Medicaid by the Department of Social Services in the county in which the person resides;
2. b. be determined by the designated Community Centered Board to have a developmental disability or developmental delay; and c. be actively enrolled in one of the following programs :
   1. 1. Home and Community Based Services for Persons with Developmental Disabilities waiver;
   2. 2. Home and Community Based Services - Supported Living Services waiver;
   3. 3. Home and Community Based Services - Children's Extensive Support waiver; or 4. Early Intervention Services.

.22 The specific programs listed in 8.761.21 (C)(1) through (4) are the only programs which are eligible for targeted case management services.

8.761.3 PROVIDER ELIGIBILITY

.31 Only designated Community Centered Boards may be reimbursed for targeted case management services for persons with developmental disabilities.

Code of Colorado Regulations 34

8.761.4 REIMBURSEMENT

.41 Claims are reimbursable only when supported by the following documentation:

1. a. the name of the client;
2. b. the date of the activity;
3. c. the nature of the activity including whether it is direct or indirect contact;
4. d. the content of the activity including the relevant observations, assessments, findings;
5. e. outcomes achieved, and as appropriate, follow up action; and f. the total number of units associated with the activity. .42 TCM providers shall put documentation in log notes and enter it into the state data system as required by the Department.

.43 Claims for travel time to and from a Targeted Case Management activity are reimbursable at the same unit rate as targeted case management services. The time claimed for travel shall be documented separately from the time claimed for the targeted case management activity. .44 Reimbursement rates shall be published prior to their effective date in accordance with Federal requirements at 42 C.F.R. 447.205, and shall be based upon a market-based rate with a unit of service equal to fifteen (15) minutes according to the State’s approved fee schedule. .45 Targeted case management services may not be claimed prior to the first day of enrollment into an eligible program nor prior to the actual date of eligibility for Medicaid benefits. .46 Targeted Case Management is limited to 60 units per client for State Fiscal Year 2011-12 (April 1 to June 30, 2012). Thereafter, Targeted Case Management is limited to 240 units per client per state fiscal year. This limitation is in effect upon approval from the Centers for Medicare and Medicaid Services (CMS).

8.761.5 EXCLUSIONS

.51 Case management services provided to any individuals enrolled in the following programs are not billable as targeted case management services for persons with developmental disabilities as specified in section 8.760:

1. a. Persons enrolled in a Home and Community Based Services waiver not included as an eligible HCBS service as described in 10 CCR 2505-10 Section 8.761.21c.
2. b. Persons residing in a Class I nursing facility.
3. c. Persons residing in an Intermediate Care Facility for the Intellectually Disabled (ICF-ID).

8.762 CASE MANAGEMENT - MENTAL HEALTH

.10 Case Management Services - Mental Health are a Medicaid benefit statewide when provided in accordance with the provisions of the following sections. .20 DEFINITION Code of Colorado Regulations 35 Case Management Services are defined as those services which will assist mentally ill individuals eligible under the state plan, in gaining access to needed medical, social educational, and other services. These services are separate from those services defined under the clinic options services in Section 8.750.

.30 DETERMINATION OF CLIENT ELIGIBILITY In addition to Medicaid eligibility, individuals must be determined by the community mental health centers to be mentally ill (see section 8.400b.) and in need of case management services as defined above.

.40 PROVIDER ELIGIBILITY Only community mental health centers and clinics designated by the Department of Institutions and licensed by the Department of Health shall be reimbursed for case management services under these provisions.

.50 REIMBURSEMENT Reimbursement shall be on a prospective fee for services basis in accordance with Federal requirements at 42 CFR 447.321 and Section 8.752.

8.765 SERVICES FOR CLIENTS IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES OR

1. RESIDING IN RESIDENTIAL CHILD CARE FACILITIES AS DEFINED BELOW

8.765.1 DEFINITIONS

Assessment means the process of continuously collecting and evaluating information to develop a client’s profile on which to base a Plan of Care, service planning, and referral. Clinical Staff means medical staff that are at a minimum licensed at the level of registered nurse, performing within the authority of the applicable practice acts. Colorado Client Assessment Record (CCAR) means a clinical instrument designed to assess the behavior/mental health status of a medically eligible client. The CCAR is used to identify current diagnosis and clinical issues facing the client, to measure progress during treatment and to determine mental health medical necessity. This instrument is used for children in the custody of a county department of human/social services or Division of youth corrections and for those children receiving mental health services in an RCCF through the Child Mental Health Treatment Act. Emergency Safety Intervention means the use of Restraint and Seclusion as an immediate response to an Emergency Safety Situation.

Emergency Safety Situation means unanticipated behavior of the client that places the client or others at serious threat of violence or injury if no intervention occurs and that calls for Emergency Safety Intervention.

Emergency Services means emergency medical and crisis management services. Independent Team means a team certifying the need for Psychiatric Residential Treatment Facility (PRTF) services that is independent of the Referral Agency and includes a physician who has competence in the diagnosis and treatment of mental illness and knowledge of the client’s condition. Interdisciplinary Team means staff in a PRTF comprised of a physician, and a Licensed Mental Health Professional, registered nurse or occupational therapist responsible for the treatment of the client. Code of Colorado Regulations 36 Licensed Mental Health Professional means a psychologist licensed pursuant to part 3 of article 43 of title 12, C.R.S., a psychiatrist licensed pursuant to part 1 of article 36 of title 12, C.R.S., a clinical social worker licensed pursuant to part 4 of article 43 of title 12, C.R.S., a marriage and family therapist licensed pursuant to part 5 of article 43 of title 12, C.R.S., a professional counselor licensed pursuant to part 6 of article 43 of title 12, C.R.S., or a social worker licensed pursuant to part 4 of article 43 or title 12, C.R.S., that is supervised by a licensed clinical social worker. Sections 12-43-301, et seq, 12-36-101, et seq, 12- 43-401, et seq, 12-43-501, et seq and 12-43-601, et seq, C.R.S. (2005) are incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1714. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library. Medication Management Services means review of medication by a physician at intervals consistent with generally accepted medical practice and documentation of informed consent for treatment. Multidisciplinary Team means staff in a Residential Child Care Facility (RCCF) providing mental health services comprised of at least one Licensed Mental Health Professional and other staff responsible for the treatment of the client and may include a staff member from the Referral Agency. Plan of Care means a treatment plan designed for each client and family, developed by an Interdisciplinary or Multidisciplinary Team.

Prone Position means a client lying in a face down or front down position. Psychiatric Residential Treatment Facility (PRTF) means a facility that is not a hospital and provides inpatient psychiatric services for individuals under age 21 under the direction of a physician, licensed pursuant to part 1 of article 36 of title 12, C.R.S.

Referral Agency means the Division of Youth Corrections, County Departments of Human/Social Services who have legal custody of a client, Behavioral Healthcare Organization or Community Mental Health Center that refers the client to a PRTF or RCCF for the purpose of placement through the Child Mental Health Treatment Act.

Restraint includes Drug Used as a Restraint, Mechanical Restraint and Personal Restraint. Drug Used as a Restraint means any drug that is administered to manage a client’s behavior in a way that reduces the safety risk to the client or to others; has the temporary affect of restricting the client’s freedom of movement and is not a standard treatment for the client’s medical or psychiatric condition. Mechanical Restraint means any device attached or adjacent to the client’s body that the client cannot easily remove that restricts freedom of movement or normal access to the client’s body. Personal Restraint means personal application of physical force without the use of any device, for the purpose of restraining the free movement of the client’s body. This does not include briefly holding a client without undue force in order to calm or comfort, or holding a client’s hand to safely escort the client from one area to another. This does not include the act of getting the client under control and into the required position for Restraint.

Residential Child Care Facility (RCCF) means any facility that provides out-of-home, 24-hour care, protection and supervision for children in accordance with 12 C.C.R. 2509-8, Section 7.705.91.A. Seclusion means the involuntary confinement of a client alone in a room or an area from which the client is physically prohibited from leaving.

8.765.2 PRTF BENEFIT

Code of Colorado Regulations 37 8.765.2.A. PRTF benefit shall include services as identified in the Plan of Care as well as other services necessary for the care of the client in the facility. These services include, but are not limited to:

1. 1. Individual therapy.
2. 2. Group therapy.
3. 3. Family, or conjoint, therapy conducted with the client present, unless client contact with family members is contraindicated.
4. 4. Emergency services.
5. 5. Medication Management Services.
6. 6. Room and Board.

8.765.3 PRTF NON-BENEFIT

8.765.3.A. The following are not a benefit in a PRTF:

1. 1. The day of discharge.
2. 2. Leave days.
3. 3. Days when the client is in detention.

8.765.4 PRTF CLIENT ELIGIBILITY

8.765.4.A. To receive benefits in a PRTF, the client shall:

1. 1. Be between the ages of three and twenty-one.
2. 2. Be certified to need PRTF level of care by an Independent Team. The Team shall certify that:
   1. a. Ambulatory care resources available in the community do not meet the treatment needs of the client.
   2. b. Proper treatment of the client’s mental illness condition requires services on an inpatient basis under the direction of a physician.
   3. c. The services can reasonably be expected to improve the client’s mental health or prevent further regression so that the services shall no longer be needed.
3. 3. Be certified to have a diagnosis of a psychiatric disorder classified as a Diagnostic Statistical Manual (DSM) IV Text Revision, Fourth Edition, diagnosis that is the primary reason for placement from one of the following diagnostic categories: 295 Schizophrenic disorders 296 Affective psychoses 297 Paranoid states 298 Other nonorganic psychoses Code of Colorado Regulations 38 300 Neurotic disorders 301 Personality disorders 307 Eating Disorders, Tic Disorders and Sleep Disorders 308 Acute reaction to stress 309 Adjustment reaction 311 Depressive disorder, not elsewhere classified 312 Disturbance of conduct, not elsewhere classified 313 Disturbance of emotions specific to childhood and adolescence 314 Hyperkinetic syndrome of childhood 4. Be certified to have a DSM Axis 5 GAF score of 40 or less.
4. 5. Be assessed using a current valid Colorado Client Assessment Record (CCAR) that supports medical necessity.

8.765.4.B. The client shall be not be eligible to receive services when:

1. 1. The client is no longer able to benefit from the service or is no longer progressing towards goals.
2. 2. The client is absent without leave in excess of 24 consecutive hours or has been removed from the facility and placed in non-PRTF services.
3. 3. The Interdisciplinary Team determines that the client has attained treatment goals.
4. 4. Admission of minors not in the custody of a County Department of Human/Social Services or DHS as a result of commitment to the Division of Youth Corrections shall be subject to the requirements set forth at Section 27-10-103, C.R.S (2005), which is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1714. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library.

8.765.5 PRTF PROVIDER ELIGIBILITY

8.765.5.A. All PRTF Providers shall have an Interdisciplinary Team.

1. 1. The Interdisciplinary Team shall include either a board-certified psychiatrist, or a clinical psychologist who has a doctoral degree and a physician licensed to practice medicine or osteopathy, and one of the following:
   1. a. A licensed clinical social worker, licensed marriage and family therapist or licensed professional counselor.
   2. b. A registered nurse with specialized training or one year's experience in treating mentally ill individuals.

Code of Colorado Regulations 39

1. c. A certified occupational therapist with specialized training or one year’s experience in treating mentally ill individuals; or d. A licensed psychologist.
2. 2. The Interdisciplinary team shall:
   1. a. Assess the client's immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities.
   2. b. Assess the potential resources of the client and client’s family.
   3. c. Develop and implement a comprehensive, individualized written Plan of Care.
   4. d. Set treatment objectives.
   5. e. Prescribe therapeutic modalities to achieve the objectives of the Plan of Care. 8.765.5.B. All PRTF providers shall implement a Plan of Care.

8.765.5 .C. An initial Plan of Care shall be developed within 72 hours of the client’s admission and shall address the immediate and emergency needs of the client.

8.765.5 .D. A comprehensive Plan of Care shall:

1. 1. Be completed within 14 days of admission.
2. 2. Be signed and dated by the client, the Referral Agency and the Licensed Mental Health Professional.
3. 3. Address clinical and other needs including the client's presenting problems, physical health, emotional status, behavior, support system in the community, available resources and discharge plan.
4. 4. Include specific goals and measurable objectives, expected dates of achievement and specific discharge criteria to be met for termination of treatment. Criteria for discharge shall include provisions for follow-up services.
5. 5. Specify the type, frequency and duration of all PRTF services necessary to meet the needs of the client and to treat the client’s current diagnosis.
6. 6. Identify the provision of or the referral for services other than PRTF Services.
7. 7. Be readily identifiable and be maintained in the client’s record.
8. 8. Document any court-ordered treatment including identifying the agency responsible for providing the court-ordered treatment.
9. 9. Include revisions to the Plan of Care at least monthly, or sooner if appropriate. 8.765.5.E. The PRTF shall designate a Licensed Mental Health Professional to act as a case manager for each client to oversee the formulation, implementation, review and revision to the Plan of Care.

8.765.5.F. The Licensed Mental Health Professional shall sign and date the Plan of Care. Code of Colorado Regulations 40 8.765.5.G. The PRTF shall ensure the client and/or legal guardian participate in the formulation, review and revision of the Plan of Care. If the client or legal guardian is unable to participate or when his or her participation is clinically contraindicated, the PRTF shall document the reasons in the client's record. Any decision to not involve the family or guardian shall be approved by the Referral Agency. In addition, other persons selected by the client, the family or guardian, the Referral Agency or the Licensed Mental Health Professional may be included in the formulation, review and revision of the Plan of Care.

8.765.5.H Except in cases of emergency, all PRTF services in the Plan of Care shall be provided. 8.765.5.I. The PRTF shall ensure that physician prescribed information is used for the component of the Plan of Care requiring Medication Management Services.

8.765.5.J. The PRTF shall ensure all clients and/or guardians are aware of the complaint and grievance procedures.

8.765.5.K. The PRTF shall ensure all clients and/or guardians are aware of the PRTFs policies regarding Restraint and Seclusion as required in 42 C.F.R. 483.350-376, which is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1714. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library.

8.765.5.L. The PRTF shall facilitate access to necessary medical care and shall be responsible for coordinating mental health treatment with medical treatment. 8.765.5.M. Client Transfers:

1. 1. A client shall be transferred only to the care of another PRTF or placement facility when adequate arrangements for care have been made by the Referral Agency.
2. 2. The client and the legal guardian shall be given a minimum of 24 hours notice before the client is transferred unless this notice is waived by the Referral Agency or legal guardian in writing or if an emergency condition exists.
3. 3. Transfers shall be documented in the clinical record. 8.765.5.N. PRTF Licensure and Certification Requirements.
4. 1. The PRTF shall:
   1. a. Be certified by the Department of Human Services (DHS), to provide mental health services as a PRTF.
   2. b. Be licensed by DHS, Division of Child Care Licensing, as a Residential Child Care Facility and a PRTF.
   3. c. Be certified as a qualified residential provider by the Department of Public Health and Environment.
   4. d. Be accredited by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children.

Code of Colorado Regulations 41

1. e. Provide an attestation to the Department that the PRTF is in compliance with the condition of participation for Restraint and Seclusion as described in Section 8.765.6.F and in federal law.
2. 2. A PRTF located in another state shall meet the requirements as set forth in Section 8.765.5.N.1.d. and e. and shall meet all other license and certification requirements for a PRTF in the state in which it is located.
3. 3. A PRTF that has more than one physical address shall have a separate Medicaid provider number for each facility.

8.765.6 PRTF PROVIDER RESPONSIBILITIES

8.765.6.A. A PRTF shall complete a CCAR and maintain an organized, legible, chronological, current treatment record for each client. Treatment records shall include:

1. 1. Admission information such as the client’s personal information and demographic data, source of referral, most current Diagnostic Statistical Manual diagnosis and substance abuse history.
2. 2. Documentation of the client’s legal status, including but not limited to guardianship, conservatorship, court orders, custody, certifications, advisement and consent.
3. 3. Copies of all CCARs.
4. 4. All Plans of Care and revisions.
5. 5. Documentation of client’s attendance at, participation in and outcomes of PRTF Services.
6. 6. Documentation that the client and/or the legal guardian was provided with a copy of the Plan of Care.
7. 7. Correspondence to and from agencies and individuals involved in the client’s treatment.
8. 8. An explanation whenever any member of the Interdisciplinary Team, client, parent or guardian, when appropriate, does not sign a Plan of Care.
9. 9. The name of the Licensed Mental Health Professional responsible for the formulation, implementation, review and revision of the client’s Plan of Care.
10. 10. A discharge report, within 30 consecutive days of the discharge from the PRTF, summarizing treatment received and outcomes.
11. 11. For transfers between facilities, documentation of appropriate clinical information and coordination of services between the two facilities.
12. 12. Documentation of any unplanned discharges without advance notice and any discharges against the Licensed Mental Health Professional's advice.
13. 13. Information regarding any serious injury sustained while in the PRTF to the client or by the client and details describing the circumstances by which the injury occurred.
14. 14. Information regarding a client’s death and details of the circumstances by which the death occurred.

Code of Colorado Regulations 42

1. 15. Dates, times and circumstances of unauthorized leave.
2. 16. Documentation of detention dates.
3. 17. Treatment entries that are signed and dated by the person providing treatment, including title or position of the person providing treatment.

8.765.6.B. All members of the Clinical Staff shall be trained annually in the development and review of Plans of Care and the details of this training shall be documented. 8.765.6.C. Records shall be kept in a secure location at the PRTF. 8.765.6.D. Data, including claims data, shall be retained for six years unless there is a written statutory requirement or regulation available from a county, state or federal agency requiring a longer retention period.

8.765.6.E. Clinical records shall be retained for six years after the client’s 21st birthday. 8.765.6.F. The PRTF shall comply with the following requirements for the use of Restraint and Seclusion:

1. 1. Personal, Mechanical and Drugs Used as Restraint shall be ordered only by a physician, physician’s assistant or nurse practitioner.
2. 2. An order for Restraint or Seclusion shall not be written as a standing order or on an as-needed basis.
3. 3. Restraint and Seclusion shall not result in harm or injury to the client and shall be used only to ensure the safety of the client or others during an Emergency Safety Situation and only until the Emergency Safety Situation has ceased.
4. 4. Restraint and Seclusion shall not be used simultaneously.
5. 5. A Personal Restraint when a client is in a Prone Position is prohibited.
6. 6. If the order for Restraint or Seclusion is verbal, it shall be received by a registered nurse, licensed practical nurse or physician’s assistant.
7. 7. The Restraint or Seclusion shall be carried out by Clinical Staff who are trained in the use of emergency safety intervention.
8. 8. Only a physician, registered nurse, licensed practical nurse or physician’s assistant shall administer a Drug Used as a Restraint.
9. 9. Clinical Staff trained in the use of emergency safety interventions that are physically present during the Restraint or Seclusion shall monitor the client during the Restraint or Seclusion period.
10. 10. Each order for Restraint or Seclusion shall never:
    1. a. Exceed the duration of the emergency safety situation; and b. Exceed four hours in length for youth ages 18 to 21; two hours in length for clients ages nine to 17; or one hour in length for clients under age of nine. Code of Colorado Regulations 43
11. 11. Within one hour of the initiation of the Emergency Safety Intervention a physician, registered nurse or physician’s assistant shall conduct a face-to-face assessment of the physical and psychological well being of the client. A psychologist may conduct the face-to-face assessment if done in conjunction with a physician, registered nurse or physician’s assistant.
12. 12. The PRTF shall report each serious occurrence to both the Department and the federally- designated Protection and Advocacy agency no later than close of business the next business day. Serious occurrences to be reported include a client’s death, a serious injury to a client, or a client’s suicide attempt.
13. 13. The PRTF shall notify the parent(s) or legal guardian(s) of a client who has been restrained or secluded as soon as possible, but not to exceed 24 hours, after the initiation of each emergency safety intervention and shall document the date and time of this notification in the client’s record.
14. 14. Within 24 hours of the use of Restraint or Seclusion, staff involved in an Emergency Safety Intervention and the client shall have a face-to-face discussion. This discussion shall include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the well-being of the client. Other staff and the client’s parent or guardian may participate in the discussion, if appropriate.
15. 15. Within 24 hours after the use of Restraint or Seclusion, all staff involved in the Emergency Safety Intervention, and appropriate supervisory and administrative staff, shall conduct a debriefing session that includes, at a minimum, a review and discussion of:
    1. a. The situation that required the intervention, including a discussion of the precipitating factors that led up to the intervention.
    2. b. Alternative techniques that may have prevented the use of the Restraint or Seclusion.
    3. c. New procedures implemented to mitigate any recurrence of the use of Restraint or Seclusion.
    4. d. The outcome of the intervention, including any injuries that may have resulted from the use of Restraint or Seclusion.

8.765.7 REIMBURSEMENT FOR PRTFs

8.765.7.A. A PRTF shall be reimbursed a per diem rate as determined by DHS and approved by the Department.

8.765.7.B. The Department shall recover the per diem reimbursement when:

1. 1. Each service is not documented in the treatment record at the frequency specified in the Plan of Care.
2. 2. There is no Plan of Care in the record, for the period of time claims were paid.
3. 3. Records are requested but not provided with 21 calendar days. 8.765.C. A PRTF may appeal the Department’s recovery actions within 30 calendar days from the date of notice. The appeal shall be submitted in accordance with 10 C.C.R. 2505-10, Section 8.050.

8.765.8 MENTAL HEALTH BENEFITS FOR CLIENTS IN AN RCCF

Code of Colorado Regulations 44 8.765.98.A. Family therapy shall not exceed maximum of one service unit per day.

1. 1. Family therapy without the client present may be provided at a maximum of one service unit per week if treatment is documented in the Plan of Care that client contact with family members is contraindicated. Family Therapy without the client present shall be for the specific benefit of the client.

8.765. 8.B. Individual therapy shall not exceed two service units per day. 8.765. 8.C. Group therapy shall not exceed eight service units per day. 8.765. 8.D. A Licensed Mental Health Professional may authorize family, individual and group therapy in excess of maximum service units per day if the following is documented in the Plan of Care:

1. 1. The reason for the additional therapy.
2. 2. How many additional units are necessary.
3. 3. How long the additional therapy is necessary.

8.765. 8.E. The Licensed Mental Health Professional shall re-authorize therapy in excess of the maximum service units per day in the Plan of Care at least every 30 days.

8.765.9 NON-COVERED BENEFITS FOR CLIENTS IN AN RCCF

8.765.9.A. The following benefits are not covered for clients in an RCCF:

1. 1. Court-ordered treatment that is not otherwise medically indicated;
2. 2. Room and board services;
3. 3. Educational, vocation and job training services;
4. 4. Recreational or social activities;
5. 5. Habilitative care for children who are developmentally disabled or mentally retarded; and 6. Services provided by public institutions or institutions for mental diseases.

8.765.10 CLIENT ELIGIBILITY FOR MENTAL HEALTH SERVICES IN AN TRCCF

8.765.10.A. To be eligible for mental health services delivered in an RCCF the client shall:

1. 1. Be between the ages of three and 21 years of age.
2. 2. Have a diagnosis of a psychiatric disorder classified by a Diagnostic and Statistical Manual of Mental Disorders (DSM).
3. 3. Have a current, and valid CCAR assessment completed by a Licensed Mental Health Professional that supports medical necessity for mental health services, and demonstrates which services the client would benefit from.

8.765.11 ELIGIBILITY FOR PROVIDERS DELIVERING SERVICES IN AN RCCF

Code of Colorado Regulations 45 8.765.11.A Individual, group and family therapy provided in an RCCF shall be provided by a Licensed Mental Health Professional or a provisionally-licensed Mental Health Professional supervised by a Licensed Mental Health Professional, employed by or contracted with an RCCF that is licensed by the Colorado Department of Human Services.

8.765.11.B. Licensed Mental Health Professionals providing mental health services to clients in an TRCCF are exempt from the direct physician supervision requirement in 10 C.C.R. 2505-10, Section 8.200.2.A through E.

8.765.11.C. Licensed Mental Health Professionals providing mental health services to clients in the RCCF enroll as Medicaid rendering providers.

8.765.12 RCCF RESPONSIBLITIES

8.765.12.A. The RCCF shall include the following in the client’s record:

1. 1. Results from the Multidisciplinary Team’s Assessment;
2. 2. Client’s Medicaid Eligibility Determination Form; and 3. Client’s diagnoses, characteristics and presenting problem. 8.765.12.B. The RCCF shall transmit the items listed in 8.765.12.A. to the Referral Agency. 8.765.12.C. The RCCF shall designate a Licensed Mental Health Professional to act as a case manager for mental health services for each client.

8.765.12.D. The Licensed Mental Health Professional shall maintain an organized, legible, chronological, current record on each client.

8.765.12.E. The client’s Plan of Treatment for mental health services shall be integrated into the agency’s comprehensive Plan of Care reviewed by the Multidisciplinary Team. The Plan of Care shall:

1. 1. Be signed and dated by the client, the Referral Agency and the Licensed Mental Health Professional and the parent/guardian.
2. 2. Include an initial plan developed prior to the onset of mental health services that needs of the client.
3. 3. Address mental health and other needs including the client's presenting problems, physical health, emotional status, behavior, support system in the community, available resources and discharge plan.
4. 4. Include specific goals and measurable objectives, expected dates of achievement and specific discharge criteria to be met for termination of treatment. Criteria for discharge shall include provisions for follow-up services.
5. 5. Specify all mental health services necessary to meet the needs of the client and to treat the client’s current diagnosis while the client is in the RCCF.
6. 6. Identify the provision of or the referral for services other than mental health services.
7. 7. Be readily identifiable and be maintained in the client’s record. Code of Colorado Regulations 46 8. Document any court-ordered mental health services including identifying the agency responsible for providing the court-ordered treatment.
8. 9. Be reviewed by the Multidisciplinary Team monthly and revised as needed. 8.765.12.F. Except in cases of emergency, all mental health services indicated in the Plan of Care shall be provided.

8.765.13 REIMBURSEMENT FOR MENTAL HEALTH SERVICES IN A TRCCF

8.765.13A. Reimbursement for Mental Health Services in a RCCF shall be the lower of billed charges or the maximum unit rate of reimbursement.

8.765.13.B. The RCCF shall enroll as a Medicaid provider for the purposes of acting as a billing entity for Licensed Mental Health Professionals providing mental health services in the RCCF.

8.766 This rule was repealed effective November 30, 2011

_______________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the History link that appears above the text in 10 CCR 2505-10. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10] Code of Colorado Regulations 47