DEPARTMENT OF HEALTH CARE POLICY AND FINANCING Medical Services Board MEDICAL ASSISTANCE - SECTION 8.200 10 CCR 2505-10 8.200 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] 8.200 PHYSICIAN SERVICES 8.200.1 DEFINITIONS Certified Family Planning Clinic means a family planning clinic certified by the Colorado Department of Public Health and Environment, accredited by a national family planning organization and staffed by medical professionals licensed to practice in the State of Colorado, including but not limited to, doctors of medicine, doctors of osteopathy, physicians’ assistants and advanced practice nurses. General Supervision means the procedure is furnished under the physician’s overall direction and control but the physician’s presence is not required during the performance of the procedure. Medically Necessary means a covered service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce or ameliorate the pain and suffering, or the physical, mental, cognitive or developmental effects of an illness, injury or disability; and for which there is no other equally effective or substantially less costly course of treatment suitable for the client’s needs. 8.200.2 COVERED PHYSICIAN SERVICES 8.200.2.A. Physician services are authorized when the service is Medically Necessary, a benefit of Medicaid and provided by the appropriate physician specialty. 8.200.2.B. Physician services in regard to family planning are considered in the same manner as any other medical visit.

8.200.2.C. Physician services in dental care are a benefit when provided for surgery related to the jaw or any structure contiguous to the jaw or reduction of fracture of the jaw or facial bones. Service includes dental splints or other devices. A provider of dental care surgery can either be enrolled as a dentist or oral surgeon, not both.

8.200.2.D. Physician services in regard to foot care are a benefit when provided by a physician or licensed podiatrist.

8.200.2.E. Physician services in regard to vision care are a benefit. 8.200.2.F. Physician services in regard to laboratory testing are a benefit in accordance with 10 C.C.R. 2505-10, Section 8.660.

8.200.2.G. Physician services in regard to the provision of immunizations are a benefit. Vaccines provided to enrolled children shall be obtained through the Colorado Department of Public Health and Environment.

8.200.2.H. Physician services in regard to mental health are a benefit. Outpatient individual and individual brief counseling visits are limited to 35 visits per state fiscal year. 8.200.3 QUALIFIED NON-PHYSICIAN PRACTITIONERS ELIGIBILE TO PROVIDE PHYSICIAN’S SERVICES 8.200.3.A. A doctor of medicine or osteopathy shall order all medical care services or goods that are benefits of Section 8.200 except for dental, podiatry, optometric and mental health services. 8.200.3.B. The following requirements apply to non-physician practitioners rendering Medicaid services: Certified registered nurse anesthetists, certified nurse practitioners, certified occupational therapists, licensed physical therapists, certified audiologists, certified speech pathologists, licensed/certified respiratory therapists and licensed physician assistants may provide services under the following conditions:

1. Services shall be rendered under the General Supervision of a physician. 2. There is appropriate consultation between the non-physician personnel who administers the service. Continuing consultation is the responsibility of the physician. Periodic review of the client’s plan of care is required and shall be documented in the client’s record. Periodic review shall be at the level required by the medical necessity of the patient, no less than once every two months.

3. A physician may prescribe occupational or physical therapy for clients when Medically Necessary. Clients are allowed a set number of units of occupational and physical therapy without prior authorization as established by the Department. If a client requires additional therapy, the provider shall obtain prior authorization before rendering services. Services not properly prior authorized shall not be reimbursed. 8.200.3.C. Reimbursement for certified registered nurse anesthetists, certified pediatric nurse practitioners, certified occupational therapists, licensed physical therapists, certified family nurse practitioners, certified audiologists, certified speech pathologists and certified/licensed respiratory therapists shall be as follows:

1. Services rendered shall be reimbursed by the methodology described in Section 8.200.8.C. 2. Services shall be reimbursed directly to the non-physician provider unless the non-physician provider is acting within the scope of his/her contract with a physician or public or private institution or employment as a salaried employee of a physician or public or private institution.

8.200.3.D. Services provided by licensed physician assistants shall be billed through an enrolled physician.

8.200.3.E. All other non-physician practitioners shall provide services under the Direct Supervision of a physician. Direct Supervision means the physician shall be on-site during the rendering of services and immediately available to give assistance and direction throughout the performance of the service.

1. Reimbursement for other non-physician practitioners shall be made as described in Section 8.200.8.A and billed to Medicaid by the enrolled physician. 2. Reimbursement shall not be made if the practitioner is acting within the scope of their graduate education training program or as contract agents or employees of a nursing home, hospital, FQHC, clinic, home heath agency, school or physician. 8.200.3.F. Supervision shall meet the specific requirements of the state laws governing each medical specialty when those supervision requirements are more stringent than the requirements contained in Section 8.200 et seq.

8.200.3.G. Licensure and required certification for non-physician providers shall be in accordance with their specific specialty practice act and with current state licensure statutes and regulations. 8.200.3.H. Certified nurse midwives shall work in coordination with a physician as described in their practice act. Reimbursements shall be made as described in Section 8.200.8.A. 8.200.3.I. Licensed dental hygienists shall be directly reimbursed for unsupervised dental hygiene services. Hygienists who serve enrolled children shall provide the child with the name of a licensed dentist. Hygienists employed by a dentist, clinic or institution shall submit claims under the employer’s provider number. Reimbursements shall be made as described in Section 8.200.8.E.

8.200.4 TELEMEDICINE 8.200.4.A. Telemedicine means the delivery of medical services and any diagnosis, consultation, treatment, transfer of medical data or education related to health care services using interactive audio, interactive video or interactive data communication instead of in-person contact. 8.200.4.B. No enrolled managed care organization may require face-to-face contact between a provider and a client for services appropriately provided through telemedicine if the client resides in a county with a population of 150,000 or fewer residents and the county has the technology necessary for the provision of telemedicine. The use of telemedicine is not required when in- person care by a participating provider is available to an enrolled client within a reasonable distance.

8.200.4.C. Any health benefits provided through telemedicine shall meet the same standard of care as in- person care.

8.200.5 MENTAL HEALTH 8.200.5.A. Services of licensed psychologists are a benefit. Services are not required to be under the direct supervision of a physician.

8.200.5.B. Psychology services shall be reimbursed under the same methodology as physician services described in Section 8.200.8.A.

8.200.5.C. Services ordered by a psychologist, but rendered by another provider shall be billed under the psychologist. The psychologist shall order the service and provide supervision as outlined under the Psychology Practice Act.

8.200.6 PHYSICAL EXAMINATIONS 8.200.6.A. Physical examinations are a benefit for annual preventative service, diagnosis and evaluation of disease or early and periodic screening, diagnosis and treatment as described in 10 C.C.R. 2505-10, Section 8.282. For the purpose of the adult annual preventive service benefit, annual shall mean state fiscal year.

8.200.7 CERTIFIED FAMILY PLANNING CLINICS 8.200.7.A. Laboratory services provided by Certified Family Planning Clinics shall be reimbursed if the laboratory has met all Clinical Laboratory Improvement Amendment requirements. 8.200.7.B. Services shall be rendered under the General Supervision of a physician. 8.200.7.C. The Certified Family Planning Clinic shall contact the client’s PCP or managed care organization if applicable prior to rendering services that require a referral. 8.200.7.D. Clinic services shall be reimbursed under the same methodology as physician services described in section 8.200.8.A and paid directly to the clinic. 8.200.8 REIMBURSEMENT 8.200.8.A. Physician services shall be reimbursed at the lower of the following: 1. Submitted charges; or 2. Fee schedule as determined by the Department.

8.200.8.B. Physician surgery shall be reimbursed at the lower of the following: 1. Submitted charges; or 2. Fee schedule as determined by the Department.

8.200.8.C. Non-physician practitioners consisting of certified nurse midwives, certified registered nurse anesthetists, certified nurse practitioners, certified audiologists, certified speech pathologists, licensed/certified respiratory therapists, and licensed physician assistants, services shall be reimbursed at the lower of the following:

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

8.200.8.D. Out patient clinical diagnostic laboratory tests preformed by a physician or independent lab shall be reimbursed at the lower of the following:

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

8.200.8.E. Dental services shall be reimbursed at the lower of: 1. Submitted charges; or 2. Fee schedule as determined by the Department.

8.201 TREATMENT OF ORAL MEDICAL CONDITIONS FOR ADULT CLIENTS 8.201.1 DEFINITIONS Adult Client means an individual who is 21 years or older and eligible for medical assistance benefits. Condition of the Oral Cavity means a problem in the oral cavity requiring treatment. Concurrent Medical Condition means a pre-existing medically-diagnosed state that can be exacerbated by a condition present in the oral cavity.

Emergency Treatment means the need for immediate intervention by a physician, osteopath or dentist to stabilize an oral cavity condition.

Immediate Intervention or Treatment means services rendered within twelve (12) hours. Oral Cavity means the jaw, mouth or any structure contiguous to the jaw. 8.201.2 BENEFITS 8.201.2.A. Treatment of a Condition of the Oral Cavity for Adult Clients with a Concurrent Medical Condition is a benefit.

1. Allowable Concurrent Medical Conditions include:

a. Neoplastic disease requiring chemotherapy and/or radiation. b. Pre and post organ transplant.

c. Pregnancy.

d. Chronic medical condition in which there is documentation that the medical condition is exacerbated by a Condition of the Oral Cavity.

8.201.2.B. Exclusions.

1. The following services/treatments are not a benefit for Adult Clients under any circumstances: a. Preventive services to include prophylaxis, fluoride treatment and oral hygiene instruction.

b. Treatment for dental caries, gingivitis and tooth fractures. c. Restorative and cosmetic procedures.

d. Inlay and onlay restorations.

e. Crowns.

f. Treatment of the Oral Cavity in preparation for partial or full mouth dentures. g. Assessment for, delivery of dentures or subsequent adjustments to dentures and bridges.

8.201.2.C. Emergency Treatment.

1. Emergency Treatment can be provided to an Adult Client who: a. Presents with an acute Condition of the Oral Cavity that requires hospitalization and or immediate surgical care.

b. Presents with a Condition of the Oral Cavity that would result in acute hospital medical care and or subsequent hospitalization if no Immediate Treatment is rendered. 2. Emergency Treatment provided to an Adult Client includes, but is not limited to: a. Immediate Treatment or surgery to repair trauma to the jaw. b. Reduction of any fracture of the jaw or any facial bone, including splints or other appliances used for this purpose.

c. Extraction of tooth or tooth structures associated with the Emergency Treatment of a Condition of the Oral Cavity.

d. Repair of traumatic Oral Cavity wounds.

e. Anesthesia services ancillary to the provision of emergency treatment. 8.201.3 PRIOR AUTHORIZATION REQUEST 8.201.3.A. Prior authorization is required for treatment rendered for an Adult Client with a Concurrent Medical Condition.

1. Emergency Services do not require a prior authorization before services can be rendered. 2. All prior authorization requests shall include:

a. Statement identifying the chronic medical condition. b. Description of Condition of the Oral Cavity that is exacerbating the chronic medical condition.

c. Narrative describing why the recommended treatment is necessary to prevent exacerbation of the Adult Client’s chronic medical condition. 8.201.4. PROVIDER REQUIREMENTS/REIMBURSEMENT 8.201.4.A. To submit claims for treatment of oral medical conditions for Adult Clients, the provider shall meet one of the following requirements:

1. Enroll as a physician and bill according to all medical billing requirements including using Current Procedural Terminology (CPT) codes.

2. Enroll as a dentist and bill according to all dental billing requirements including using Current Dental Terminology (CDT) codes.

8.205 MEDICAID MANAGED CARE PROGRAM 8.205.1 CLIENT ELIGIBILITY 8.205.1.A. A Medicaid client may choose to enroll in the Medicaid Managed Care Program in the Primary Care Physician Program or with a Managed Care Organization. 8.205.1.B. A Medicaid client who receives limited benefits and is not otherwise eligible for Medicaid, shall not be eligible to receive services through a Managed Care Organization. 8.205.1.C. In order to be eligible to be enrolled with a Managed Care Organization, a Medicaid client must live within the service area covered by the Managed Care Organization. 8.205.2 CLIENT RESPONSIBILITIES 8.205.2.A. By choosing to enroll in the Primary Care Physician Program, a client agrees to comply with the following responsibilities:

1. Select a primary care physician from those physicians participating in the Primary Care Physician Program.

2. Obtain a referral from his/her primary care physician for care provided by anyone other than his/her primary care physician. Referrals are not necessary for family planning services and emergency services as defined at 42 CFR 438.114.

3. Request any change of primary care physician from the Department or its designee. 4. Pay for any health care provided, except for family planning services and emergency services as defined at 42 CFR 438.114, when health care services are sought and received without a referral from his/her primary care physician. 5. Pay for any services received which are not Medicaid covered services. 6. Notify the primary care physician of any third party insurance, including Medicare. 8.205.2.B. By choosing to enroll with a Managed Care Organization, a client agrees to comply with the following responsibilities:

1. Select a primary care physician from those physicians available in the Managed Care. Organization.

2. Follow all requirements of the Medicaid managed care program as described in the Member Handbook of the Managed Care Organization.

3. Obtain a referral from his/her primary care physician for specialty care. 4. Follow the Managed Care Organization's procedures for complaints and grievances. 5. Request any change of primary care physician from the Managed Care Organization. 6. Pay for any health care provided, except for emergency services as defined at 42 CFR 438.114, when health care services are sought and received without a referral from his/her primary care physician in the Managed Care Organization. This shall not apply where the health care services is a Medicaid covered service that is not covered by the Managed Care Organization.

7. Pay for any services received which are not Medicaid covered services. 8. Notify the Managed Care Organization of any third party insurance, including Medicare. 8.205.3 CLIENT RIGHTS AND PROTECTIONS 8.205.3.A. A client who chooses to enroll in the Primary Care Physician Program or with a Managed Care Organization shall have the following rights and protections: 1. To be treated with respect and with due consideration for his/her dignity and privacy. 2. To receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee's condition and ability to understand. 3. To participate in decisions regarding his/her health care, including the right to refuse treatment and the right to a second opinion.

4. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.

5. To obtain family planning services directly from any provider duly licensed or certified to provide such services without regard to enrollment in the Primary Care Physician Program or in a Managed Care Organization, without referral. 6. To request and receive a copy of his/her medical records and to request that they be amended or corrected, as specified in 45. CFR Part 164.

7. To exercise his/her rights without any adverse effect on the way he/she is treated. 8.205.4 CLIENT ENROLLMENT AND DISENROLLMENT 8.205.4.A. Enrollment in the managed care program shall be voluntary. 8.205.4.B. Members who are disenrolled from a managed care provider for a period of two (2) months or less shall be reenrolled with the same managed care provider upon regaining eligibility within the two (2) month period.

8.205.4.C. A client who enrolls with a managed care provider shall remain assigned to the managed care provider for a period of twelve (12) months except as otherwise provided in these rules. 8.205.4.D. A client may request disenrollment from their managed care provider without cause during the ninety (90) days following the date of their initial enrollment or the date the Department or its designee sends the notice of enrollment, whichever is later. 8.205.4.E. A client may request disenrollment without cause at least every twelve (12) months after the date of initial enrollment with a managed care provider. A client may request disenrollment upon automatic enrollment if the temporary loss of eligibility has caused the client to miss the annual disenrollment opportunity.

8.205.4.F. A client may request disenrollment when the Department imposes intermediate sanctions as set forth in the Department's contract with the managed care provider. 8.205.4.G. A client may request disenrollment for cause at any time. Cause shall be defined as any of the following:

1. The client moves out of the managed care provider's service area. 2. The managed care provider does not, because of moral or religious objections, cover the service the client needs.

3. The client needs related services (for example, a caesarian section and a tubal ligation) to be performed at the same time; not all related services are available within the network; and the client's primary care provider or another provider determines that receiving the services separately would subject the client to unnecessary risk. 4. Administrative error on the part of the Department or its designee, the Managed Care Organization or the Primary Care Physician including, but not limited to, system error. 5. Poor quality of care, as documented by the Department. 6. Lack of access to covered services, as documented by the Department. 7. Lack of access to providers experienced in dealing with the client's health care needs, as documented by the Department.

8. The client enrolled in a Managed Care Organization with his/her physician and the physician leaves the Managed Care Organization.

9. Other reasons satisfactory to the Department.

8.205.4.H. For clients who are unable to make decisions for themselves, a family member, legal guardian or designated advocate shall be included in all decision-making concerning enrollment and disenrollment of the client.

8.205.4.I. Primary care physicians participating in the program may dismiss an enrolled client from their practice for cause at any time. The primary care physician shall give no less than 45 days notice to both the Department and the client Cause shall be defined as any of the following: 1. The client misses multiple scheduled appointments.

2. The client fails to follow the recommended treatment plan or medical instructions. 3. The primary care physician cannot provide the level of care necessary to meet the client's needs.

4. The client and /or client's family is abusive to provider and/or staff in compliance with 42 CFR 438.56(a)(2).

5. The physician moves out of the service area.

6. Other reasons satisfactory to the Department.

8.205.5 ESSENTIAL COMMUNITY PROVIDERS 8.205.5.A In order to be eligible for designation as an Essential Community Provider, the following health care providers shall be determined to have historically served medically needy or medically indigent patients and demonstrated a commitment to serve low-income and medically indigent populations who make up a significant portion of their patient population or, in the case of a sole community provider, serve the medically indigent patients within their medical capability: 1. Disproportionate share hospitals.

2. Local county and district health departments, county nursing services and regional health department operating pursuant to Title 25, C.R.S., as amended. 3. Federally Qualified Health Centers (FQHCs).

4. School based health centers that can verify that 25% of students enrolled in the school are at or below 185% of the Federal Poverty Level and that services are offered to the entire student population enrolled in the school without regard to the patient's ability to pay. 5. Family Medicine Residency Training Programs that can verify that 25 % of the patients served are at or below 185% of the Federal Poverty Level.

6. Rural Health Clinics that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.

7. State certified Title X Family. Planning Agencies that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.

8. Sole community providers that are not located within a metropolitan statistical area, as designated by the U.S. Office of Management and Budget, and in whose community there is no other similar type of health care and the provider can verify that it provides health care services to patients below 185% of the Federal Poverty Level within its medical capability.

9. New health care providers operating under a sponsoring or participating entity that qualifies as an Essential Community Provider.

10. Health care providers that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.

8.205.6 In order to be eligible for designation as an Essential Community Provider, the provider shall waive charges or charge for services on a sliding scale for patients/families at or below 185% of the Federal Poverty Level.

8.205.7 Health care providers, except those set forth a 8.206.1(1) through (3), who seek to be designated as an Essential Community Provider, shall submit their application, including a copy of their sliding fee scale to the Department.

8.205.8 QUALIFIED PHARMACY PROVIDERS 8.205.8.A. A Managed Care Organization shall contract with qualified pharmacy providers in a manner permitting a nursing facility to continue to comply with federal Medicaid requirements of participation.

8.205.8.B. A qualified pharmacy provider shall meet all of the following requirements: 1. Employ, on a full-time basis, a pharmacist licensed by the State of Colorado. 2. Demonstrate a capability of procuring, preparing, dispensing and distributing pharmaceutical products in an institutional setting.

3. Demonstrate a capability of monitoring clients on an ongoing basis to identify, prevent and resolve drug-related problems including, but not limited to, the monitoring of drug-drug interactions and drag-allergy interactions.

4. Provide pharmaceutical consulting services twenty-four (24) hours per day. 5. Perform medication-use assessments with the assistance of a pharmacist licensed by the State of Colorado at least once each month. Such assessments shall be client-centered, ensuring that the client's medication regimen meets his or her needs. 6. Participate with the client's physicians, nurses, dieticians and other health care professionals in inter-disciplinary care planning.

7. Provide continuous pharmaceutical care and services to clients twenty-four (24) hours per day every day.

8. Reasonably respond to emergency situations and maintain an emergency kit registered with the. Colorado. State Board of Pharmacy at each nursing home. 9. Utilize appropriate unit dose or unit of issue distribution systems to ensure that clients receive proper medications, at the proper time, and at the proper dosage. 10. Demonstrate its capability to provide physician orders and medication administration records on a monthly basis.

8.205.9 PERSONS WITH SPECIAL HEALTH CARE NEEDS 8.205.9.A. Persons with Special Health Care Needs shall mean persons having ongoing health conditions that 1. Have a biologic, psychologic or cognitive basis;

2. Have lasted or are virtually certain to last for at least one year; and 3. Produce one or more of the following sequelae:

a. Significant limitation in areas of physical, cognitive or emotional function; b. Dependency on medical or assistive devices to minimize limitation of function or activities;

c. In addition, for children:

(i) Significant limitation in social growth or developmental function; (ii) Need for psychologic, educational, medical or related services over and above the usual for the child's age; or (iii) Special ongoing treatments such as medications, special diets, interventions or accommodations at home or at school.

8.209 MEDICAID MANAGED CARE GRIEVANCE AND APPEAL PROCESSES 8.209.1 GENERAL PROVISIONS Medicaid members or their Designated Client Representatives enrolled in Managed Care Organizations (MCOs) may access and utilize the Medicaid Managed Care Grievance and Appeal Systems. The Grievance and Appeal Systems shall include a grievance process and an appeal process for handling grievances and appeals at the MCO or Prepaid Inpatient Health Plan (PIHP) level and access to the State fair hearing process for appeals. [Eff 08/30/2006] 8.209.2 DEFINITIONS Action shall mean: [Eff 08/30/2006] 1. The denial or limited authorization of a requested service, including the type or level of service; [Eff 08/30/2006] 2. The reduction, suspension or termination of a previously authorized service; [Eff 08/30/2006] 3. The denial, in whole or in part, of payment for a service (except payment denials issued by a mental health prepaid inpatient health plan); [Eff 08/30/2006] 4. The failure to provide services in a timely manner; [Eff 08/30/2006] 5. The failure to act within the timeframes provided below; or [Eff 08/30/2006] 6. The denial of a Medicaid member’s request to exercise his or her right to obtain services outside the network for members in rural areas with only one MCO. [Eff 08/30/2006] Appeal shall mean a request for review of an action. [Eff 08/30/2006] Designated Client Representative shall mean any person, including a treating health care professional, authorized in writing by the member or the member's legal guardian to represent his or her interests related to complaints or appeals about health care benefits and services. [Eff 08/30/2006] Fair Hearing shall mean the formal adjudication process for appeals described at 10 CCR 2505- 10, §8.057. [Eff 08/30/2006] Grievance shall mean an oral or written expression of dissatisfaction about any matter other than an action, including but not limited to quality of care or services provided and aspects of interpersonal relationships such as rudeness of provider or employee, or failure to respect the member’s rights. [Eff 08/30/2006] Prepaid Inpatient Health Plan (PIHP) shall mean an entity that provides medical services to members under contract with the State agency, and on the basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates; provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its members; and does not have a comprehensive risk contract. [Eff 08/30/2006] Quality of Care Complaint shall mean any grievance made in regards to the professional competence and/or conduct of a physician or other health care provider, which could adversely affect the health, or welfare of a member. [Eff 08/30/2006] Timely Filing shall mean filing on or before the later of the following: within ten days of the MCO or PIHP postmarking the notice of action; or the intended effective date of the MCO’s or PIHP’s proposed action. [Eff 08/30/2006] 8.209.3 GRIEVANCE SYSTEM 8.209.3.A. The Grievance System is the overall system that includes grievances and appeals handled at the MCO and PIHP level and access to the State fair hearing process for appeals. [Eff 08/30/2006] 8.209.3.B. The MCO or PIHP shall provide a Department approved description of the grievance, appeal and fair hearing procedures and timeframes to all providers and subcontractors at the time the provider or subcontractor enters into a contract with the MCO or PIHP. The description shall include: [Eff 08/30/2006] 1. The member’s right to a State fair hearing for appeals. [Eff 08/30/2006] a. The method to obtain a hearing, and [Eff 08/30/2006] b. The rules that govern representation at the hearing. [Eff 08/30/2006] 2. The member’s right to file grievances and appeals. [Eff 08/30/2006] 3. The requirements and timeframes for filing grievances and appeals. [Eff 08/30/2006] 4. The availability of assistance in the filing process. [Eff 08/30/2006] 5. The toll-free numbers that the member can use to file a grievance or an appeal by telephone. [Eff 08/30/2006] 6. The fact that, when requested by a member: [Eff 08/30/2006] a. Benefits will continue if the member files an appeal or a request for State fair hearing within the timeframes specified for filing; and [Eff 08/30/2006] b. The member may be required to pay the cost of services furnished while the appeal is pending if the final decision is adverse to the member. [Eff 08/30/2006] 8.209.3.C. The MCO or PIHP shall maintain record of grievances and appeals and submit a quarterly report to the Department. [Eff 08/30/2006] 8.209.4 APPEAL PROCESS 8.209.4.A. Notice of Action [Eff 08/30/2006] 1. The MCO or PIHP shall send the member written notice for each action. The notice shall be in writing and shall be available in English and the prevalent non-English languages spoken by members throughout the State. “Prevalent” means a non-English language spoken by a significant number or percentage of members in the service area as identified by the State. [Eff 08/30/2006] 2. The notice shall state the following: [Eff 08/30/2006] a. The action the MCO or PIHP or its contractor has taken or intends to take; [Eff 08/30/2006] b. The reasons for the action; [Eff 08/30/2006] c. The member’s or the Designated Client Representative's right to file an MCO or PIHP appeal; [Eff 08/30/2006] d. The date the appeal is due; [Eff 08/30/2006] e. The member’s right to request a State fair hearing; [Eff 08/30/2006] f. The procedures for exercising the right to a fair hearing; [Eff 08/30/2006] g. The circumstances under which expedited resolution is available and how to request it; [Eff 08/30/2006] h. The member’s right to have benefits continue pending resolution of the appeal, and how to request that benefits be continued; and [Eff 08/30/2006] i. The circumstances under which the member may be required to pay the cost of these services. [Eff 08/30/2006] 3. The MCO or PIHP shall mail the notice of action within the following timeframes: [Eff 08/30/2006] a. For termination, suspension or reduction of previously authorized Medicaid covered services, at least ten (10) calendar days before the date of action, except in the following circumstances: [Eff 08/30/2006] i) The MCO or PIHP may shorten the period of advance notice to five (5) calendar days for the date of action if: [Eff 08/30/2006] 1) The MCO or PIHP has facts indicating probable fraud by the member; and [Eff 08/30/2006] 2) The facts have been verified, if possible, through secondary sources. [Eff 08/30/2006] ii) The MCO or PIHP may mail notice not later than the date of action if: [Eff 08/30/2006] 1) The MCO or PIHP has factual information confirming the death of the member; [Eff 08/30/2006] 2) The MCO or PIHP receives a clear written statement signed by the member stating that: [Eff 08/30/2006] a) He or she no longer wishes services; or [Eff 08/30/2006] b) Gives information that requires termination or reduction of services and indicates that he/she understands that this is the result of supplying the information; [Eff 08/30/2006] iii) The member has been admitted to an institution where he/she is ineligible under the plan for further services; [Eff 08/30/2006] iv) The member’s whereabouts is unknown and the post office returns mail directed to him or her indicating no forwarding address; [Eff 08/30/2006] v) The MCO or PIHP establishes the fact that the member has been accepted for Medicaid services by another local jurisdiction, state, territory, or commonwealth; [Eff 08/30/2006] vi) A change in the level of medical care is prescribed by the member’s physician; [Eff 08/30/2006] vii) The notice involves an action made with regard to the preadmission screening requirements of 1919(e) (7) of the Social Security Act; or [Eff 08/30/2006] viii) Notice may be made as soon as practicable before transfer or discharge when: [Eff 08/30/2006] 1) The safety of individuals in the facility would be endangered; [Eff 08/30/2006] 2) The health of individuals in the facility would be endangered; [Eff 08/30/2006] 3) The resident's health improves sufficiently to allow a more immediate transfer or discharge; [Eff 08/30/2006] 4) An immediate transfer or discharge is required by the resident's urgent medical needs; or [Eff 08/30/2006] 5) A resident has not resided in the facility for 30 days. [Eff 08/30/2006] b. For denial of payment (except for payment denials issued by a mental health prepaid inpatient health plan), at the time of any action affecting the claim. [Eff 08/30/2006] c. For standard service authorization decisions that deny or limit services, within ten (10) calendar days. [Eff 08/30/2006] 4. If the MCO or PIHP extends the timeframe it must give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file an appeal if he or she disagrees with that decision and issue and carry out its determination as expeditiously as the member’s health condition requires and no later than the due date the extension expires. [Eff 08/30/2006] 5. For service authorization decisions not reached within ten (10) calendar days on the date the timeframes expire. [Eff 08/30/2006] 6. For expedited service authorization decisions, within three (3) days. [Eff 08/30/2006] 8.209.4.B. The member of an MCO or PIHP shall file an appeal within twenty (20) calendar days from the date of the MCO’s or PIHP’s notice of action. [Eff 08/30/2006] 8.209.4.C. The MCO or PIHP shall give members reasonable assistance in completing any forms required by the MCO or PIHP, putting oral requests for a State fair hearing into writing and taking other procedural steps, including, but not limited to, providing interpretive services and toll-free numbers that have adequate TTY/TTD and interpreter capability. [Eff 08/30/2006] 8.209.4.D. The MCO or PIHP shall send the member written acknowledgement of each appeal within two (2) working days of receipt, unless the member or designated client representative requests an expedited resolution. [Eff 08/30/2006] 8.209.4.E. The MCO or PIHP shall ensure that the individuals who make decisions on appeals are individuals who were not involved in any previous level of review or decision-making and who have the appropriate clinical expertise in treating the member’s condition or disease if deciding any of the following: an appeal of a denial that is based on lack of medical necessity, a grievance regarding denial of expedited resolution of an appeal, or a grievance or appeals that involves clinical issues. [Eff 08/30/2006] 8.209.4.F The MCO or PIHP shall accept appeals orally or in writing. [Eff 08/30/2006] 8.209.4.G The MCO or PIHP shall provide the member a reasonable opportunity to present evidence, and allegations of fact or law, in person as well as in writing. The MCO or PIHP shall inform the member of the limited time available in the case of expedited resolution. [Eff 08/30/2006] 8.209.4.H The MCO or PIHP shall provide the member and the designated client representative opportunity, before and during the appeal process, to examine the member’s case file, including medical records and any other documents and records considered during the appeal process. [Eff 08/30/2006] 8.209.4.I. The MCO or PIHP shall include as parties to the appeal, the member and the designated client representative or the legal representative of a deceased member’s estate. [Eff 08/30/2006] 8.209.4.J. The MCO or PIHP shall resolve each appeal, and provide notice as expeditiously as the member’s health condition requires, not to exceed the following: [Eff 08/30/2006] 1. For standard resolution of an appeal and notice to the affected parties, ten (10) working days from the day the MCO or PIHP receives the appeal. [Eff 08/30/2006] 2. For expedited resolution of an appeal and notice to affected parties, three (3) working days after the MCO or PIHP receives the appeal. [Eff 08/30/2006] 8.209.4.K. The MCO or PIHP may extend timeframes for the resolution of appeals by up to fourteen (14) calendar days: [Eff 08/30/2006] 1. If the member requests the extension; or [Eff 08/30/2006] 2. The MCO or PIHP shows that there is a need for additional information and that the delay is in the member’s best interest. The MCO or PIHP shall give the member prior written notice of the reason for delay if the timeframe is extended. [Eff 08/30/2006] 8.209.4.L. The MCO or PIHP shall notify the member in writing of the resolution of an appeal. For notice of an expedited resolution, the MCO or PIHP shall also make reasonable efforts to provide oral notice. [Eff 08/30/2006] 8.209.4.M. The written notice shall include the results of the disposition/resolution process and the date it was completed. [Eff 08/30/2006] 1. For appeals not resolved wholly in favor of the member, [Eff 08/30/2006] a. The right to request a State fair hearing and how to do so; [Eff 08/30/2006] b. The right to request and to receive benefits while the hearing is pending, and how to make the request; and [Eff 08/30/2006] c. That the member may be held liable for the cost of those benefits if the hearing decision upholds the MCO’s or PIHP’s action. [Eff 08/30/2006] 8.209.4.N. The member of an MCO or PIHP need not exhaust the MCO or PIHP level appeal process before requesting a state fair hearing. The member shall request a state fair hearing within twenty (20) calendars days from the date of the MCO’s or PIHP’s notice of action. [Eff 08/30/2006] 8.209.4.O. In cases where the parent or guardian submits a request for a third party review to the Department of Human Services under 27-10.3-104 (1)(b) C.R.S. of the Child Mental Health Treatment Act, the member, parent or guardian and the MCO or PIHP shall have the right to request a state fair hearing. The request for the state fair hearing shall be submitted to the Division of Administrative Hearings within twenty (20) calendar days from the date of the determination. The state fair hearing shall be considered a recipient appeal. [Eff 08/30/2006] 8.209.4.P. The MCO or PIHP shall establish and maintain an expedited review process for appeals when the MCO or PIHP determines, or the provider indicates, that taking the time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function. [Eff 08/30/2006] 8.209.4.Q. The MCO or PIHP shall ensure that punitive action is not taken against a provider who requests an expedited resolution or supports a member’s appeal. [Eff 08/30/2006] 8.209.4.R. If the MCO or PIHP denies a request for expedited resolution, it shall transfer the appeal in the timeframe for standard resolution, make reasonable effort to give the member prompt oral notice of the denial and send a written notice of the denial for an expedited resolution within two (2) calendar days. [Eff 08/30/2006] 8.209.4.S. The MCO or PIHP shall provide for the continuation of benefits while the MCO or PIHP level appeal and the State fair hearing are pending if the member files the appeal timely, the appeal involves the termination, suspension or reduction of a previously authorized course of treatment, the services were ordered by an authorized provider, the original period covered by the original authorization has not expired and the member requests extension of benefits. [Eff 08/30/2006] 8.209.4.T. If at the member’s request, the MCO or PIHP continues or reinstates the member’s benefits while the appeal is pending, the benefits shall be continued until the member withdraws the appeal, ten days pass after the MCO or PIHP mails the notice providing the resolution of the appeal against the member, a State fair hearing office issues a final agency decision adverse to the member, or the time period or service limits of a previously authorized service has been met. [Eff 08/30/2006] 8.209.4.U. If the final resolution of the appeal upholds the MCO’s or PIHP’s action, the MCO or PIHP may recover the cost of the services furnished to the member while the appeal is pending to the extent that the services were furnished solely because of the requirements of this rule. [Eff 08/30/2006] 8.209.4.V. If the final resolution of the appeal reverses the MCO's or PIHP's action to deny, limit or delay services that were not furnished while the appeal was pending, the MCO or PIHP shall authorize or provide the disputed services promptly and as expeditiously as the member’s health condition requires. [Eff 08/30/2006] 8.209.4.W. If the final resolution of the appeal reverses the MCO's or PIHP's action to deny authorization of services and the member received the services while the appeal was pending, the MCO or PIHP must pay for those services. [Eff 08/30/2006] 8.209.5 GRIEVANCE PROCESS 8.209.5.A The member of the MCO or PIHP shall have twenty (20) calendar days from the date of the incident to file a grievance expressing his/her dissatisfaction with any matter other than an action. [Eff 08/30/2006] 8.209.B. The MCO or PIHP shall send the member written acknowledgement of each grievance within two (2) working days of receipt. [Eff 08/30/2006] 8.209.5.C. The MCO or PIHP shall ensure that the individuals who make decisions on grievances are individuals who were not involved in any previous level of review or decision-making and who have the appropriate clinical expertise in treating the member’s condition or disease if deciding a grievance that involves clinical issues. [Eff 08/30/2006] 8.209.5.D. The MCO or PIHP shall accept grievances orally or in writing. [Eff 08/30/2006] 1. The MCO or PIHP shall dispose of each grievance and provide notice as expeditiously as the member’s health condition requires, not to exceed fifteen (15) working days from the day the MCO or PIHP receives the grievance. [Eff 08/30/2006] 8.209.5.E. The MCO or PIHP may extend timeframes for the disposition of grievances by up to fourteen (14) calendar days: [Eff 08/30/2006] 1. If the member requests the extension; or [Eff 08/30/2006] 2. The MCO or PIHP shows that there is a need for additional information and that the delay is in the member’s best interest. The MCO or PIHP shall give the member prior written notice of the reason for delay if the timeframe is extended. [Eff 08/30/2006] 8.209.5.F. The MCO or PIHP shall notify the member in writing of the disposition of a grievance. [Eff 08/30/2006] 8.209.5.G. The written notice shall include the results of the disposition/resolution process and the date it was completed. [Eff 08/30/2006] 8.209.5.H. If the member is dissatisfied with the disposition of a grievance provided by the MCO or PHIP, the member may bring the unresolved grievance to the Department. [Eff 08/30/2006] 1. The Department will acknowledge receipt of the grievance and dispose of the issue. [Eff 08/30/2006] 2. The disposition offered by the Department will be final. [Eff 08/30/2006] 8.209.6 OMBUDSMAN ASSISTANCE CONCERNING SERVICES FOR CLIENTS ENROLLED IN MANAGED CARE ORGANIZATIONS A. An Ombudsman under contract with the Department of Health Care Policy and Financing shall provide Ombudsman assistance concerning services for clients enrolled in Medicaid managed care organizations (MCOs).

B. Upon request, the Ombudsman shall respond to and analyze a complaint from a client enrolled in a Medicaid managed care organization (MCO), or that client’s designated client representative (DCR), by:

1. Assisting the client or DCR to articulate the complaint, to understand the options available to resolve the complaint and his/her rights and responsibilities, and to negotiate the appropriate complaint process for his/her MCO;

2. Acting as the client’s DCR if the client requests except that the Ombudsman shall not act as the DCR in any State fair hearing as described at 10 CCR 2505-10, §8.057; 3. Facilitating problem resolution with the MCO or its network providers; 4. Referring clients to other agencies as appropriate, including agencies that can directly assist clients in a State fair hearing;

5. Conducting and reporting client satisfaction studies and/or quality assessment surveys authorized by the Department to measure client experience and satisfaction with Ombudsman staff and services;

6. Providing clients with information on the exclusions and limitations that may be imposed on care, services, equipment and supplies under the Medicaid benefits structure; 7. Having a practical understanding of all applicable provisions of Title X, Article 16, C.R.S. and Medicaid Volume 8 rules; and 8. Avoiding any relationship or circumstance which creates or gives the appearance of a conflict of interest.

8.209.7 COMPLIANCE REQUIREMENTS FOR ALL MCOS AND THE OMBUDSMAN A. MCOs and the Ombudsman shall recognize and ensure clients’ rights to make and file complaints and to appeal adverse determinations through the complaint and appeal process for any reason. B. For clients with a disability, if the medical necessity of a requested procedure has not been established by the MCO, the requesting physician must be consulted in person or by telephone before a final determination is made. If the requesting physician is not available, another network provider of the client/DCR’s choice shall be consulted. Such consultation shall be referenced in the notice. If the requesting physician is not available and the client/DCR does not choose another network provider within two working days of the MCO’s request to make such a choice, the MCO may proceed without consultation.

C. MCOs and the Ombudsman shall develop written procedures for accepting, processing, and responding to all complaints from Medicaid clients. For MCOs, summaries of these procedures shall be disseminated to all participating providers and shall include summaries in the Member Handbook as described in Department contract requirements. The MCO shall provide its complete complaint and appeal procedures to subcontractors and ensure subcontractor compliance with these rules and the MCO’s procedures. MCOs and the Ombudsman shall obtain written approval from the Department for their internal Complaint procedures. D. MCOs and the Ombudsman shall establish and maintain a timely and organized system(s) for recording, tracking, and resolving Medicaid clients’ complaints and appeals as specified in contract.

E. MCOs and the Ombudsman shall confidentially maintain original records of all Complaints from Medicaid clients, including the original Complaint, action, or resolution taken by the entity, and evidence of review activities. All such information shall be archived for six (6) years from the date of the initial Complaint.

F. MCOs shall ensure that neither cultural, expressive, or receptive communication differences negatively impact the Complaint process. MCOs shall provide services to facilitate clients’ and DCRs’ effective use of the Complaint process, inclusive of qualified interpreters for (1) persons with communication disabilities or differences and (2) non-English-speaking clients. The MCO shall consult with the client or the DCR about the individual or medium that will assist, and such assistance shall be at the cost of the MCO.

G. MCOs shall provide the client, DCR, or any other person, upon written release from the client or the client's legal guardian, access to or a copy of medical records, at no cost to the client, for dates of service occurring during enrollment in the MCO. Such records shall be provided within a time frame that provides clients copies of their records prior to any decision on a Complaint or appeal, or in two weeks or less, if required by C.R.S. § § 25-1-801 and 25-1-802. The MCO is only obligated to provide one copy of the client's medical records free of charge for each of the Medicaid client's Complaints.

H. MCOs shall monitor participating network subcontractors or providers to ensure compliance with all Complaint rules and contract requirements.

I. MCOs and the Ombudsman shall handle specific Medicaid client Complaint information in the same way that medical record information is handled confidentially under State and Federal law and regulations.

J. Upon request by a client, the client's DCR, or the client's provider, the MCO shall disclose its standards for denial of treatments or other benefits on the grounds that such treatment or other covered benefit is not medically necessary, appropriate, effective, or efficient. K. To assist clients in making inquiries and filing Complaints, MCOs and the Ombudsman shall ensure that clients and DCRs can contact them during routine business hours through a toll-free telephone number.

8.212 COMMUNITY MENTAL HEALTH SERVICES 8.212.1 ENROLLMENT 8.212.1.A. The following individuals are not eligible for enrollment in the Community Mental Health Services program:

1. Qualified Medicare Beneficiary only (QMB-only).

2. Qualified Working Disabled Individuals (QWDI).

3. Qualified Individuals 1 (QI 1).

4. Special Low Income Medicare Beneficiaries (SLMB).

5. Undocumented aliens.

6. Program of All-Inclusive Care for the Elderly (PACE). 7. Individuals who are inpatient at the Colorado Mental Health Institute at Pueblo who are: a. Found by a criminal court to be Not Guilty by Reason of Insanity (NGRI) b. Found by a criminal court to be Incompetent to Proceed (ITP) c. Ordered by a criminal court to the Institute for evaluation (eg. Competency to proceed, sanity, conditional release revocation, pre-sentencing). 8. Individuals between ages 21 and 64 who receive inpatient treatment who are inpatient at the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan.

9. Individuals who are NGRI and who are in the community on Temporary Physical Removal (TPR) from the Colorado Mental Health Institute at Pueblo and who are eligible for Medicaid are exempted from the Community Mental Health Services program while they are on TPR. TPR individuals remain under the control and care of the Institute. 10. Classes of individuals determined by the Department to require exclusion from the Community Mental Health Services program.

11. Individuals who receive an individual exemption as set forth at 8.212.2. 8.212.1.B. All other Medicaid clients shall be enrolled in the Community Mental Health Services program. 8.212.2 INDIVIDUAL EXEMPTIONS 1. A client may request to be exempt from enrollment in the Community Mental Health Services program if:

a. The client has a clinical relationship with a provider of mental health services that the client wishes to maintain and that provider is not part of the provider network of the behavioral health organization in the client’s geographic area; or b. The client and the behavioral health organization have been unable to develop a healthy working relationship and continued enrollment would not be in the best clinical interest of the client.

2. If the client requests an exemption based on Section 8.212.2.1.a: a. The client shall notify the behavioral health organization of his/her request to receive necessary mental health services from the provider with whom the client has established a clinical relationship.

b. Within fourteen (14) calendar days of receiving notice from the client, the behavioral health organization shall determine whether it can contract with the client’s chosen provider to provide necessary mental health services to the client and provide written notice to the client and the client’s provider of that determination. c. If the behavioral health organization is unable to approve the client’s request, the notice shall:

i) Identify one or more providers within the behavioral health organization’s network who can appropriately meet the client’s mental health needs; ii) Include information on the client’s right to request an exemption, the process for requesting an exemption and assistance available to the client. d. The client may request an exemption with the Department within fourteen (14) calendar days of the date of the notice from the behavioral health organization disapproving the client’s request.

e. Within thirty (30) calendar days after receipt of the client’s request for exemption, the Department shall provide written notice of its determination to the client, the client’s provider and the behavioral health organization. 3. If the client requests an exemption based on Section 8.212.2.1.b: a. The client shall request an exemption from the Department. b. Within thirty (30) calendar days after receipt of the client’s request for exemption, the Department shall provide written notice of its determination to the client, the client’s provider and the behavioral health organization. 4. A client whose request for exemption has been denied by the Department has the right to appeal the determination pursuant to Section 8.057.

5. A newly Medicaid eligible client who requests an exemption shall be enrolled in the Community Mental Health Services program pending the outcome of the request for exemption and any appeal pursuant to Section 8.057.

6. A client who is enrolled in the Community Mental Health Services program and is requesting an exemption shall continue to be enrolled in the Community Mental Health Services program pending the outcome of the request for exemption and any appeal pursuant to Section 8.057.

7. A client who wants to reenroll in the Community Mental Health Services program shall notify the Department. The client will be reenrolled within thirty (30) calendar days of receipt of the client’s request. The Department shall notify the client and the behavioral health organization of the reenrollment prior to the effective date of reenrollment. 8.212.3 CLIENT RIGHTS AND PROTECTIONS 8.212.3.A. A client enrolled in the Community Mental Health Services program shall have the following rights and protections:

1. To be treated with respect and with due consideration for his/her dignity and privacy. 2. To receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. 3. To participate in decisions regarding his/her health care, including the right to refuse treatment and the right to a second opinion.

4. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.

5. To request and receive a copy of his/her medical records and to request that they be amended or corrected, as specified in 45 CFR Part 164.

6. To exercise his/her rights without any adverse effect on the way he/she is treated. 7. To enforce, pursuant to Section 8.209, the provisions of the community mental health services contracting regarding rights or duties owed to the client under the contract.

8.212.4 MENTAL HEALTH SERVICES 8.212.4.A. The following are required services of the Community Mental Health Services program: 1. Inpatient Hospital -- A program of psychiatric care in which the consumer remains 24 hours a day in a facility licensed as a hospital by the State. This service is limited to forty-five (45) days per State fiscal year, except as otherwise required by EPSDT as described in 10 C.C.R. 2505-10, Section 8.282.

2. Under 21 Psychiatric -- A program of care for consumers under age 21 in which the consumer remains 24 hours a day in a psychiatric hospital, or other facility licensed as a hospital by the State. This service is limited to forty-five (45) days per State fiscal year, except as otherwise required by EPSDT as described in 10 C.C.R. 2505-10, Section 8.282.

3. 65 and Over Psychiatric -- A program of care for consumers age 65 and over in which the consumer remains 24 hours a day in an institution for mental diseases, or other facility licensed as a hospital by the State. This service is limited to forty-five (45) days per State fiscal year.

4. Outpatient -- A program of care in which the consumer receives services in a hospital or other health care facility, but does not remain in the facility 24 hours a day. 5. Psychiatrist -- Services provided within the scope of practice of medicine as defined by State law.

6. Rehabilitation -- Services provided under the Rehabilitation Option of the Medicaid Program, including:

a. Partial Long Day -- Therapeutic contact with a consumer lasting more than four hours but less than 24 hours. Activities are programmatically linked. b. Partial Short Day -- Therapeutic contact with a consumer lasting more than two hours, but no more than four hours. Activities are programmatically linked. c. Group – Therapeutic contact with more than one consumer, of up to and including two hours.

d. Individual -- Therapeutic contact with one consumer of more than 30 minutes, but no more than two hours. This service, in conjunction with Individual Brief services, is limited to thirty-five (35) visits per State fiscal year, except as otherwise required by EPSDT as described in 10 C.C.R. 2505-10, Section 8.282. e. Individual Brief -- Therapeutic contact with one consumer of up to and including 30 minutes. This service, in conjunction with Individual services, is limited to thirty- five (35) visits per State fiscal year, except as otherwise required by EPSDT as described in 10 C.C.R. 2505-10, Section 8.282.

7. Psychosocial Rehabilitation -- Rehabilitative services include any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under state law, for maximum reduction of physical or mental disability and restoration of a recipient to his/her best possible functional level. 8. Case Management -- Medically necessary case management services provided in a licensed community mental health center or clinic by a licensed/qualified non-physician practitioner or physician.

9. Medication Management -- Monitoring of medications prescribed and consultation provided to consumers by a physician.

10. Emergency -- Services provided during a mental health emergency which involve unscheduled, immediate, or special interventions in response to crisis situation with a consumer.

11. Residential -- Any type of 24 hour care provided in a non-hospital, non-nursing home setting, where the contractor provides room, board and supervision. Residential services are appropriate for children, youth, adults and older adults who need 24 hour supervised care in a therapeutic environment.

12. School-Based Services -- Mental health services provided to school aged children and adolescents on site in their schools, with the cooperation of the schools. 8.212.4.B. Alternative services of the Community Mental Health Services program include, but are not limited to:

1. Vocational -- Services designed to help adult and adolescent consumers to gain employment skills and employment.

2. Home-Based Services for Children and Adolescents -- Therapeutic services for children/adolescents and their families provided in their homes. 3. Intensive Case Management -- Community-based services averaging more than one hour per week, provided to children with serious emotional disturbances and adults with serious mental illness who are at risk of a more intensive 24 hour placement and who need extra support to live in the community. Services may include but are not limited to mentoring.

8.212.5 EMERGENCY SERVICES 8.212.5.A. A client enrolled in the Community Mental Health Services program shall seek all mental health services from the behavioral health organization with which he/she is enrolled except as specified in 8.212.5.B.

8.212.5.B. Clients with an emergency medical condition may seek emergency services outside of the network of the behavioral health organization in which they are enrolled. 8.212.5.C. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention or mental health services to result in the following: 1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) or the health of another in serious jeopardy. 2. Serious impairment to bodily functions.

3. Serious dysfunction of any bodily organ or part.

8.212.5.D. Emergency services means covered inpatient and outpatient services that are as follows: 1. Furnished by a provider that is qualified to furnish these services. 2. Needed to evaluate or stabilize an emergency medical condition. 8.212.6 ESSENTIAL COMMUNITY PROVIDERS 8.212.6.A. In order to be eligible for designation as an Essential Community Provider, the following health care providers shall be determined to have historically served medically needy or medically indigent patients and demonstrated a commitment to serve low-income and medically indigent populations who make up a significant portion of their patient population or, in the case of a sole community provider, serve the medically indigent patients within their medical capability: 1. Disproportionate share hospitals.

2. Local county and district health departments, county nursing services and regional health department operating pursuant to Title 25, C.R.S., as amended. 3. Federally Qualified Health Centers (FQHCs).

4. School based health centers that can verify that 25% of students enrolled in the school are at or below 185% of the Federal Poverty Level and that services are offered to the entire student population enrolled in the school without regard to the patient’s ability to pay. 5. Family Medicine Residency Training Programs that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.

6. Rural Health Clinics that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.

7. State certified Title X Family Planning Agencies that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.

8. Sole community providers that are not located within a metropolitan statistical area, as designated by the U.S. Office of Management and Budget, and in whose community there is no other similar type of health care and the provider can verify that it provides health care services to patients below 185% of the Federal Poverty Level within its medical capability.

9. New health care providers operating under a sponsoring or participating entity that qualifies as an Essential Community Provider.

10. Health care providers that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.

8.212.6.B. In order to be eligible for designation as an Essential Community Provider, the provider shall waive charges or charge for services on a sliding scale for patients/families at or below 185% of the Federal Poverty Level.

8.212.6.C. Health care providers, except those set forth a 8.212.6.A(1) through (3), who seek to be designated as an Essential Community Provider, shall submit their application, including a copy of their sliding fee scale to the Department.

8.220 COMPETITIVE PROCUREMENT AND SELECTIVE CONTRACTING, INCLUDING GLOBAL FEE PAYMENT PROGRAMS This section of Staff Manual Volume 8 describes Medicaid competitive procurement and selective contracting.

8.221 GENERAL PROVISIONS The Colorado Department of Health Care Policy and Financing (the State) may enter into contracts to provide a range of health care benefits identified in the State Plan to persons determined eligible for medical care under Title XIX of the Social Security Act (Medicaid). The Department under provisions of State and Federal law and regulation, and contingent upon Federal waiver(s), may elect to competitively procure and/or selectively contract for organ and other transplant services. A. Transplant Services 1. The Department, after consultation with affected groups, may issue Requests for Proposals from providers to contract with the State for the provision of certain organ transplants and related services. A limited number of contracts may be executed with providers whose proposals demonstrate that they are qualified to provide adequate access to quality services, and whose price proposals are most advantageous to the State. 2. Effective on or after July 1, 1995 the Department may contract with selected providers under a global fee arrangement for transplant services related to heart, lung, liver, kidney, and bone marrow transplants. Under these contracts providers will receive a single payment for all services related to the transplant procedure, and a monthly case management fee as the Primary Care Physician for six months following the transplant. The following services are included under the global transplant payment: a. Patient access to the transplant network b. Provision of general assistance and education for the transplant patient and families or attendants c. Transplant procedures d. All services required by a transplant patient including organ acquisition, physician services, and certain non-hospital post-transplant care for a period not to exceed 6 months.

e. Related transportation for patients and necessary family member(s) or attendant(s) 3. The method of payment to be used for transplants under this program will be an inclusive rate per discharge.

4. All transplant services will be prior authorized as described in 8.317. 5. All transplant services will be subject to Quality Assurance review by the Peer Review Organization as described at 8.312.12., and as required under provisions of the Federal waiver and/or specific contract provisions of the competitively procured transplant program.

8.280 EARLY PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT) 8.280 DEFINITIONS .01 Department shall be defined as the Department of Health Care Policy and Financing (HCPF). .02 Department's Designated Entity shall be defined as an agency whose function is to reimburse, coordinate, provide or prior authorize EPSDT services for Medicaid-enrolled children. .03 Diagnosis shall be defined as the determination of the nature or cause of physical or mental disease or abnormality through the evaluation of health history, physical and developmental examination, laboratory tests and x-rays.

.04 Health Maintenance Organization (HMO) shall be defined as a prepaid health plan contracted with the Department that provides comprehensive health care. .05 Managed Care Organization (MCO) shall be defined as an entity contracting with the Department that provides, delivers, arranges for, pays for or reimburses the costs of health care services through the child's use of health care providers managed by, owned by, under contract with, or employed by the entity.

.06 Medically necessary, or medical necessity, shall be defined as a Medicaid service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce or ameliorate the pain and suffering, or the physical, mental, cognitive or developmental effects of an illness, injury, or disability; and for which there is no other equally effective or substantially less costly course of treatment suitable for the child's needs.

8.281 EPSDT ELIGIBILITY .01 ELIGIBILITY To receive EPSDT services, the child shall be:

A. Enrolled in Medicaid; and B. Under the age of 21.

.02 NOTIFICATION OF ELIGIBILITY A. General Guidelines:

1. All Medicaid-enrolled children and their parents or legal guardians shall be informed about the services included in the EPSDT benefit and how these services may be accessed.

2. Notification shall be defined as the process of informing Medicaid-enrolled clients, their parents or legal guardians, about the services included in the EPSDT benefit and how those services may be accessed. A combination of oral or written methods must be used, within 60 days following the date of the Medicaid eligibility determination. Oral notifications shall include face-to-face meetings, discussions or telephone conversations.

3. Written communications shall be prepared in a format using clear non-technical language and at a 6th grade reading level whenever possible. 4. Written and oral information shall be culturally appropriate and provided in a manner and format appropriate for children, or their parents or legal guardians, who have limited English proficiency or sensory impairments.

B. Responsibility for notification and information about EPSDT, shall be provided to children and their parents or legal guardians by County Departments of Human/Social Services, and a written notification from the child's HMO if the child is enrolled in managed care. .03 RE-NOTIFICATION Re-Notification of EPSDT benefits shall occur at least annually and shall be completed by the County Departments of Human/Social Services for children/families not enrolled in a HMO or by HMOs for children/families enrolled in their organization. 8.282 SERVICES/BENEFITS .01 SCREENINGS A. A screening shall be defined as the use of procedures to determine a child's mental and physical growth progress, and in particular, to identify a disease or abnormality and the need for more definitive study and treatment of possible physical or emotional problems. B. Screenings shall include comprehensive health assessments that are performed soon after birth or as early as possible in a child's life and repeated at prescribed periodic intervals of time through the age of 20 as described in the Periodicity Schedule. 1. The Periodicity Schedule describes the intervals at which preventive physical, sensory, developmental and behavioral screening, including vision, hearing and dental services shall be performed for enrolled children through the age of 20, as recommended by the American Academy of Pediatrics.

2. A copy of the Periodicity Schedule may be obtained from the American Academy of Pediatrics website at http://www.aap.org or from the Department's EPSDT Benefit Coordinator.

C. Screenings shall be performed in a culturally sensitive and age appropriate manner by, or under the supervision of, a participating Medicaid provider qualified to furnish primary medical and health care services, including:

1. The child's Primary Care Physician (PCP) who is a health care professional, licensed to practice medicine (e.g., an M.D. or D.O.) or a facility with a licensed physician on staff.

2. Local organized County Health Department and/or local County Nursing Service when performed by a registered nurse under the supervision of a physician; 3. Community Health Center physician; or 4. Another Medicaid provider including physicians' assistant or nurse practitioner. D. The components of an EPSDT screen shall include:

1. A detailed health and development history including growth and development milestones.

2. A comprehensive unclothed physical examination.

3. An assessment of the following:

a) Vision;

b) Hearing;

c) Mouth, oral cavity and teeth (shall not replace a full oral screen by a dentist); d) Mental/behavioral health;

e) Nutritional status;

f) Cardiovascular and respiratory function;

g) Genital status; and h) Gastrointestinal status.

4. Immunizations to bring a child current with the schedule recommended and approved annually by the Advisory Committee on Immunization Practices (ACIP). Current information about approved immunizations is found at the Center for Disease Control website at http://www.cdc.gov 5. Any appropriate age-specific screening or laboratory tests at intervals recommended by the American Academy of Pediatrics:

a) Laboratory tests must include lead toxicity tests for all children who shall be tested at twelve (12) and twenty-four (24) months of age, or any child through age 6 not previously tested; and b) If the blood lead measures equal to or greater than 10 micrograms per deciliter of blood (ug/dL) as identified by a finger-stick sample, it shall be followed by a venous sample to confirm the results of the first test. 6. A developmental assessment shall include a range of activities to determine whether a child's emotional and developmental processes fall within a normal range of achievement according to the child's age group and cultural background. This assessment shall include: self-help and self-care skills; gross and fine motor development; communication skills or language development; social-emotional development; cognitive skills; and appropriate mental/behavioral health screening.

7. Health Education including anticipatory guidance shall include: a) Counseling provided by a qualified health care professional to the parent or legal guardian of a child during any visit. Such counseling includes information about what to expect developmentally and behaviorally from the child;

b) Health education and counseling based on the results of the screening process and shall be required for parents or guardians, and children; c) Age appropriate, culturally specific education, designed to assist the parent or guardian to understand what to expect in terms of the child's development;

d) Information about the child's nutritional needs, physical growth, mental development and care for current conditions shall be provided, as well as information about the timeframe for the next exam; and e) Information about the benefits of healthy lifestyles and practices. .02 PERIODIC EXAMINATIONS A. The recommended frequency of follow-up examinations is outlined in the Periodicity Schedule.

B. The intervals in the schedule as found at http://www.aap.org indicate the minimum frequency in performing the various procedures as recommended by the American Academy for Pediatrics and local medical review, and for which payment can be provided under the Colorado Medicaid EPSDT benefit.

.03 INTER-PERIODIC EXAMINATIONS Inter-periodic visit shall be any health care that occurs outside the periodic preventive care screening exam such as a further diagnosis, evaluation, acute or sick care visit. .04 RESULTS OF SCREENINGS AND INTER-PERIODIC EXAMINATIONS Results shall be recorded in the child's medical record. Documentation shall include at a minimum the following components:

A. Identified problems and negative findings on the initial and periodic EPSDT medical screenings;

B. Documentation of further diagnostic studies and/or treatments needed and date ordered; C. Referral from a child's PCP to obtain medically necessary specialty services through another Medicaid provider specified by the PCP. Referrals must be obtained before services are rendered to ensure reimbursement by the Department.

D. Referrals to other health care providers or facilities are covered if: 1. The child receives a referral from the provider who documents the reason for the referral, including the name of the provider;

2. Referred to a participating Medicaid provider;

3. The diagnosis is identified as a result of an EPSDT screening or inter-periodic exam; and 4. The services are medically necessary.

E. A referral to a dentist twice a year, starting no later than age one. 1. A physician's oral exam during a visit shall not be a substitute or replacement for a dental exam.

2. A PCP or Medicaid-enrolled physician referral to the dentist may be a verbal referral and does not require completion of a referral form.

F. Clients may self-refer without a referral from their PCP for routine vision, dental or mental health services; and hearing services provided by the Health Care Program for Children with Special Needs, through the Colorado Department of Public Health and Environment. .05 DIAGNOSIS AND TREATMENT A. GENERAL GUIDELINES:

1. Diagnosis and treatment are a covered benefit if the services are: a) For a defect, illness or condition which has been:

(i) Newly discovered by the screening or inter-periodic exam; (ii) Previously identified but not treated; or (iii) Previously identified and treated, but is shown to have increased in severity or continues to require treatment.

b) Medically necessary and are reasonably expected to correct or ameliorate defects which include physical, dental or mental illness conditions; c) In accordance with generally accepted standards of medical practice; d) Clinically appropriate in terms of type, frequency, site and duration; and e) Not primarily for the convenience of the child, parent or legal guardian, physician, or other health care provider.

B. Vision services for Medicaid-enrolled children may be provided by an ophthalmologist, optometrist or optician. These services include testing, diagnosis, and treatment for visual defects, and eyeglasses if medically necessary.

1. Services may require prior authorization by the Department's Designated Entity or the child's HMO if the child is enrolled in managed care.

a) If the child is not enrolled in an HMO, providers shall refer to the Fiscal Agent's provider manuals, billing instructions and Medicaid bulletins for further information about vision services requiring prior authorization. b) If the child is enrolled in an HMO, the provider shall contact the child's HMO for information about the HMO's prior authorization requirements for vision services.

2. Eyeglasses dispensed by an optician shall be a benefit only when ordered by an ophthalmologist or an optometrist.

3. Vision benefits include one or two single or multi-focal clear glass lenses, one standard frame; repair or replacement of plain eyeglasses due to broken frames or lenses; dispensing fee and materials.

4. Replacement glasses shall be provided when:

a) The glasses are medically necessary;

b) There is a change in the prescription; or c) The glasses are damaged to the extent that repairs are not cost effective. 5. Contact lenses or orthoptic vision treatment services shall be a benefit only when prior authorized by the Department or the child's HMO if enrolled in managed care. C. Audiological benefits include identification, diagnostic evaluation and treatment for children with hearing impairments. Conditions treated may be either congenital or acquired. Conditions treated may be provided by board certified otolarygnologists, audiologists, speech pathologists and certified and licensed Colorado Home Intervention Program (CHIP) early interventionists or other approved providers. Services shall include, but are not limited to:

1. Audiological evaluation;

2. Hearing aids including:

a) Purchase, maintenance, repairs and accessories;

b) Selection, testing and fitting of hearing aides for children with bilateral or unilateral hearing loss; and c) Auditory training in the use of hearing aids.

3. Therapy for children with hearing impairments;

4. Family-focused, home-based, early language intervention for children, birth to three, with a hearing loss through the Colorado Home Intervention Program (CHIP). a.

D. Dental Services 1. Diagnostic and treatment services available for Medicaid-enrolled children shall include, but are not limited to:

a) Routine periodic oral examinations to be provided no more than once every six (6) months (180 days) unless there is medical necessity and the service is prior authorized;

b) Radiographs;

c) Preventive services;

d) Restorations;

e) Endodontics;

f) Periodontics;

g) Prosthodontics, fixed and removable; and h) Oral surgery.

2. Emergency dental services shall be defined as those services necessary to control bleeding, relieve pain, eliminate acute infection; operative procedures which are required to prevent pulpal death and the imminent loss of teeth; treatment of injuries to the teeth or supporting structures; and palliative therapy for pericoronitis associated with impacted teeth.

3. Orthodontic services are available for children with congenital, severe developmental or acquired handicapping malocclusions when the orthodontist's documented medical necessity is confirmed by pre-treatment case review. a) Orthodontist completes and submits a handicapping malocclusion orthodontic assessment, documented medical necessity and treatment plan. b) Treatment plan benefits are available after the Department's Designated Entity has reviewed each case for medical necessity, the specific requirements of an unusually severe handicapping malocclusion and approved the appropriateness of treatment plan for the client. c) Orthodontic services are considered as part of a single, individual course of treatment accomplished over time.

E. Family Planning Services shall be in accordance with Section 8.730 through Section 8.733, and include family planning counseling, treatment and follow-up, information on birth control, including insertion and removal of approved contraceptive devices, and measurement for contraceptive diaphragms.

1. Obstetrical Services shall include:

a) Prenatal care services; and b) Physician or nurse-midwife services in pregnancy, labor, birth and 60 days postpartum.

F. Lead Blood Level diagnosis and follow-up shall include: 1. Retesting to confirm the diagnosis;

2. Reporting high blood lead levels to the provider and to the Colorado Department of Public Health and Environment, which will provide case management including: a) Routine reminders for follow-up tests;

b) Home investigation to determine the source of the lead poisoning; and c) Nutritional counseling and laboratory work to test for iron deficiency. G. Wrap-around services include:

1. Those services not included in the client's HMO benefit package, but which are covered by Medicaid; or 2. Services that exceed coverage limitations under the contract between the HMO and the Department and are billed to the Medicaid Fiscal Agent. H. Other health care services may include Expanded EPSDT benefits in addition to those offered in the State Plan, if the need for such services is identified during an EPSDT visit, the services are medically necessary and meet the requirements at Section 8.284.05. I. EPSDT Extraordinary Home Health Services are those services available to Medicaid enrolled children if the child needs care above the daily home health units, services are to be provided outside the home, skilled personal care is needed and meet the requirements at Section 8.284.06.

.06 EPSDT OUTREACH AND CASE MANAGEMENT A. EPSDT outreach and case management shall be defined as facilitating and maintaining the child's contact with a comprehensive and continuous health care service source. B. EPSDT outreach and case management shall be offered and provided to Medicaid-enrolled children receiving health services within 60 days, and shall include: 1. Informing Medicaid-enrolled children, their parents and/or legal guardians about the EPSDT benefit and encourage their participation in the program; 2. Educating families on the importance of preventive health care; 3. Assisting children/families in selecting a primary care provider. Children without a primary care provider shall be informed of the choices of PCP and/or HMOs available to them and how to notify the Enrollment Broker of their choice, as described in Section 8.207 through Section 8.207.5;

4. Assisting in arranging EPSDT screening appointments, inter-periodic examinations, dental appointments, or non-emergent medical transportation if such assistance is required;

5. Verifying follow-up of appointments to determine whether the child kept the appointment, and whether services were received within a reasonable time period. If the appointment was not kept, efforts shall be made to assist with the rescheduling of a second screening appointment; and 6. Assisting in identifying the names and locations of health care providers from whom the services may be obtained, and scheduling services when there is a need for further diagnosis or treatment.

C. Case managers shall perform notification and outreach to include instructing Medicaid- enrolled children and their families to understand:

1. The need for early detection of disease or disability; 2. Where and when EPSDT screening takes place and what the screening visit entails; 3. Screening is not enough to prevent or treat disease and that diagnostic and treatment services must be acquired when recommended;

4. Assistance in arranging and getting to medical, dental and mental health care can be provided if needed; and 5. EPSDT is a voluntary program.

D. Medicaid-enrolled children and their families shall be informed of how to obtain a listing of the names and locations of primary care providers (PCP) or HMOs available within the child's area.

E. Medicaid-enrolled children and families shall be informed about how and when to access emergency transportation services, that non-emergent medical transportation assistance is available if needed, and how such transportation may be accessed if necessary. 8.283 PROVIDER REQUIREMENTS/RESPONSIBILITIES .01 Medicaid providers offering EPSDT screening, diagnostic and treatment services shall assure that services provided meet the Federal and State minimum standards for ESPDT services. .02 Providers shall be responsible for verifying Medicaid eligibility and managed care enrollment status prior to rendering services.

.03 If services require prior authorization, providers shall be responsible for obtaining appropriate prior authorization and meeting the documentation requirements of the Department's Designated Entity or the child's HMO.

.04 Providers shall be responsible for documenting the results of EPSDT screening, inter-periodic examinations, diagnostic and treatment encounters, and completing appropriate screening and claim forms.

8.284 PRIOR AUTHORIZATIONS .01 GENERAL GUIDELINES:

A. Prior authorization shall be approved from the Department's Designated Entity for reimbursement of specific health care services based on a review of medical information and a finding that the services are both medically necessary and covered benefits of the Medicaid program.

B. Providers shall obtain Prior Authorization of services when required from the Department's Designated Entity or the child's HMO.

1. Fee-for-service providers shall contact the Fiscal Agent to obtain information about services requiring prior authorization.

2. If the child is enrolled in an HMO, providers may obtain information from the child's HMO about services that require prior authorization and network providers that may be utilized.

3. If services are approved, the child, or the parent or legal guardian, the physician; and care providers shall receive an authorization letter describing the services and the specific provider which has been authorized.

C. It is the responsibility of the provider to obtain prior authorization. 1. The child's provider shall determine medically necessary treatment and enumerate those services that require prior authorization on the Medicaid claim form. 2. This form, and applicable x-rays and/or other evidence of medical necessity, shall be sent to the Fiscal Agent for prior authorization review. 3. The Fiscal Agent shall review the treatment proposed, verify the medical necessity of services proposed and approve or deny authorization of treatment. D. In order to obtain prior authorization, all EPSDT services shall be ordered by the child's Primary Care Physician, dentist or provider designated by the PCP. E. Prior authorization of services is not a guarantee of payment if the child is not a Medicaid- eligible child on the date the services are rendered.

.02 VISION SERVICES Requests for authorization of glasses and/or contacts shall be submitted to the Fiscal Agent or the child's HMO.

.03 AUDIOLOGICAL and ORTHODONTIC SERVICES Requests for authorization of covered audiological or orthodontic services shall be submitted to the Department's Fiscal Agent.

.04 DENTAL SERVICES A. Prior authorization is a requirement for reimbursement for specific dental services, as determined by the Department. Such services are a reimbursable benefit only if authorized by the Fiscal Agent or the child's HMO if the child is enrolled in managed care and there is a concurrent medical condition.

B. A child may present to a dentist with a dental emergency requiring immediate care and/or treatment without prior authorization.

1. Such emergency care and/or treatment is a benefit of EPSDT only to the extent that treatment is necessary for the control of bleeding, immediate relief of pain, or elimination of acute infection.

2. Emergency services exceeding limits established by the Department shall be subject to post payment review.

.05 EPSDT EXPANDED SERVICES A. Expanded EPSDT are services not provided under the State Plan but are available to Medicaid-enrolled children.

B. If expanded EPSDT services are requested, a copy of the EPSDT screening results identifying the medical need for the particular service shall be attached to the request for prior authorization. In addition to the requirements described at Section 8.282.05(I), expanded EPSDT services shall meet these requirements:

1. The service is in accordance with generally accepted standards of medical practice; 2. The service is clinically appropriate in terms of type, frequency, extent, site and duration;

3. The service provides a safe environment or situation for the child; 4. The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated;

5. The service is not primarily for the convenience of the child, the child's parents or legal guardians, the physician or other health care provider; and 6. The service is cost effective.

.06 EPSDT EXTRAORDINARY HOME HEALTH SERVICES A. EPSDT extraordinary home health services are covered services above and beyond those provided under the State Plan but available to EPSDT clients, from birth through 20 years of age, as a wrap-around benefit through Medicaid fee-for-service, if it is medically necessary.

B. Requests for authorization of EPSDT extraordinary home health services shall be submitted to the Department's Designated Entity.

C. If the child has a skilled need that meets the home health rules and requires care above the daily cost limits:

1. The home health agency shall submit a prior authorization request to exceed the daily cap; and 2. Medical documentation shall be required to verify that the extra services are skilled and medically necessary.

D. If the child requires a home health provider to render care outside of the home, the home health agency must submit a request for prior authorization and documentation justifying why the required skilled services need to take place outside of the home. 8.285 REIMBURSEMENT .01 GENERAL GUIDELINES:

A. Reimbursement shall be in accordance with the regulations for pricing physician services as reflected at Section 8.200 for all EPSDT medical screening, diagnostic and treatment services.

B. No reimbursement shall be made for services requiring prior authorization unless such authorization has been obtained.

C. Providers shall not bill nor receive payment from the child, his/her family, or relative, and shall abide by all other applicable regulations of the Medicaid program. D. Medicaid shall be the payer of last resort. Enrolled children are not entitled to have Medicaid reimbursement made on their behalf if all, or any part of, the items or services are covered by private insurance, Workmen's Compensation, third party liability, or any federal, state, county, municipal or private benefit systems for which the eligible person is qualified.

.02 VISION BENEFITS A. Pricing of vision care benefits shall be in accordance with the regulations for pricing physician services as contained in Section 8.200 and Medicaid bulletins or as established by provider contracts with the child's HMO.

B. When the child or parent or legal guardian desires options that have additional costs, the amount reimbursed by the Department for standard frames and clear glass lenses shall be applied to the total cost of these services. This shall also apply to repair or replacement of broken eyeglasses.

1. The provider shall be permitted to charge the child for the difference between the retail price of the service and the amount paid by Medicaid.

2. Providers must notify the child and the child's parent or legal guardian or the child's designated client representative in writing of the difference and obtain the signature of the child or the child's parent or guardian or designated client representative indicating agreement to pay the additional costs. 8.290 SCHOOL HEALTH SERVICES 8.290.1 DEFINITIONS Care Coordination Plan means a document written by the District that describes how the District coordinates client services across multiple providers to assure effective and efficient access to service delivery and prevent duplication of services.

Disability means a physical or mental impairment that substantially limits one or more major life activities. Individualized Plan means an Individualized Education Plan or Individualized Family Services Plan developed pursuant to the federal Individuals with Disabilities Education Act, an Accommodation Plan developed pursuant to Section 504 of the federal Rehabilitation Act of 1973, as amended, 29 U.S.C., Section 794 or an Individualized Health Services Plan developed in accordance with "The Procedure Guidelines for Health Care of Students with Special Needs in the School Setting" published by the Colorado Department of Education.

Local Services Plan (LSP) means a document written by the District that describes the types and the costs of services to be provided with the reimbursed federal funds. Medically at Risk means a client who has a diagnosable physical or mental condition having a high probability of impairing cognitive, emotional, neurological, social, or physical development. Medically Necessary service means a benefit service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce or ameliorate the pain and suffering, or the physical, mental, cognitive or developmental effects of an illness, injury or disability and for which there is no other equally effective or substantially less costly course of treatment suitable for the client's needs. Qualified Health Care Professional means an individual who is registered, certified or licensed by the Department of Regulatory Agencies as a health care professional and who acts within the profession's scope of practice. In the absence of state regulations, a qualified health care professional means an individual who is registered or certified by the relevant national professional health organization. Transportation means transportation service necessary to provide a client with access to Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) Medicaid services. 8.290.2 ELIGILBILTY 8.290.2.A. An eligible client shall be:

1. Enrolled in Medicaid, 2. Enrolled in a public school of a participating District and 3. Under the age of 21.

8.290.2.B. A person with a disability or who is Medically at Risk is eligible for targeted case management benefits as set forth in § 8.290.3.C when he or she receives a referral for or services according to an Individualized Plan.

8.290.3 SERVICES, BENEFITS AND LIMITATIONS 8.290.3.A. EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) Services 1. EPSDT services shall meet the requirements at 10 C.C.R. 2505-10, Section 8.280 et seq. 2. EPSDT rehabilitation services shall be services to reduce physical or mental disability and which may improve physical or mental health level. Rehabilitation services shall be recommended by a physician or other licensed practitioner of the healing arts. 3. EPSDT services shall not be for academic assessment. 4. Except for services delivered pursuant to the federal Individuals with Disabilities Education Act or Section 504 of the federal Rehabilitation Act of 1973, the District shall not claim reimbursement for EPSDT services to clients enrolled in health maintenance organizations that would normally be provided for clients by their health maintenance organization.

8.290.3.B. Transportation shall be required on the client's Individualized Plan or shall be for EPSDT screens provided during the normal school day at non-school locations. Transportation shall be to and from a client’s place of residence and the school, or the site of a Medicaid reimbursable service if the service is not provided at the school.

8.290.3.C. Targeted Case Management Services (TCM)

1. TCM services shall be services to assist the individual client who is Medically at Risk to access needed medical, social, educational, and other services. 2. TCM services may include:

a. Individualized strengths and needs assessment, b. Needs-based service planning that provides an individualized written, comprehensive service plan based on needs identified in the assessments, c. Service coordination, monitoring and advocacy, d. Crisis assistance planning.

3. Targeted case management services shall not include: a. Program activities of the District that do not meet the description of the TCM benefit, b. Administrative activities necessary for the operation of the District, c. Diagnostic, treatment or instructional services, including academic testing, or d. Services that are an integral part of another service already reimbursed by Medicaid. 8.290.4 PROVIDER STANDARDS 8.290.4.A. The District shall have a Department approved Local Services Plan to obtain a contract with the Department.

8.290.4.B. Individual EPSDT service providers employed by or subcontracted by the District shall be Qualified Health Care Professionals. The following providers are considered qualified: 1. Occupational therapy assistants certified by the National Board for Certification of Occupational Therapy when providing services according to the standards of practice described in the American Journal of Occupational Therapy (December 1998), 2. Physical therapy assistants when providing services pursuant to Section 12-41-101, C.R.S. , et seq. , and 3. Health technicians when providing skilled nursing services under the delegation clause of Section 12-38-101, C.R.S., et seq.

8.290.4.C. The District shall have a Care Coordination Plan approved by the Department for the delivery of TCM services.

8.290.4.D. The District shall complete and submit to the Department a Care Coordination Plan for the delivery of TCM services. The District shall have a representative group of parents and community-based providers, including the local public health department, EPSDT case managers and any existing school-based health centers to assist in developing the Care Coordination Plan. Included in the care coordination plan is the provision for coordination of benefits and case management across multiple providers to:

1. Achieve service integration, monitoring, and advocacy, 2. Provide needed medical, social, educational, and other services, 3. Ensure that services effectively complement one another and 4. Prevent duplication of services.

8.290.4.E. Individual TCM providers shall be Qualified Health Care Professionals or shall meet the qualifications established by the Colorado Department of Education to develop and implement Individualized Plans or services under the Individuals with Disabilities Education Act. 8.290.5 COORDINATION OF CARE 8.290.5.A. The District shall coordinate the provision of care with the client’s primary health care provider for routine and preventive health care.

8.290.5.B. The District shall refer clients to their primary care provider, health maintenance organization or managed care provider for further diagnosis and treatment that may be identified as the result of an EPSDT screen or service.

8.290.5.C. When the client is receiving Medicaid services from other health care providers and the District, the District shall coordinate medical care with the providers to ensure that service goals are complementary and mutually beneficial to the client or shall show cause as to why coordination did not occur.

8.290.5.D. When the client of the targeted population is receiving case management services from another provider agency as the result of being members of other covered targeted groups, the District shall ensure that case management activities are coordinated to avoid unnecessary duplication of services.

8.290.5.E. The District shall inform a family receiving case management services from more than one provider that the family may choose one lead case manager to facilitate coordination. 8.290.6 REIMBURSEMENT 8.290.6.A. The District shall obtain from the client or the client's guardian a written informed consent to submit Medicaid claims on behalf of the client.

8.290.6.B. The District shall abide by the Third Party Liability rule at 10 C.C.R. 2505-10, Section 8.061.2.23.

8.290.6.C. Rates 1. Transportation rates are based on special transportation cost information received from the Department of Education.

2. Rates, other than transportation rates, are developed according to Department methodology based on averaged costs to Districts for providing services. Costs are the salary and fringe benefits of qualified providers, direct support and indirect support. 3. The District shall provide salary and fringe benefits cost data for use in rate setting as part of the required independent audit report submitted annually to the Department of Education. 4. The District shall periodically participate in a time study to determine the direct support rate. 5. The indirect support rate is a standard rate published annually by the Department of Education.

8.290.6.D. Payment 1. The District shall submit a claim for each benefit service provided for each client. 2. The District shall receive reimbursement on a fee for service basis. 3. The District shall receive the federal share of the determined rate, not to exceed 100% of the federal match rate, as payment.

8.290.7 CERTFICATION OF MATCH The District shall certify to the Department that it has expended local and state monies to provide Medicaid services in an amount sufficient to meet the nonfederal share of expenditures claimed for federal financial participation.

___________________________________________________ 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]