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

8.900 COLORADO INDIGENT CARE PROGRAM (CICP)

PROGRAM OVERVIEW AND LEGAL BASIS The Colorado Indigent Care Program (CICP) is a program that distributes federal and State funds to partially compensate Qualified Health Care Providers for uncompensated costs associated with services rendered to the indigent population. Qualified Health Care Providers who receive this funding render discounted health care services to Colorado residents, migrant workers and legal immigrants with limited financial resources who are uninsured or underinsured and not eligible for benefits under the Medicaid Program or the Children’s Basic Health Plan.

The Colorado Department of Health Care Policy and Financing (Department) administers the CICP by distributing funding to Qualified Health Care Providers who serve eligible persons who are indigent. The CICP issues procedures to ensure the funding is used to serve the indigent population in a uniform method. Any significant departure from these procedures will result in termination of the approval of, and the funding to, a health care provider. The CICP is authorized by state law at part 1 of article 3 of title 25.5, C.R.S. (2016).

The CICP does not offer a specified discounted medical benefit package or an entitlement to medical benefits or funding to individuals or medical providers. The CICP does not offer a health coverage plan as defined in Section 10-16-102 (34), C.R.S. Medically indigent persons receiving discounted health care services from Qualified Health Care Providers are subject to the limitations and requirements imposed by part 1 of article 3 of title 25.5, C.R.S.

8.901 DEFINITIONS

A. Applicant means an individual who has applied at a Qualified Health Care Provider to receive discounted health care services.

B. Children’s Basic Health Plan or the Child Health Plan Plus (CHP+) means the Children’s Basic Health Plan as defined in article 8 of title 25.5, C.R.S. (2016).

C. Client means an individual whose application to receive discounted health care services has been approved by a Qualified Health Care Provider.

D. Clinic Provider means any Qualified Health Care Provider that is a community health clinic licensed or certified by the Department of Public Health and Environment pursuant to C.R.S §25- 1.5-103, a federally qualified health center as defined in 42 U.S.C. 1395x (aa)(4), or a rural health clinic, as defined in 42 U.S.C. 1395x (aa)(2).

E. Colorado Indigent Care Program or CICP or Program means the Colorado Indigent Care Program as authorized by state law at part 1 of article 3 of title 25.5, C.R.S. (2016).

F. Denver Metropolitan Area means the Denver-Aurora-Lakewood, CO metropolitan area as defined by the Bureau of Labor Statistics.

G. Department means the Department of Health Care Policy and Financing established pursuant to title 25.5, C.R.S. (2016).

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

I. General Provider means a general hospital, birth center, or community health clinic licensed or certified by the Department of Public Health and Environment pursuant to Section 25-1.5- 103(1)(a)(I) or (1)(a)(II), C.R.S., a federally qualified health center, as defined in 42 U.S.C. 1395x (aa)(4), a rural health clinic, as defined in 42 U.S.C. 1395x (aa)(2), a health maintenance organization issued a certificate authority pursuant to Section 10-16-402, C.R.S., and the University of Colorado Health Sciences Center when acting pursuant to Section 25.5-3-108 (5)(a)(I) or (5)(a)(II)(A), C.R.S. For the purposes of the Program, General Provider includes associated physicians.

42 U.S.C. 1395x is incorporated by reference. Such incorporation, however, excludes later amendments to or editions of the referenced material. Pursuant to Section 24-4-103(12.5), C.R.S., the Department of Health Care Policy and Financing maintains either electronic or written copies of the incorporated texts for public inspection. Copies may be obtained at a reasonable cost or examined during regular business hours at 1570 Grant Street, Denver, Colorado 80203. Additionally, any incorporated material in these rules may be examined at any State publications depository library.

J. Hospital Provider means any Qualified Health Care Provider that is a general hospital licensed or certified by the Department of Public Health and Environment pursuant to Section 25-1.5-103, C.R.S. and which operates inpatient facilities.

K. Liquid Resources means resources that can be readily converted to cash, including but not limited to checking and savings accounts, health savings accounts, prepaid bank cards, certificates of deposit less the penalty for early withdrawal.

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

M. Qualified Health Care Provider means any General Provider who is approved by the Department to provide, and receive funding for, discounted health care services under the Colorado Indigent Care Program.

N. Spend Down means when an Applicant uses his or her available Liquid Resources to pay off part or all of a medical bill to lower his or her financial determination to a level that will allow him or her to qualify for the Program.

O. Urgent Care means treatment needed because of an injury or serious illness that requires immediate treatment.

8.902 PROVISIONS APPLICABLE TO QUALIFIED HEALTH CARE PROVIDERS

A. Requirements for Qualified Health Care Providers 1. Agreements will be made annually between the Department and Qualified Health Care Providers through an application process.

2. Agreements may be executed with Hospital Providers throughout Colorado that meet the following requirements:

a. Licensed or certified as a general hospital or birth center by the Department of Public Health and Environment.

b. Hospital Providers shall assure that Emergency Care is available to all Clients throughout the Program year.

c. Hospital Providers shall have at least two obstetricians with staff privileges at the Hospital Provider who agree to provide obstetric services to individuals under Medicaid. In the case where a Hospital Provider is located in a rural area (that is, an area outside of a metropolitan statistical area, as defined by the Executive Office of Management and Budget), the term “obstetrician” includes any physician with staff privileges at the Hospital Provider to perform non-emergency obstetric procedures.

This requirement does not apply to a Hospital Provider in which the inpatients are predominantly under 18 years of age or which does not offer non-emergency obstetric services as of December 21, 1987.

d. Using the information submitted by an Applicant, the Qualified Health Care Provider shall determine whether the Applicant meets all requirements to receive discounted health care services under the Program. If the Applicant is eligible to receive discounted health care services under the Program, the Qualified Health Care Provider shall determine an appropriate copayment for the Client. Hospital Providers shall determine if the Applicant is eligible to receive discounted services under the Program at the time of application, unless required documentation is not available, in which case a determination should be made within 15 working days of the date the Applicant provides a signed application and such other information, written or otherwise, as is necessary to process the application. Hospital Providers shall determine Client financial eligibility using the following information:

I. Income from each Applicant age eighteen (18) and older;

II. Household size, where all non-spouse or civil union partner, non-student adults ages eighteen (18) to sixty-four (64) included on the application must have financial support demonstrated or attested to; and III. Liquid Resources. Including Liquid Resources in the financial eligibility determination is optional for Hospital Providers. If a Hospital Provider chooses to include Liquid Resources in the financial eligibility determination, at least $2,500 must be protected for each family member counted in household size, and the Hospital Provider must include a Spend Down opportunity.

e. Hospital Providers shall submit a Sliding Fee Scale for Department approval with their annual application that shows copayments for different service categories divided into at least three income tiers covering 0 to 250% of the federal poverty level. Copayments shall be expressed in dollar amounts and shall not exceed the copayments in the Standard Client Copayment Table found in Appendix A.

f. Hospital Providers shall submit Program utilization and charge data in a format and timeline determined by the Department.

3. Agreements may be executed with Clinic Providers throughout Colorado that meet the following minimum criteria:

a. Licensed or certified as a community health clinic by the Department of Public Health and Environment, or certified by the U.S. Department of Health and Human Services as a federally qualified health center or rural health clinic.

b. Using the information submitted by an Applicant, the provider shall determine whether the Applicant meets all requirements to receive discounted health care services under the Program. If the Applicant is eligible to receive discounted health care services under the Program, the Qualified Health Care Provider shall determine an appropriate copayment for the Client. Clinic Providers should determine if the Applicant is eligible to receive discounted services under the Program at the time of application, unless required documentation is not available, in which case a determination should be made within 15 days of the date the Applicant provides a signed application and such other information, written or otherwise, as is necessary to process the application. Clinic Providers who are federally qualified health centers shall determine Client financial eligibility as required under federal regulations and guidelines. Clinic Providers who are not federally qualified health centers shall determine Client financial eligibility using the following information:

I. Income from each Applicant age eighteen (18) and older, and II. Household size.

c. Clinic Providers shall submit a Sliding Fee Scale for Department approval with their annual application that shows copayments for different service categories. Copayments for Clients between 0 and 100% of the federal poverty level shall be nominal or $0. Sliding Fee Scales shall have at least three tiers between 101 and 250% of the federal poverty level.

I. Sliding fee scales used by federally qualified health centers approved by the federal government meet all requirements of the Program.

II. Copayments for Clients between 101 and 250% of the federal poverty level may not be less than the copayments for Clients between 0 and 100% of the federal poverty level.

III. The same sliding fee scale shall be used for all Clients eligible for the Program.

IV. Sliding fee scales shall be reviewed by the Qualified Health Care Provider on a regular basis to ensure there are no barriers to care.

d. Clinic Providers shall submit Program data and quality metrics with their annual application. Specific quality metrics are listed in Section 8.905.B. The data and quality metrics shall be submitted in a format determined by the Department and provided as part of the annual application.

4. Determination of Lawful Presence a. Qualified Health Care Providers shall develop procedures for handling original lawful presence documents to ensure that the documents are not lost, damaged or destroyed. Qualified Health Care Providers shall develop and follow procedures for returning or mailing original documents to Applicants within five business days of receipt.

b. Qualified Health Care Providers shall accept copies of an Applicant’s lawful presence documentation that have been verified by other CICP providers, Medical Assistance sites, county departments of social services, or any other entity designated by the Department of Health Care Policy and Financing through an agency letter, provided that the verification identifies that the copy is from an original and that the individual who reviewed the document(s) signifies such by including their name, organization, address, telephone number and signature on the copy.

c. Qualified Health Care Providers shall retain photocopies of the Applicant’s affidavit and lawful presence documentation.

d. Qualified Health Care Providers shall not discriminate against Applicants on the basis of race, national origin, gender, religion, age or disability. If an Applicant has a disability that limits the Applicant’s ability to provide the required evidence of citizenship or lawful presence, the provider shall assist the individual to obtain the required evidence.

I. Examples of reasonable assistance that may be expected include, but are not limited to, providing contact information for the appropriate agencies that issue required documents; explaining the documentation requirements and how the Applicant may provide the required documentation; or referring the Applicant to other agencies or organizations which may be able to provide assistance.

II. Examples of additional assistance that shall be provided to Applicants who are unable to comply with the documentation requirements due to physical or mental impairments or homelessness and who do not have a guardian or representative who can provide assistance include, but are not limited to, contacting any known family members who may have the required documentation; contacting any known health care providers who may have the required documentation; or contacting other social services agencies or organizations that are known to have provided assistance to the Applicant.

III. The Qualified Health Care Provider shall not be required to pay for the cost of obtaining required documentation.

IV. The Qualified Health Care Provider shall document its efforts of providing additional assistance to the Applicant and retain such documentation.

5. Qualified Health Care Providers shall provide the Applicant and/or representative a written notice of the provider's determination as to the Applicant’s eligibility to receive discounted services under the Program. If eligibility to receive discounted health care services is granted by the Qualified Health Care Provider, the notice shall include the date when eligibility began. If eligibility to receive discounted health care services is denied, the notice shall include a brief, understandable explanation of the reason(s) for the denial. Every notice of the Qualified Health Care Provider's decision, whether an approval or a denial, shall include an explanation of the Applicant's appeal rights found at Section 8.902.B in these regulations.

6. Qualified Health Care Providers shall screen all Applicants for eligibility for Medicaid and the Children’s Basic Health Plan and refer Applicants to those programs if they appear eligible. The Qualified Health Care Provider shall refer Applicants to Colorado’s health insurance marketplace for information about private health insurance.

B. Client Appeals 1. If an Applicant or Client feels that a financial determination or denial is in error, he or she shall only challenge the financial determination or denial by filing an appeal with the Qualified Health Care Provider who determined eligibility to receive discounted health care services under the CICP pursuant to this Section 8.902. There is no appeal process available through the Office of Administrative Courts.

2. Instructions for Filing an Appeal The Qualified Health Care Provider shall inform the Applicant or Client that he or she has the right to appeal the financial determination or denial if he or she is not satisfied with the Qualified Health Care Provider's decision.

If the Applicant or Client wishes to appeal the financial determination or denial of the application, the Applicant or Client shall submit a written request for appeal to the Qualified Health Care Provider, which includes any documentation supporting the reasons for the request.

3. Appeals An Applicant or Client may file an appeal if he or she wishes to challenge the accuracy of his or her initial financial determination.

A Client or Applicant shall have 15 calendar days to request an appeal from the date of the Qualified Health Care Provider's decision.

If the Qualified Health Care Provider receives the Applicant’s or Client’s appeal after the 15 working day deadline, the Qualified Health Care Provider shall notify the Applicant or Client in writing that the appeal was denied because it was not submitted timely. At the discretion of the Qualified Health Care Provider and for good cause shown, including a death in the Applicant’s or Client’s immediate family member, the Qualified Health Care Provider may review an appeal received after 15 working days. An Applicant or Client can request an appeal for the following reasons:

a. The initial financial determination or denial was based on inaccurate information because the family member or representative was uninformed;

b. The Applicant or Client believes that the calculation is inaccurate for some other reason; or c. Miscommunication between the Applicant or Client and the financial determination technician cause incomplete or inaccurate data to be recorded on the application.

Each Qualified Health Care Provider shall designate a manager to review appeals. An appeal involves receiving a written request from the Applicant or Client, and reviewing the application completed by the financial determination technician, including all back-up documentation, to determine if the application to receive discounted health care services under the CICP is accurate.

If the manager finds that the initial financial determination or denial is not accurate, the designated manager shall correct the financial determination to receive discounted health care services under the CICP and assign the correct financial determination to the Applicant or Client. The correct financial determination is effective retroactive to the initial date of application, and charges incurred 90 days prior to the initial date of application must be discounted. The Qualified Health Care Provider shall notify the Applicant or Client in writing of the results of an appeal within 15 working days following receipt of the appeal request from the Applicant or Client.

4. Provider Management Exception Each Qualified Health Care Provider shall designate a manager to review provider management exceptions. At the discretion of the Qualified Health Care Provider and for good cause shown, the designated manager may grant the Applicant or Client a provider management exception to the Client’s financial determination. This process can be used during the initial financial determination, simultaneously with an appeal, or within 15 working days of the Qualified Health Care Provider’s decision regarding an appeal. A Client may request and a Qualified Health Care Provider may grant a provider management exception if the Client can demonstrate that there are circumstances that should be taken into consideration when establishing his or her initial financial determination. Provider Management Exceptions shall always result in a lower Client financial determination.

A Client may request a provider management exception simultaneously with an appeal, or within 15 working days of the Qualified Health Care Provider’s decision regarding an appeal.

The facility shall notify the Client in writing of the Qualified Health Care Provider’s findings within 15 working days of receipt of the written request. The Qualified Health Care Provider must note provider management exceptions on the application. Qualified Health Care Providers shall treat Clients equitably in the provider management exception process.

A financial determination from a provider management exception is effective as of the initial date of application. Charges incurred 90 days prior to the initial date of application must be discounted. Qualified Health Care Providers are not required to honor provider management exceptions granted by other Qualified Health Care Providers.

C. Financial Eligibility General Rule: An Applicant shall be financially eligible for discounted health care services under the CICP if his or her household income is no more than 250% of the most recently published federal poverty level (FPL) for a household of that size.

1. Qualified Health Care Providers determine eligibility for the CICP and shall maintain auditable files of applications for discounted health care services under the CICP.

2. The determination of financial eligibility process looks at the financial circumstances of a household as of the date that a signed application is completed.

3. All Qualified Health Care Providers must accept each other’s CICP financial determinations unless the Qualified Health Care Provider believes that the financial determination was determined incorrectly, the Qualified Health Care Provider’s financial determination process is materially different from the process used by the issuing Qualified Health Care Provider, or that the financial determination was a result of a provider management exception.

4. CICP eligibility is retroactive for services received from a Qualified Health Care Provider up to 90 days prior to application.

5. Documentation concerning the Applicant’s financial status shall be maintained by the provider.

6. Beyond the distribution of available funds made by the CICP, allowable Client copayments, and other third-party sources, a provider shall not seek payment from a Client for the provider's CICP discounted health care services to the Client.

7. Emergency Application for Providers a. In emergency circumstances, an Applicant may be unable to provide all of the information or documentation required by the usual application process. For emergency situations, the Qualified Health Care Provider shall follow these steps in processing the application:

I. Use the regular application to receive discounted health care services under the CICP, but indicate emergency application on the application.

II. Ask the Applicant to give spoken answers to all questions and to sign the application to receive discounted health care services under the CICP.

III. Determine a federal poverty level based on the spoken information provided.

b. An emergency application is good for only one episode of service in an emergency room and any subsequent service related to the emergency room episode. If the Client receives any care other than the emergency room visit, the Hospital Provider must request the Client to submit documentation to support all figures on the emergency application or complete a new application. If the documentation submitted by the Client does not support the earlier, spoken information, the Hospital Provider must obtain a new application from the Client. If the Client does not submit any supporting documentation or complete a new application upon the request of the provider, the provider shall use the information contained in the emergency application.

c. In emergency circumstances, an Applicant is not required to provide identification or execute an affidavit as specified at 10 C.C.R. 2505-10, Section 8.904.D.

D. Audit Requirements The Department will conduct audits of Qualified Health Care Providers. Qualified Health Care Providers shall comply with requests for data and other information from the Department. Qualified Health Care Providers shall complete corrective actions when required by the Department. The Department’s intention is to audit at minimum one-sixth of the participating Qualified Health Care Providers in state fiscal year 2018-19 and at minimum one-third of the participating Qualified Health Care Providers each year beginning in state fiscal year 2019-20.

E. HIPAA The CICP does not meet the definition of a covered entity or business associate under the Health Insurance Portability and Accountability Act of 1996 at 45 CFR 160.103. The CICP is not a part of the Colorado Medical Assistance Program, nor of Health First Colorado, Colorado’s Medicaid program. CICP’s principal activity is the making of grants to providers who serve eligible persons who are medically indigent. The state personnel administering the CICP will provide oversight in the form of procedures and conditions to ensure funds provided are being used to serve the target population, but they will not be significantly involved in any health care decisions or disputes involving a Qualified Health Care Provider or Client.

8.903 DISCOUNTED HEALTH CARE SERVICES

A. Funding provided under the CICP shall be used to provide Clients with discounted health care services determined to be medically necessary by the Qualified Health Care Provider.

B. All health care services normally provided at the Qualified Health Care Provider should be available at a discount to Clients. If health care services normally provided at the Qualified Health Care Provider are not available to Clients at a discount, Clients must be informed that the services can be offered without a discount prior to the rendering of such services.

C. Qualified Health Care Providers receiving funding under the CICP shall prioritize the use of funding such that discounted health care services are available in the following order:

1. Emergency Care;

2. Urgent Care; and 3. Any other medical care.

D. Additional discounted health care services may include:

1. Emergency mental health services if the Qualified Health Care Provider renders these services to a Client at the same time that the Client receives other medically necessary services.

2. Qualified Health Care Providers may provide discounted pharmaceutical services. The Qualified Health Care Provider should only provide discounted prescriptions that are written by doctors on its staff, or by a doctor that is under contract with the Qualified Health Care Provider. Qualified Health Care Providers shall exclude prescription drugs included in the definition of Medicare Part-D from eligible Clients who are also eligible for Medicare.

3. Qualified Health Care Providers may provide packages of services to patients with modified copayment requirements.

a. Packages of services benefit Clients who need to utilize services more often than average Clients. Things that would be beneficial to the client include but are not limited to charging a lower copay, charging the copay on an alternative schedule (i.e. once a week, or ever other time), or setting a cap on the amount or number of copayments made towards the packaged services. Examples of packages may include but are not limited to oncology treatments, physical therapy, and dialysis.

b. Qualified Health Care Providers may provide a prenatal benefit with a predetermined copayment designed to encourage access to prenatal care for indigent women. This prenatal benefit shall not cover the delivery or the hospital stay, or visits that are not related to the pregnancy. The Qualified Health Care Provider is responsible for providing a description of the services included in the prenatal benefit to the Client prior to services rendered. Services and copayments may vary among sites.

E. Excluded Discounted Health Care Services Funding provided under the CICP shall not be used for providing discounted health care services for the following:

1. Non-urgent dental services.

2. Nursing home care.

3. Chiropractic services.

4. Sex change surgical procedures.

5. Cosmetic surgery.

6. Experimental and non-United States Federal Drug Administration approved treatments.

7. Elective surgeries that are not medically necessary.

8. Court ordered procedures, such as drug testing.

9. Abortions - Except as specified in Section 25.5-3-106, C.R.S.

10. Mental health services in clinic settings pursuant to Section 25.5-3-110, C.R.S., part 2 of article 66 of title 27, C.R.S., any provisions of article 22 of title 23, C.R.S., or any other provisions of law relating to the University of Colorado Psychiatric Hospital.

8.904 PROVISIONS APPLICABLE TO CLIENTS

A. Overview of Requirements In order to qualify to receive discounted health care services under available CICP funds, an Applicant shall satisfy the following requirements:

1. Execute an affidavit regarding citizenship status;

2. Be lawfully present in the United States;

3. Be a resident of Colorado;

4. Meet all CICP eligibility requirements as defined by state law and procedures; and 5. Furnish a social security number (SSN) or evidence that an application for a SSN has been submitted, where required by 10 C.C.R. 2505-10, Section 8.904.G (2016).

B. Applicants 1. Any adult age 18 and older may apply to receive discounted health care services on behalf of themselves and members of the Applicant’s family household.

2. If an Applicant is deceased, the executor of the estate or a family member may complete the application on behalf of the Applicant. The family member completing the application will not be responsible for any copayments incurred on behalf of the deceased member.

3. The application to receive discounted health care services under available CICP funding shall include the names of all members of the Applicant's family household. All non- spouse or civil union partner, non-student adults ages 18-64 must have financial support demonstrated or attested to in order to be included in household size. All minors and those 65 or older do not need documentation of financial support to be counted in household size. Income from spouses or civil union partners and all non-student adults must be included in the application.

4. A minor shall not be rated separately from his or her parents or guardians unless he or she is emancipated or there exists a special circumstance. A minor is an individual under the age of 18.

C. Signing the Application The Applicant or an authorized representative of the Applicant must sign the application to receive discounted health care services submitted to the Qualified Health Care Provider within 90 calendar days of the date of health care services. If an Applicant is unable to sign the application or has died, a spouse, civil union partner, relative, or guardian may sign the application. Until it is signed, the application is not complete, the Applicant cannot receive discounted health care services under the CICP and the Applicant has no appeal rights. All information needed by the provider to process the application must be submitted before the application is signed.

D. Affidavit 1. Each first-time Applicant, or Applicant seeking to reapply, eighteen (18) years of age or older shall execute an affidavit stating:

a. That he or she is a United States citizen, or b. That he or she is a legal permanent resident, or is otherwise lawfully present in the United States pursuant to federal law.

2. For an Applicant who has executed an affidavit stating that he or she is lawfully present in the United States but is not a United States citizen, the provider shall, within 30 days of the application date, verify lawful presence through the Federal Systematic Alien Verification of Entitlement Program operated by the United States Department of Homeland Security or a successor program designated by the United States Department of Homeland Security. Until verification of lawful presence is made, the affidavit may be presumed to be proof of lawful presence.

E. Establishing Lawful Presence 1. Each first-time Applicant, or Applicant seeking to reapply, eighteen (18) years of age or older shall be considered lawfully present in the country if they produce a document or waiver in accordance with 1 CCR 204-30 Rule 5 (effective August 30, 2016), which is hereby incorporated by reference. This incorporation of 1 CCR 204-30 Rule 5 excludes later amendments to, or editions of, the referenced material. Pursuant to Section 24-4- 103 (12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203. Certified copies of incorporated materials are provided at cost upon request.

2. Submission of Documentation Lawful presence documentation may be accepted from the Applicant, the Applicant’s spouse, civil union partner, parent, guardian, or authorized representative in person, by mail, or facsimile.

3. Expired or absent documentation for non-U.S. citizens a. If an Applicant presents expired documents or is unable to present any documentation evidencing his or her immigration status, refer the Applicant to the local Department of Homeland Security office to obtain documentation of status.

b. In unusual circumstances involving Applicants who are hospitalized or medically disabled or who can otherwise show good cause for their inability to present documentation and for whom securing such documentation would constitute undue hardship, if the Applicant can provide an alien registration number, the provider may file U.S.C.I.S. Form G-845 and Supplement, along with the alien registration and a copy of any expired Department of Homeland Security document, with the local Department of Homeland Security office to verify status.

c. If an Applicant presents a receipt indicating that he or she has applied to the Department of Homeland Security for a replacement document, file U.S.C.I.S. Form G-845 and Supplement with a copy of the receipt with the local Department of Homeland Security office to verify status.

F. Residence in Colorado An Applicant must be a resident of Colorado. A Colorado resident is a person who currently lives in Colorado and intends to remain in the state.

Migrant workers and all dependent family members must meet all of the following criteria to comply with residency requirements:

1. Maintains a temporary home in Colorado for employment reasons;

2. Meet the lawful presence criteria, as defined in paragraph E of this Section; and 3. Employed in Colorado.

G. Except in the circumstances enumerated below, social security number(s) shall be required for all Clients receiving discounted health care services under the Program. If an Applicant does not have a social security number, documentation that the Applicant has applied for a social security number must be provided to complete the application to receive discounted health care services under the Program. This section shall not apply to unborn children, homeless individuals who are unable to provide a social security number, individuals who are not eligible to receive a social security number, individuals who may only be issued a social security number for a valid non- work reason in accordance with 20 CFR 422.104, or individuals who refuse to obtain a social security number because of well-established religious objections.

H. Applicants Not Eligible 1. The following individuals are not eligible to receive discounted services under the CICP:

a. Individuals for whom lawful presence cannot be verified.

b. Individuals who are being held or confined involuntarily under governmental control in State or federal prisons, jails, detention facilities or other penal facilities. This includes those individuals residing in detention centers awaiting trial, at a wilderness camp, residing in half-way houses who do not have freedom of movement and association, and those persons in the custody of a law enforcement agency temporarily released for the sole purpose of receiving health care.

c. College students whose residence is from outside Colorado or the United States that are in Colorado for the purpose of higher education. These students are not Colorado residents and cannot receive services under the CICP.

d. Visitors from other states or countries temporarily visiting Colorado and have primary residences outside of Colorado.

e. Persons who qualify for Medicaid. However, Applicants whose only Medicaid benefits are the following shall not be excluded from consideration for CICP eligibility:

I. QMB benefits described at Section 10 C.C.R. 2505-10, Section 8.100.6.L (2016) of these regulations;

II. SLMB benefits described at Section 10 C.C.R. 2505-10, Section 8.1006.M (2016), or III. The QI1 benefits described at Section 10 C.C.R. 2505-10, Section 8.100.6.N (2016).

f. Individuals who are eligible for the Children's Basic Health Plan.

I. Health Insurance Information The Applicant shall submit all necessary information related to health insurance, including a copy of the insurance policy or insurance card, the address where the medical claim forms must be submitted, policy number, and any other information determined necessary.

J. Subsequent Insurance Payments If a Client receives discounted health care services under the CICP, and their insurance subsequently pays for services, or if the Client is awarded a settlement, the insurance company or patient shall reimburse the Qualified Health Care Provider for discounted health care services rendered to the Client.

8.905 DEPARTMENT RESPONSIBILITIES

A. Provider Application 1. The Department shall produce and publish a provider application annually.

a. The application will be updated annually to incorporate any necessary changes and update any Program information.

b. The application will include data and quality metric submission templates.

2. The Department shall determine Qualified Health Care Providers annually through the application process.

3. An agreement will be executed between the Department and Denver Health for the purpose of providing discounted health care services to the residents of the City and County of Denver, as required by Section 25.5-3-108 (5)(a)(I), C.R.S.

4. An agreement will be executed between the Department and University Hospital for the purpose of providing discounted health care services in the Denver Metropolitan Area and complex care that is not contracted for in the remaining areas of the state, as required by Section 25.5-3-108 (5)(a)(II), C.R.S.

5. The Department shall produce and publish a provider directory annually.

B. Payments to Providers 1. Funding for hospitals shall be distributed in accordance with 10 CCR 2505-10 Section

8.3000 and 8.905 B.3.

2. Clinics a. Funding for Clinic Providers is appropriated through the Colorado General Assembly under the Children’s Hospital, Clinic Based Indigent Care line item. Effective July 1, 2018, funding for clinics shall be separated into two different groups, as follows:

I. Seventy-five (75) percent of the funding will be distributed based on Clinic Providers’ write off costs relative to the total write off costs for all Clinic Providers.

II. Twenty-five (25) percent of the funding will be distributed based on a points system granted to Clinic Providers based on their quality metric scores multiplied by the Clinic Provider’s total visits from their submitted Program data.

b. The quality metric scores will be calculated based on the following four metrics. The metrics are defined by the Health Resources & Services Administration (HRSA):

I. Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow Up II. Preventative Care and Screening: Screening for Clinical Depression and Follow-up Plan III. Diabetes: Hemoglobin A1c Poor Control IV. Controlling High Blood Pressure c. Write off costs will be calculated as follows:

I. Distribution of available funds for indigent care costs will be calculated based upon historical data. Third-party liabilities and the patient liabilities will be deducted from total charges to generate medically indigent charges.

II. Clinic Providers shall deduct amounts due from third-party payment sources from total charges declared on the summary statistics submitted to the Department.

III. Clinic Providers shall deduct the full patient liability amount from total charges, which is the amount due from the Client as identified in the CICP Standard Client Copayment Table, as defined under Appendix A in these rules, or an alternative sliding fee scale that is submitted by the provider with the annual application for the CICP and approved by the Department. The summary information submitted to the Department by the provider shall include the full CICP patient liability amount even if the Clinic Provider receives the full payment at a later date or through several smaller installments or no payment from the Client.

IV. Medically indigent charges will be converted to medically indigent costs using the most recently available cost-to-charge ratio from the Clinic Provider’s cost report or other financial documentation accepted by the Department.

d. The Department shall notify Clinic Providers of their expected payment no later than August 31 of each year. The notification shall include the total expected payment and a description of the methodology used to calculate the payment.

e. For the 2017-18 Program year, Clinic Provider payments will be based solely on calendar year 2016 write-off costs relative to the total write off costs for all Clinic Providers. Write off charges shall be calculated as described in part c of this section.

3. Pediatric Major Teaching Hospital Payment. Hospital Providers shall qualify for additional payment when they meet the criteria for being a major teaching hospital provider and when their Medicaid-eligible inpatient days combined with indigent care days (days of care provided under the Colorado Indigent Care Program) equal or exceed 30 percent of their total inpatient days for the most recent year for which data are available. A major teaching hospital provider is defined as a Colorado hospital, which meets the following criteria:

a. Maintains a minimum of 110 total Intern and Resident (I/R) F.T.E.'s;

b. Maintains a minimum ratio of .30 Intern and Resident (I/R) F.T.E.'s per licensed bed;

c. Qualifies as a Pediatric Specialty Hospital under the Medicaid Program, such that the hospital provides care exclusively to pediatric populations.

d. Has a percentage of Medicaid-eligible inpatient days relative to total inpatient days that equal or exceeds one standard deviation above the mean; and e. Participates in the Colorado Indigent Care Program The Major Teaching Hospital Rate is set by the Department such that the payment will not exceed the appropriation set by the General Assembly.

C. Provider Appeals 1. Any provider who submits an application to become a Qualified Health Care Provider whose application is denied may appeal the denial to the Department.

2. The provider’s first level appeal must be filed within five (5) business days of the receipt of the denial letter. The Department’s Special Financing Division Director will respond to any first level appeals within ten (10) business days of receipt of the appeal.

3. If a provider disagrees with the Department’s Special Financing Division Director’s first level appeal determination, they may file a second level appeal within five (5) business days of the receipt of the first level appeal determination. The Department’s Executive Director will respond to the second level appeal within ten (10) business days of the receipt of the second level appeal.

D. Advisory Council The Department shall create a CICP Stakeholder Advisory Council, effective July 1, 2017. The Executive Director of the Department shall appoint 11 members to the CICP Stakeholder Advisory Council. Members shall include:

1. A member representing the Department;

2. Three consumers who are eligible for the Program or three representatives from a consumer advocate organization or a combination of each;

3. A representative from a federally qualified health center as defined at 42 U.S.C. 1395x (aa)(4);

4. A representative from a rural health clinic as defined at 42 U.S.C. 1395x (aa)(2), or a representative from a clinic licensed or certified as a community health clinic by the Department of Public Health and Environment, or a representative from an organization that represents clinics who are not federally qualified health centers;

5. A representative from either Denver Health or University Hospital;

6. A representative from an urban hospital;

7. A representative from a rural or critical access hospital;

8. A representative of an organization of Colorado community health centers, as defined in the federal “Public Health Service Act”, 42 U.S.C. sec. 254b;

9. A representative from an organization of Colorado hospitals. Members shall serve without compensation or reimbursement of expenses. The Executive Director shall at least annually select a chair for the council to serve for a maximum period of twelve months. The Department shall staff the council. The council shall convene at least twice every fiscal year according to a schedule set by the chair. Members of the council shall serve three-year terms. Of the members initially appointed to the advisory council, the executive director shall appoint six for two-year terms and five for three-year terms. In the event of a vacancy on the advisory council, the executive director shall appoint a successor to fill the unexpired portion of the term of such member.

The council shall 1. Advise the Department of operation and policies for the Program 2. Make recommendations to the Medical Services Board regarding rules for the Program E. Annual Report 1. The Department shall prepare an annual report concerning the status of the Program to be submitted to the Health and Human Services committees of the Senate and House of Representatives, or any successor committees, no later than February 1 of each year.

2. The report shall at minimum include charges for each Qualified Health Care Provider, numbers of Clients served, and total payments made to each Qualified Health Care Provider.

10 CCR 2505-10 § 8.900 APPENDIX A: STANDARD CICP CLIENT COPAYMENT A. Client Copayments - General Policies A Client is responsible for paying a portion of his or her medical bills. The Client’s portion is called the Client Copayment. Qualified Health Care Providers are responsible for charging the Client a copayment. Qualified Health Care Providers may require Clients to pay their copayment prior to receiving care (except for Emergency Care). Qualified Health Care Providers may charge copayments in accordance with the Standard Client Copayment Table or an alternate sliding fee scale that is submitted by the provider with the annual application for the CICP and approved by the Department.

Percent of FPL 0 - 40% 0 - 41 - 63 - 82 - 101 - 118 - 134 - 160 - 186 - 201 - and 40% 62% 81% 100% 117% 133% 159% 185% 200% 250% Homeless Ambulatory $0 $15 $65 $105 $155 $220 $300 $390 $535 $600 $630 Surgery Inpatient $0 $15 $65 $105 $155 $220 $300 $390 $535 $600 $630 Facility Hospital $0 $7 $35 $55 $80 $110 $150 $195 $270 $300 $315 Physician Emergency $0 $15 $25 $25 $30 $30 $35 $35 $45 $45 $50 Room Emergency $0 $15 $25 $25 $30 $30 $35 $35 $45 $45 $50 Transportation Outpatient Hospital $0 $7 $15 $15 $20 $20 $25 $25 $35 $35 $40 Services Clinic Services $0 $7 $15 $15 $20 $20 $25 $25 $35 $35 $40 Specialty $0 $15 $25 $25 $30 $30 $35 $35 $45 $45 $50 Outpatient Prescription $0 $5 $10 $10 $15 $15 $20 $20 $30 $30 $35 Laboratory $0 $5 $10 $10 $15 $15 $20 $20 $30 $30 $35 Basic Radiology & $0 $5 $10 $10 $15 $15 $20 $20 $30 $30 $35 Imaging High-Level Radiology & $0 $30 $90 $130 $185 $250 $335 $425 $580 $645 $680 Imaging There are different copayments for different service charges. The following information explains the different types of medical care charges and the related Client Copayments under the Standard Client Copayment Table.

1. Inpatient facility charges are for all non-physician (facility) services received by a Client while receiving care in the hospital setting for a continuous stay of 24 hours or longer.

2. Ambulatory Surgery charges are for all non-physician (facility) Ambulatory Surgery operative procedures received by a Client who is admitted to and discharged from the hospital setting on the same day. The Client is also responsible for the corresponding Hospital Physician charges.

3. The Hospital Physician charges are for services provided directly by a physician in the hospital setting, including inpatient, ambulatory surgery, and emergency room care.

4. Clinic Services charges are for all non-physician (facility) and physician services received by a Client while receiving care in the outpatient clinic setting. Outpatient charges include primary and preventive medical care. This charge does not include radiology or laboratory services performed at the clinic.

5. Emergency Room charges are for all non-physician (facility) services received by a Client while receiving Emergency Care or Urgent Care in the hospital setting for a continuous stay less than 24 hours (i.e., emergency room care).

6. Specialty Outpatient charges are for all non-physician (facility) and physician services received by a Client while receiving care in the specialty outpatient setting. These services can be provided in standalone clinics and outpatient hospital settings. Specialty Outpatient charges include distinctive medical care (i.e., oncology, orthopedics, hematology, pulmonary) that is not normally available as primary and preventive medical care. Specialty Outpatient charges do not include radiology, laboratory, emergency room, or ambulatory surgery services provided in a hospital setting.

7. Emergency Transportation charges are for transportation provided by an ambulance.

8. Laboratory Service charges are for all laboratory tests received by a Client while receiving care in the outpatient hospital or clinic setting. Laboratory Service charges may not be charged in addition to charges for emergency room or inpatient services provided in the hospital setting.

9. Basic Radiology and Imaging Service charges are for all radiology and imaging services received by a Client while receiving care in the outpatient hospital or clinic setting. Basic Radiology and Imaging Service charges may not be charged in addition to charges for emergency room or inpatient services provided in the hospital setting.

10. Prescription charges are for prescription drugs received by a Client at a Qualified Health Care Provider’s pharmacy as an outpatient service. To encourage the availability of discounted prescription drugs, providers are allowed to modify (increase or decrease) the Prescription Copayment with the written approval of the Department.

11. High-Level Radiology and Imaging Service charges are for Clients receiving a Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Positron Emission Tomography (PET) or other Nuclear Medicine services, Sleep Studies, or Catheterization Laboratory (cath lab) in the outpatient hospital, emergency room, or clinic setting.

12. Outpatient Hospital Service charges are for all non-physician (facility) and physician services received by a Client while receiving non-Emergency Care or non-Urgent Care in the outpatient clinic setting. Outpatient Hospital Services charges include primary and preventive medical care. This charge does not include radiology, laboratory, emergency room, or ambulatory surgery services provided in a hospital setting.

13. Clients who are seen in the hospital setting in an observation bed should be charged the emergency room copay if their stay is less than 24 hours and the inpatient facility copay if their stay is 24 hours or longer.

B. Homeless Clients, Clients living in transitional housing, Clients residing with others, or recipients of Colorado’s Aid to the Needy Disabled financial assistance program, who are at or below 40% of the Federal Poverty Level are exempt from Client Copayments.

1. Homeless. A person is considered homeless who lacks a fixed, regular, and adequate night-time residence or has a primary night time residency that is: (A) a supervised publicly or privately operated shelter designed to provide temporary living accommodations, (B) an institution that provides a temporary residence for individuals intended to be institutionalized, or (C) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings. This does not include an individual imprisoned or otherwise detained pursuant to federal or state law. In addition, homeless Clients are exempt from Client Copayments, the income verification requirement, and providing proof of residency when completing the CICP application.

2. Transitional Housing. Transitional housing is designed to assist individuals in becoming self-supporting, but not referenced in 8.904.E.2. Clients living in transitional housing must provide a written statement from their counselor or program director asserting that they are participating in a transitional housing program.

In addition, transitional housing Clients are exempt from the income verification requirement when completing the CICP application.

3. Residing with Others. Clients who have no permanent housing of their own and who are temporarily living with a person who has no legal obligation to financially support the Client are considered residing with others. The individual allowing the Client to reside with him or her may be asked to provide a written statement confirming that the Client is not providing financial assistance to the household and that the living arrangement is not intended to be permanent.

4. Recipient of Colorado’s Aid to the Needy Disabled financial assistance program. A Client who is eligible and enrolled to receive the monthly grant award from Colorado’s Aid to the Needy Disabled financial assistance program.

In addition, recipients of Colorado’s Aid to the Needy Disabled financial assistance program are exempt from Client Copayments, and the income verification requirement when completing the CICP application.

C. Client Annual Copayment Cap 1. Homeless Clients whose financial determination is between 0 and 40% of the federal poverty level are exempt from copayments, so their copayment cap is $0. Clients whose financial determination is between 0 and 40% of the federal poverty level who are not homeless have a copayment cap that is the lesser of 10% of the family’s net income or $120. Clients who are also Old Age Pension Health and Medical Care Program clients have a copayment cap of $300 as mandated by 10 CCR 2505-10 8.941.10. For all other CICP Clients, annual copayments shall not exceed 10% of the family’s financial determination.

2. Clients who are also Old Age Pension Health and Medical Care Program clients have annual copayment caps based on a calendar year. All other Client annual copayment caps (annual caps) are based on the Client’s date of eligibility.

3. Clients are responsible for any charges incurred prior to the determination of the Client’s financial eligibility.

4. Clients are responsible for tracking their CICP copayments and informing the provider in writing, including documentation, within 90 days after meeting or exceeding their annual cap. If a Client overpays the annual cap and informs the Qualified Health Care Provider of that fact in writing, the Qualified Health Care Provider shall reimburse the Client for the overpayment.

5. A CICP Client is eligible to receive a new determination if his or her financial or family situation has changed since the initial financial determination. CICP copayments made under the prior financial determination will not count toward a new CICP copayment cap and the Client’s annual copayment cap resets when the Client completes a new application.

6. An annual cap applies only to charges incurred after a Client is eligible to receive discounted health care services, and applies only to discounted services incurred at a CICP Qualified Health Care Provider.

D. The Client must pay the lower of the copayment listed, the patient responsibility portion if the Client is insured, or actual charges.

E. Clients shall be notified at or before time of services rendered of their copayment responsibility.

F. Grants for Client Copayments Grants from foundations to Clients from non-profit, tax exempt, charitable foundations specifically for Client copayments are not considered other medical insurance or income. The provider shall honor these grants and may not count the grant as a resource or income.

8.930 [Repealed effective 8/12/2011.]

8.940 OLD AGE PENSION HEALTH CARE PROGRAM

8.941 EXTENT AND LIMITATIONS OF MEDICAL CARE

8.941.1 GENERAL DESCRIPTION - OLD AGE PENSION HEALTH CARE PROGRAM

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

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

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

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

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

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

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

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

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

8.941.2 DEFINITIONS

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

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

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

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

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

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

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

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

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

8.941.3 GROUPS ASSISTED UNDER THE OLD AGE PENSION HEALTH CARE PROGRAM

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

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

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

8.941.4 FINANCIAL ASSISTANCE

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

8.941.5 CERTIFICATION OF PAYMENT FOR PROVIDERS

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

8.941.6 OUT-OF-STATE MEDICAL CARE

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

8.941.7 SUBMISSION OF CLAIMS

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

8.941.8 REIMBURSEMENT TO PROVIDERS

T When reimbursement rates are modified, notifications shall be published on the Department’s website and will be published in the Provider Bulletin.

8.941.9 CLIENT CO-PAYMENT

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

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

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

8.942.1 MEDICAID QUALIFICATION

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

8.943 IDENTIFICATION AND AFFIDAVIT REQUIREMENTS

8.943.1 Lawful Presence Documentation

A. Each applicant eighteen (18) years of age or older, shall be considered lawfully present in the country if they produce a document or waiver in accordance with 1 CCR 204-30 Rule 5 (effective September 17, 2020), which is hereby incorporated by reference. This incorporation of 1 CCR 204-30 Rule 5 excludes later amendments to, or editions of, the referenced material. Pursuant to Section 24-4-103 (12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203. Certified copies of incorporated materials are provided at cost upon request.

B. If an applicant does not have the required documentation, he or she must be given a reasonable opportunity period of up to ten (10) business days to provide the required documentation. If the applicant does not provide the required documentation within those ten (10) business days, then the application shall be denied.

C. If an applicant whose benefits are terminated on the basis of not having the documents required by this section provides such documentation within ten (10) weeks of the date of denial, the denial shall be rescinded, and the client made eligible back to the data of application, provided he or she meet all other eligibility requirements.

8.943.2 Each applicant eighteen (18) years of age or older shall execute an affidavit stating:

A. That he or she is a United States Citizen or legal permanent resident; OR B. That he or she is a legal permanent resident or otherwise lawfully present in the United States pursuant to 1 CCR 204-30 Rule 5.

8.943.3 For an applicant who has executed an affidavit stating that he or she is an alien lawfully present in the United States under 8.943.2.B, the following shall apply:

A. Verification of lawful presence shall be made through the Federal Systematic Alien Verification for Entitlements (SAVE) Program operated by the United States Department of Homeland Security or a successor program designated by the United States Department of Homeland Security.

B. The county or medical assistance site shall perform the verification of lawful presence no more than three business days after receipt of the affidavit stating that the applicant is otherwise lawfully present in the United States pursuant to 1 CCR 204-30 Rule 5. A SAVE verification is not needed for Applicants who provide an ID issued by a REAL ID Act compliant state that bears the REAL ID Act indicator.

8.943.4 Photocopies of the identification listed in 8.943.1 shall be acceptable identification.

A. The county shall retain a photocopy of the documentation required under section 8.943.

8.950 PRIMARY CARE FUND

8.950.1 GENERAL DESCRIPTION

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

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

8.950.2 DEFINITIONS

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

8.950.2.B. Children’s Basic Health Plan also known as Child Health Plan Plus (CHP+) - As specified in Article 19 of Title 26, C.R.S.

8.950.2.C. Colorado Indigent Care Program (CICP) - As specified in Article 15 of Title 26, C.R.S. 8.950.2.D. Comprehensive Primary Care - Basic, entry-level health care provided by health care practitioners or non-physician health care practitioners that is generally provided in an outpatient setting. At a minimum, this includes providing or arranging for the provision of the following services on a Year-Round Basis: primary health care; maternity care, including prenatal care; preventive, developmental, and diagnostic services for infants and children; adult preventive services, diagnostic laboratory and radiology services; emergency care for minor trauma; Pharmaceutical Services; and coordination and follow-up for hospital care. It may also include optional services based on a patient’s needs such as dental, behavioral health and eyeglasses. 8.950.2.E. Cost-Effective Care - Provides or Arranges for Comprehensive Primary Care that is appropriate and at a reasonable average cost per patient Visit and/or Encounter. 8.950.2.F. Eligible Qualified Provider - A qualified Provider who is identified by the Department to receive funding from the Primary Care Fund.

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

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

2. Any applicable policies, processes or procedures;

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

8.950.2.H. Medical Assistance Program (Medicaid) - As specified in Article 4 of Title 26, C.R.S. 8.950.2.I. Medically Indigent Patient - A patient receiving medical services from a Qualified Provider:

1. Whose yearly family income is below two hundred percent (200%) of the Federal Poverty Level (FPL);

2. Who is not eligible for the Medical Assistance Program, , the Children’s Basic Health Plan, Medicare or any other governmental reimbursement for health care costs such as through Social Security, the Veterans Administration, Military Dependency (TRICARE or CHAMPUS), or the United States Public Health Service. (Payments received from the Colorado Indigent Care Program are not considered a governmental reimbursement for health care costs related to a specific patient); and 3. There is no Third Party Payer.

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

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

8.950.2.L. Outside Entity - A business or professional that is not classified as an employee of the provider or the Department and does not have a direct or indirect financial interest with the provider. The business or professional shall have auditing experience or experience working directly with the Medical Assistance Program or similar services or grants for Medically Indigent Patients.

8.950.2.M. Pharmaceutical Services - Provides prescription drugs, or coordinates access to or Arranges For client to receive prescription drugs prescribed by the Qualified Provider on a Sliding Fee Schedule or at no charge.

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

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

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

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

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

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

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

2. Surveying and monitoring of patient satisfaction;

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

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

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

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

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

8.950.2.P. Sliding Fee Schedule - A tiered co-payment system that determines the level of patient’s financial participation and guarantees that the patient financial participation is below usual and customary charges. Factors considered in establishing the tiered co-payment system shall only be financial status and the number of members in the patient’s family unit. 8.950.2.Q. Third Party Payments or Third Party Payer - Any individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient. Examples include the Medical Assistance Program; the Children’s Basic Health Plan; Medicare; commercial, individual or employment-related health insurance; court-ordered health insurance (such as that required by non-custodial parents); workers' compensation; automobile insurance; and long-term care insurance. The Colorado Indigent Care Program is not considered a Third Party Payer and payments received from the Colorado Indigent Care Program are not considered Third Party Payments.

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

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

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

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

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

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

8.950.3 PROVIDER ELIGIBILITY

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

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

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

8.950.4 APPLICATION

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

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

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

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

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

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

8.950.5 DISBURSEMENT

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

8.950.5.C. The schedule for the disbursement of moneys to all Eligible Qualified Providers shall be dependent on actual tax collections allocated to the Primary Care Fund such that:

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

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

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

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

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

8.960 COLORADO DENTAL HEALTH CARE PROGRAM FOR LOW-INCOME SENIORS

8.960.1 Definitions

Arrange For or Arranging For means demonstrating established relations with Qualified Providers for any of the Covered Dental Care Services not directly provided by the applicant. Covered Dental Care Services include Diagnostic Imaging, Emergency Services, Endodontic Services, Evaluation, Oral and Maxillofacial Surgery, Palliative Treatment, Periodontal Treatment, Preventive Services, Prophylaxis, Removable Prosthesis, and Restorative Services as listed by alphanumeric procedure code in Appendix A.

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

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

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

Department means the Colorado Department of Health Care Policy and Financing established pursuant to title 25.5, C.R.S. (2020).

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

Economically Disadvantaged means a person whose Income is at or below 250% of the most recently published federal poverty level for a household of that size. Eligible Senior or Client means an adult who is 60 years of age or older, who is Economically Disadvantaged, who is able to demonstrate lawful presence in the country, who is not eligible for dental services under Medicaid or the Old Age Pension Health and Medical Care Program, and who does not have private dental insurance. An Eligible Senior or client is not ineligible solely because he/she is receiving dental benefits under Medicare or Medicare Advantage Plans. An Eligible Senior shall be considered lawfully present in the country if they produce a document or waiver in accordance with 1 CCR 204-30 Rule 5 (effective August 30, 2016), which is hereby incorporated by reference. This incorporation of 1 CCR 204-30 Rule 5 excludes later amendments to, or editions of, the referenced material. Pursuant to § 24-4-103 (12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203. Certified copies of incorporated materials are provided at cost upon request. Emergency Services means the need for immediate intervention by a Qualified Provider to stabilize an oral cavity condition.

Endodontic Services means services which are concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues, including pulpectomy. Evaluation means an assessment that may include gathering of information through interview, observation, examination, and use of specific tests that allows a dentist to diagnose existing conditions. Federally Qualified Health Center means a federally funded nonprofit health center or clinic that serves medically underserved areas and populations as defined in 42 U.S.C. section 1395x (aa)(4). Income means any cash, payments, wages, in-kind receipt, inheritance, gift, prize, rents, dividends, or interest that are received by an individual or family. Income may be self-declared. Resources are not included in Income.

Max Allowable Fee means the total reimbursement listed by procedure for Covered Dental Care Services under the Colorado Dental Health Care Program for Low-Income Seniors in Appendix A. The Max Allowable Fee is the sum of the Program Payment and the Max Client Co-Pay. Max Client Co-Pay means the maximum amount that a Qualified Provider may collect from an Eligible Senior listed by procedure in Appendix A for Covered Dental Services under the Colorado Dental Health Care Program for Low-Income Seniors.

Medicaid means the Colorado medical assistance program as defined in article 4 of title 25.5, C.R.S. (2020).

Medicare means the federal health insurance program for people who are 65 or older; certain younger people with disabilities; or people with End-Stage Renal Disease. Medicare Advantage Plans mean the plans offered by Medicare-approved private companies that must follow rules set by Medicare and may provide benefits for services Medicare does not, such as vision, hearing, and dental care.

Old Age Pension Health and Medical Care Program means the program described at 10 CCR 2505-10, section 8.940 et. seq. and as defined in sections 25.5-2-101 and 26-2-111(2), C.R.S. (2020). Oral and Maxillofacial Surgery means the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.

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

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

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

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

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

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

1. An Area Agency on Aging, as defined in section 26-11-201, C.R.S. (2020);

2. A community-based organization or foundation;

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

4. A local public health agency; or 5. A private dental practice.

Qualified Provider means a licensed dentist or dental hygienist in good standing in Colorado or a person who employs a licensed dentist or dental hygienist in good standing in Colorado and who is willing to accept reimbursement for Covered Dental Services. A Qualified Provider may also be a Qualified Grantee if the person meets the qualifications of a Qualified Grantee. Removable Prosthesis means complete or partial Dental Prosthesis, which after an initial fitting by a dentist, can be removed and reinserted by the eligible senior. Restorative Services means services rendered for the purpose of rehabilitation of dentition to functional or aesthetic needs of the client.

Senior Dental Advisory Committee means the advisory committee established pursuant to section 25.5-3- 406, C.R.S. (2020).

8.960.2 Legal Basis

The Colorado Dental Health Care Program for Low-Income Seniors is authorized by state law at part 4 of article 3 of title 25.5, C.R.S. (2020).

8.960.3 Request of Grant Proposals and Grant Award Procedures

8.960.3.A Request for Grant Proposals Grant awards shall be made through an application process. The request for grant proposals form shall be issued by the Department and posted for public access on the Department’s website at https://www.colorado.gov/hcpf/research-data-and-grants at least 30 days prior to the due date. 8.960.3.B Evaluation of Grant Proposals Proposals submitted for the Colorado Dental Health Care Program for Low-Income Seniors will be evaluated by a review panel in accordance with the following criteria developed under the advice of the Senior Dental Advisory Committee.

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

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

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

a. Outreach to and identify Eligible Seniors;

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

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

8.960.3.C Grant Awards The Department’s executive director, or his or her designee, shall make the final grant awards to selected Qualified Grantees for the Colorado Dental Health Care Program for Low-Income Seniors. 8.960.3.D Qualified Grantee Responsibilities A Qualified Grantee that is awarded a grant under the Colorado Dental Health Care Program for Low- Income Seniors is required to:

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

2. Demonstrate collaboration with community-based organizations;

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

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

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

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

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

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

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

3. Eligible Seniors shall not be charged more than the Max Client Co-Pay as listed in Appendix A.

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

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

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

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

1. The number of Eligible Seniors served;

2. The types of Covered Dental Care Services provided;

3. An itemization of administrative expenditures;

4. The procedures and amounts billed to Medicare Advantage Plans for Eligible Seniors; and 5. Any other information deemed relevant by the Department. 10 CCR 2505-10 § 8.960 APPENDIX A: COLORADO DENTAL HEALTH CARE PROGRAM FOR LOW- INCOME SENIORS COVERED SERVICES AND PROCEDURE CODES Capitalized terms within this appendix shall have the meaning specified in the Definitions section. Evaluation performed on a client of record to determine any changes in the client’s dental and medical health status since a previous comprehensive or periodic Periodic oral evaluation - D0120 $46.00 $46.00 $0.00 evaluation. This may established client include an oral cancer evaluation and periodontal evaluation, diagnosis, treatment planning.

Frequency: One time per 6 month period per client.

Evaluation limited to a specific oral health problem or complaint. This code must be used in association with a specific oral health problem or complaint and is not to be used to address situations that arise during multi-visit treatments covered by a single fee, such as, endodontic or Limited oral evaluation - D0140 $62.00 $52.00 $10.00 post-operative visits related problem focused to treatments including prosthesis. Specific problems may include dental emergencies, trauma, acute infections, etc. Cannot be used for adjustments made to prosthesis provided within previous 6 months. Cannot be used as an encounter fee.

Evaluation used by general dentist or a specialist when evaluating a client comprehensively.

Applicable to new clients;

established clients with significant health changes or other unusual circumstances; or established clients who have been absent from active treatment for three or more years. It is a thorough Comprehensive oral evaluation evaluation and recording of D0150 $81.00 $81.00 $0.00 - new or established client the extraoral and intraoral hard and soft tissues, and an evaluation and recording of the client's dental and medical history and general health assessment. A periodontal evaluation, oral cancer evaluation, diagnosis and treatment planning should be included. Frequency: 1 per 3 years per client. Cannot be charged on the same date as D0180.

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

Frequency: 1 per 3 years per client. Cannot be charged on the same date as D0150.

Radiographic survey of whole mouth, usually consisting of 14-22 periapical & posterior bitewing images intended to display the crowns & roots of all teeth, periapical areas of alveolar bone. Panoramic radiographic image & bitewing radiographic images taken on the same date of service shall not be billed as a D0210. Payment for additional periapical radiographs within 60 days Intraoral - complete series of D0210 $125.00 $125.00 $0.00 of a full month series or a radiographic images panoramic film is not covered unless there is evidence of trauma.

Frequency: 1 per 5 years per client. Any combination of x-rays taken on the same date of service that equals or exceeds the max allowable fee for D0210 must be billed and reimbursed as D0210.

Should not be charged in addition to panoramic film D0330. Either D0330 or D0210 per 5 year period.

D0220 one (1) per day per client. Report additional radiographs as D0230. Any combination of D0220, D0230, D0270, D0272, D0273, D0274, or D0277 Intraoral - periapical first D0220 $25.00 $25.00 $0.00 taken on the same date of radiographic image service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. D0210 will only be reimbursed every 5 years.

D0230 must be utilized for additional films taken beyond D0220. Any combination of D0220, D0230, D0270, D0272, D0273, D0274, or D0277 Intraoral - periapical each D0230 $23.00 $23.00 $0.00 taken on the same date of additional radiographic image service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. D0210 will only be reimbursed every 5 years.

Frequency: 1 in a 12 month period. Report more than 1 radiographic image as:

D0272 two (2); D0273 three (3); D0274 four (4). Any combination of D0220, Bitewing - single radiographic D0270 $26.00 $26.00 $0.00 D0230, D0270, D0272, image D0273, D0274, or D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: 1 time in a 12 month period. Any combination of D0220, D0230, D0270, D0272, Bitewings - two radiographic D0273, D0274, or D0277 D0272 $42.00 $42.00 $0.00 images taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: 1 time in a 12 month period. Any combination of D0220, D0230, D0270, D0272, Bitewings - three radiographic D0273, D0274, D0277 D0273 $52.00 $52.00 $0.00 images taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: 1 time in a 12 month period. Any combination of D0220, D0230, D0270, D0272, Bitewings - four radiographic D0273, D0274, or D0277 D0274 $60.00 $60.00 $0.00 images taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: 1 time in a 12- month period. This does not constitute a full mouth intraoral radiographic series. Any combination of Vertical bitewings – seven to D0220, D0230, D0270, D0277 $68.32 $68.32 $0.00 eight radiographic images D0272, D0273, D0274, or D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.

Frequency: 1 per 5 years per client. Cannot be charged in addition to full Panoramic radiographic image D0330 $63.00 $63.00 $0.00 mouth series D0210. Either D0330 or D0210 per 5 years.

Removal of plaque, calculus and stains from the tooth structures with intent to control local irritational factors. Frequency:

• 1 time per 6 calendar months; 2 week window accepted.

• May be billed for routine prophylaxis.

• D1110 may be billed with D4341 and D4342 one time during initial periodontal therapy for prophylaxis of areas of the mouth not receiving nonsurgical periodontal therapy. When this option is used, individual should still be Prophylaxis - adult D1110 $88.00 $88.00 $0.00 placed on D4910 for maintenance of periodontal disease.

1. D1110 can only be charged once, not per quadrant, and represents areas of the mouth not included in the D4341 or D4342 being reimbursed.

• May be alternated with D4910 for maintenance of periodontally- involved individuals.

• D1110 cannot be billed on the same day as D4346 • Cannot be used as 1 month re-evaluation following nonsurgical periodontal therapy.

Topical fluoride application is to be used in conjunction with prophylaxis or preventive appointment.

Topical application of fluoride D1206 $52.00 $52.00 $0.00 Should be applied to whole varnish mouth. Frequency: up to four (4) times per 12 calendar months. Cannot be used with D1208.

Any fluoride application, including swishing, trays or paint on variety, to be used in conjunction with prophylaxis or preventive Topical application of fluoride - appointment. Frequency: D1208 $52.00 $52.00 $0.00 excluding varnish one (1) time per 12 calendar months. Cannot be used with D1206. D1206 varnish should be utilized in lieu of D1208 whenever possible.

Two of D1354 per 12 months per patient per tooth for primary and permanent teeth. Not to exceed 4 times Interim caries arresting per tooth in a lifetime.

medicament application – per D1354 $5.60 $5.60 $0.00 Cannot be billed on the tooth same day as D1355 or any D2000 series code (D2140– D2954). Must Report both tooth number and surface(s).

For primary prevention or remineralization.

Medicaments applied do not include topical fluorides.

Medicaments that may be applied during the delivery of D1355 procedure include Silver Diamine Fluoride (SDF), Silver Nitrate (SN), thymol-CHX varnish, and Caries preventive medicament topical povidone iodine D1355 $5.47 $5.47 $0.00 application – per tooth (PVP-I). Cannot be billed on the same day as: D1206, D1208, D1354, D0140, D9110, or any restoration codes on the same day or within 12 months of D2140 thru D2954. Maximum of four D1355 per tooth per lifetime. Must report both tooth number and surface(s).

Includes tooth preparation, all adhesives, liners, polishing, and bases.

Amalgam - one surface, D2140 $112.67 $102.67 $10.00 Adjustments are included.

primary or permanent Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, polishing, and bases.

Amalgam - two surfaces, D2150 $141.20 $131.20 $10.00 Adjustments are included.

primary or permanent Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, polishing, and bases.

Amalgam - three surfaces, D2160 $170.88 $160.88 $10.00 Adjustments are included.

primary or permanent Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, Amalgam - four or more polishing, and bases.

surfaces, primary or D2161 $204.96 $194.96 $10.00 Adjustments are included. permanent Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, etching, and bases.

Resin-based composite - one D2330 $115.00 $105.00 $10.00 Adjustments are included.

surface, anterior Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, etching, and bases.

Resin-based composite - two D2331 $146.00 $136.00 $10.00 Adjustments are included.

surfaces, anterior Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, etching, and bases.

Resin-based composite - three D2332 $179.00 $169.00 $10.00 Adjustments are included.

surfaces, anterior Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, Resin-based composite - four etching, and bases.

or more surfaces or involving D2335 $212.00 $202.00 $10.00 Adjustments are included. incisal angle (anterior) Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, etching, and bases.

Resin-based composite - one D2391 $134.00 $124.00 $10.00 Adjustments are included.

surface, posterior Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, etching, and bases.

Resin-based composite -two D2392 $176.00 $166.00 $10.00 Adjustments are included.

surfaces, posterior Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, etching, and bases.

Resin-based composite - three D2393 $218.00 $208.00 $10.00 Adjustments are included.

surfaces, posterior Frequency: 36 months for the same restoration. See Explanation of Restorations.

Includes tooth preparation, all adhesives, liners, etching, and bases.

Resin-based composite - four D2394 $268.00 $258.00 $10.00 Adjustments are included.

or more surfaces, posterior Frequency: 36 months for the same restoration. See Explanation of Restorations.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, Crown - porcelain/ceramic D2740 $780.00 $730.00 $50.00 D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, Crown - porcelain fused to D2783, D2790, D2791, D2750 $780.00 $730.00 $50.00 high noble metal D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, Crown - porcelain fused to D2783, D2790, D2791, D2751 $780.00 $730.00 $50.00 predominantly base metal D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, Crown - porcelain fused to D2783, D2790, D2791, D2752 $780.00 $730.00 $50.00 noble metal D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, Crown - 3/4 cast D2783, D2790, D2791, D2781 $780.00 $730.00 $50.00 predominantly base metal D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, Crown - 3/4 cast noble metal D2782 $780.00 $730.00 $50.00 D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, Crown - 3/4 porcelain/ceramic D2783 $780.00 $730.00 $50.00 D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, Crown - full cast high noble D2783, D2790, D2791, D2790 $780.00 $730.00 $50.00 metal D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, Crown - full cast predominantly D2783, D2790, D2791, D2791 $780.00 $730.00 $50.00 base metal D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, Crown - full cast noble metal D2792 $780.00 $730.00 $50.00 D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

Only one of the following will be reimbursed each 84 months per client per tooth:

D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, Crown - titanium D2794 $780.00 $730.00 $50.00 D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.

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

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

Only one of the following will be reimbursed per 84 months per client per tooth.

D2950, D2952, or D2954.

Refers to building up of coronal structure when there is insufficient retention Core buildup, including any D2950 $225.00 $200.00 $25.00 for a separate extracoronal pins when required restorative procedure. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation. Not payable on the same tooth and same day as D2951.

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

Only one of the following will be reimbursed per 84 months per client per tooth.

D2950, D2952, or D2954.

Cast post and core in addition Refers to building up of D2952 $332.00 $307.00 $25.00 to crown anatomical crown when restorative crown will be placed. Not payable on the same tooth and same day as D2951.

Only one of the following will be reimbursed per 84 months per client per tooth.

D2950, D2952, or D2954.

Core is built around a prefabricated post. This Prefabricated post and core in D2954 $269.00 $244.00 $25.00 procedure includes the core addition to crown material and refers to building up of anatomical crown when restorative crown will be placed. Not payable on the same tooth and same day as D2951.

Complete root canal therapy; Includes all appointments necessary to complete treatment; also Endodontic therapy, anterior includes intra-operative tooth (excluding final D3310 $566.40 $516.40 $50.00 radiographs. Does not restoration) include diagnostic evaluation and necessary radiographs/diagnostic images. Teeth covered: 6- 11 and 22-27.

Complete root canal therapy; Includes all appointments necessary to complete treatment; also includes intra-operative Endodontic therapy, premolar radiographs. Does not tooth (excluding final D3320 $661.65 $611.65 $50.00 include diagnostic restoration)

evaluation and necessary radiographs/diagnostic images. Teeth covered: 4, 5, 12, 13, 20, 21, 28, and 29.

Complete root canal therapy; Includes all appointments necessary to complete treatment; also includes intra-operative Endodontic therapy, molar radiographs. Does not tooth (excluding final D3330 $786.31 $736.31 $50.00 include diagnostic restoration)

evaluation and necessary radiographs/diagnostic images. Teeth covered: 2, 3, 14, 15, 18, 19, 30, and 31.

Involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. For clients with periodontal disease and is therapeutic, not prophylactic. D4341 and D1110 can be reported on same service date when D1110 is utilized for areas of the mouth that are not affected by periodontal disease. D1110 can only be charged once, not per quadrant; A diagnosis of periodontitis with clinical attachment loss (CAL)

included. Diagnosis and classification of the periodontology case type must be in accordance with documentation as currently established by the Periodontal scaling & root American Academy of planing - four or more teeth per D4341 $177.00 $167.00 $10.00 Periodontology. Current quadrant periodontal charting must be present in client chart documenting active periodontal disease.

Frequency:

• 1 time per quadrant per 36 month interval.

• No more than 2 quadrants may be considered in a single visit in a non-hospital setting. Documentation of other treatment provided at same time will be requested.

• Cannot be charged on same date as D4346.

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

Involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. For clients with periodontal disease and is therapeutic, not prophylactic. D4342 and D1110 can be reported on same service date when date when D1110 is utilized for areas of the mouth that are not affected by periodontal disease. D1110 can only be charged once, not per quadrant; A diagnosis of periodontitis with clinical attachment loss (CAL) included. Current periodontal charting must be present in client chart Periodontal scaling & root documenting active planing - one to three teeth per D4342 $128.00 $128.00 $0.00 periodontal disease.

quadrant Frequency:

• 1 time per quadrant per 36 month interval.

• No more than 2 quadrants may be considered in a single visit in a non-hospital setting.. Documentation of other treatment provided at same time will be requested.

• Cannot be charged on same date as D4346.

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

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

once in a lifetime.

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

• Cannot be charged on the same date as D1110, D4341, D4342, or D4910.

One of (D4335) per 3 year(s) per patient.

Prophylaxis D1110 is not reimbursable when provided on the same day Full mouth debridement to of service as D4355. D4355 enable a comprehensive is not reimbursable if patient D4355 $94.02 $84.02 $10.00 evaluation and diagnosis on a record indicates D1110 or subsequent visit D4910 have been provided in the previous 12 month period. Other D4000 series codes are not reimbursable when provided on the same date of service as D4355.

Procedure following periodontal therapy D4341 or D4342. This procedure includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated and polishing the teeth.

Frequency:

Periodontal maintenance D4910 $136.00 $136.00 $0.00 procedures • Up to four times per fiscal year per client.

• Cannot be charged on the same date as D4346.

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

Reimbursement made upon delivery of a complete maxillary denture to the client. D5110 or D5120 cannot be used to report an immediate denture, D5130 or D5140. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement.

A complete denture is made after teeth have been removed and the gum and bone tissues have healed - Complete denture - maxillary D5110 $874.52 $794.52 $80.00 or to replace an existing denture. Complete dentures are provided once adequate healing has taken place following extractions. This can vary greatly depending upon client, oral health, overall health, and other confounding factors.

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

Reimbursement made upon delivery of a complete mandibular denture to the client. D5110 or D5120 cannot be used to report an immediate denture, D5130, D5140. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement.

A complete denture is made after teeth have been removed and the gum and bone tissues have healed - Complete denture - mandibular D5120 $875.94 $795.94 $80.00 or to replace an existing denture. Complete dentures are provided once adequate healing has taken place following extractions. This can vary greatly depending upon client, oral health, overall health, and other confounding factors.

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

Reimbursement made upon delivery of an immediate maxillary denture to the client. Routine follow-up adjustments/soft tissue condition relines within 6 months are to be anticipated and are included in the initial reimbursement.

An immediate denture is made prior to teeth being extracted and is inserted Immediate denture – maxillary D5130 $874.52 $794.52 $80.00 same day of extraction of remaining natural teeth.

Frequency: D5130 can be reimbursed only once per lifetime per client. Complete denture, D5110, may be considered 5 years after immediate denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of an immediate mandibular denture to the client. Routine follow-up adjustments/soft tissue condition relines within 6 months are to be anticipated and are included in the initial reimbursement.

An immediate denture is made prior to teeth being extracted and is inserted Immediate denture – D5140 $875.94 $795.94 $80.00 same day of extraction of mandibular remaining natural teeth.

Frequency: D5140 can be reimbursed only once per lifetime per client. Complete dentures, D5120, may be considered 5 years after immediate denture was reimbursed – documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of a complete partial maxillary denture to the client. D5211 and D5212 are considered definitive treatments.

Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement.

A partial resin base denture can be made right after having teeth extracted (healing from only a few Maxillary partial denture - resin teeth is not as extensive as base (including healing from multiple). A D5211 $700.00 $640.00 $60.00 retentive/clasping materials, partial resin base denture rests, and teeth) can also be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal.

Several impressions and “try-in” appointments may be necessary and are included in the cost.

Frequency: Program will only pay for one resin maxillary per every 3 years - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of a complete partial mandibular denture to the client. D5211 and D5212 are considered definitive treatment. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement.

A partial resin base denture can be made right after having teeth extracted (healing from only a few Mandibular partial denture - teeth is not as extensive as resin base (including healing from multiple). A D5212 $778.00 $718.00 $60.00 retentive/clasping materials, partial resin base denture rests, and teeth) can also be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal.

Several impressions and “try-in” appointments may be necessary and are included in the cost.

Frequency: Program will only pay for one resin mandibular per every 3 years - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of a complete partial maxillary denture to the client. D5213 and D5214 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial cast metal base can also be made right after having teeth extracted (healing Maxillary partial denture – cast from only a few teeth is not metal framework with resin as extensive as healing denture bases (including any D5213 $844.31 $784.31 $60.00 from multiple). A partial cast conventional clasps, rests and metal base denture can be teeth) made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and “try-in”

appointments may be necessary and are included in the cost. Frequency:

Program will only pay for one maxillary per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of a complete partial mandibular denture to the client. D5213 and D5214 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial cast metal base can be made right after having teeth extracted (healing Mandibular partial denture – from only a few teeth is not cast metal framework with as extensive as healing resin denture bases (including D5214 $844.31 $784.31 $60.00 from multiple). A partial cast any conventional clasps, rests metal base denture can and teeth) also be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and “try-in”

appointments may be necessary and are included in the cost. Frequency:

Program will only pay for one mandibular per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of an immediate partial maxillary denture to the client. D5221 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction.

Routine follow-up adjustments or relines within 6 months is to be anticipated and are included in the initial reimbursement.

An immediate partial resin Immediate maxillary partial base denture can be made denture – resin base (including before having teeth D5221 $607.61 $547.61 $60.00 any conventional clasps, rests extracted if the teeth being and teeth) removed are in the front or necessary healing will be minimal. Several impressions and “try-in”

appointments may be necessary and are included in the cost. Frequency: A maxillary partial denture may be considered 3 years after immediate partial denture was reimbursed.

Documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of an immediate partial mandibular denture to the client. D5222 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction.

Routine follow-up adjustments or relines within 6 months is to be anticipated and are included in the initial reimbursement.

An immediate partial resin Immediate mandibular partial base denture can be made denture – resin base (including before having teeth D5222 $607.61 $547.61 $60.00 any conventional clasps, rests extracted if the teeth being and teeth) removed are in the front or necessary healing will be minimal. Several impressions and “try-in”

appointments may be necessary and are included in the cost. Frequency: A mandibular partial denture may be considered 3 years after immediate partial denture was reimbursed.

Documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of an immediate partial maxillary denture to the client. D5223 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction.

Routine follow-up adjustments or relines within 6 months is to be anticipated and are included in the initial reimbursement.

An immediate partial cast Immediate maxillary partial metal framework with resin denture – cast metal base denture can be made framework with resin denture D5223 $844.31 $784.31 $60.00 before having teeth bases (including any extracted if the teeth being conventional clasps, rests and removed are in the front or teeth)

necessary healing will be minimal. Several impressions and “try-in”

appointments may be necessary and are included in the cost. Frequency: A maxillary partial denture may be considered 5 years after immediate partial denture was reimbursed.

Documentation that existing prosthesis cannot be made serviceable must be maintained.

Reimbursement made upon delivery of an immediate partial mandibular denture to the client. D5224 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction.

Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement.

An immediate partial cast Immediate mandibular partial metal framework with resin denture – cast metal base denture can be made framework with resin denture D5224 $844.31 $784.31 $60.00 before having teeth bases (including any extracted if the teeth being conventional clasps, rests and removed are in the front or teeth)

necessary healing will be minimal. Several impressions and “try-in”

appointments may be necessary and are included in the cost. Frequency: A mandibular partial denture may be considered 5 years after immediate partial denture was reimbursed.

Documentation that existing prosthesis cannot be made serviceable must be maintained.

Repair broken complete Repair broken complete D5511 $123.70 $113.70 $10.00 denture base, mandibular denture base, mandibular Repair broken complete Repair broken complete D5512 $123.70 $113.70 $10.00 denture base, maxillary denture base, maxillary Replace missing or broken Replacement/repair of teeth - complete denture (each D5520 $92.91 $82.91 $10.00 missing or broken teeth.

tooth)

Repair resin partial denture Repair resin partial denture D5611 $95.00 $85.00 $10.00 base, mandibular base, mandibular Repair resin partial denture Repair resin partial denture D5612 $95.00 $85.00 $10.00 base, maxillary base, maxillary Repair cast partial framework, Repair cast partial D5621 $121.29 $111.29 $10.00 mandibular framework, mandibular Repair cast partial framework, Repair cast partial D5622 $121.29 $111.29 $10.00 maxillary framework, maxillary Repair or replace broken Repair of broken clasp on retentive/clasping materials – D5630 $131.00 $121.00 $10.00 partial denture base – per per tooth tooth.

Repair/replacement of Replace broken teeth-per tooth D5640 $94.02 $84.02 $10.00 missing tooth.

Adding tooth to partial denture base.

Add tooth to existing partial Documentation may be D5650 $109.00 $99.00 $10.00 denture requested when charged on partial delivered in last 12 months.

Adding clasp to partial denture base – per tooth.

Add clasp to existing partial Documentation may be D5660 $136.05 $126.05 $10.00 denture requested when charged on partial delivered in last 12 months.

Rebasing the denture base material due to alveolar ridge resorption. Frequency:

one (1) time per 12 months.

Rebase complete maxillary Completed at laboratory.

D5710 $322.00 $297.00 $25.00 denture Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a reline in a 12 month period.

Rebasing the denture base material due to alveolar ridge resorption. Frequency:

one (1) time per 12 months.

Rebase complete mandibular Completed at laboratory.

D5711 $322.00 $297.00 $25.00 denture Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a reline in a 12 month period.

Rebasing the partial denture base material due to alveolar ridge resorption.

Frequency: one (1) time per 12 months. Completed at Rebase maxillary partial D5720 $304.00 $279.00 $25.00 laboratory. Cannot be denture charged on denture provided in the last 6 months. Cannot be charged in addition to a reline in a 12 month period.

Rebasing the partial denture base material due to alveolar ridge resorption.

Frequency: one (1) time per 12 months. Completed at Rebase mandibular partial D5721 $304.00 $279.00 $25.00 laboratory. Cannot be denture charged on denture provided in the last 6 months. Cannot be charged in addition to a reline in a 12 month period.

Chair side reline that resurfaces without processing denture base.

Frequency: One (1) time Reline complete maxillary per 12 months. Cannot be D5730 $182.00 $172.00 $10.00 denture (chairside) charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period.

Chair side reline that resurfaces without processing denture base.

Frequency: One (1) time Reline complete mandibular per 12 months. Cannot be D5731 $182.00 $172.00 $10.00 denture (chairside) charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period.

Chair side reline that resurfaces without processing partial denture base. Frequency: one (1)

Reline maxillary partial denture time per 12 months. Cannot D5740 $175.82 $165.82 $10.00 (chairside) be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period.

Chair side reline that resurfaces without processing partial denture base. Frequency: one (1)

Reline mandibular partial time per 12 months. Cannot D5741 $177.49 $167.49 $10.00 denture (chairside) be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period.

Laboratory reline that resurfaces with processing denture base. Frequency:

one (1) time per 12 months.

Reline complete maxillary Cannot be charged on D5750 $243.00 $218.00 $25.00 denture (laboratory) denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period.

Laboratory reline that resurfaces with processing denture base. Frequency:

one (1) time per 12 months.

Reline complete mandibular Cannot be charged on D5751 $243.00 $218.00 $25.00 denture (laboratory) denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period.

Laboratory reline that resurfaces with processing partial denture base.

Frequency: one (1) time per Reline maxillary partial denture 12 months. Cannot be D5760 $239.00 $214.00 $25.00 (laboratory) charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period.

Laboratory reline that resurfaces with processing partial denture base.

Frequency: one (1) time per Reline mandibular partial 12 months. Cannot be D5761 $239.00 $214.00 $25.00 denture (laboratory) charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period.

Routine removal of tooth structure, including minor smoothing of socket bone, Extraction, erupted tooth or and closure as necessary.

exposed root (elevation and/or D7140 $111.78 $101.78 $10.00 Treatment notes must forceps removal)

include documentation that an extraction was done per tooth.

Includes removal of bone, Surgical removal of erupted and/or sectioning of erupted tooth requiring removal of tooth, smoothing of socket bone and/or sectioning of bone and closure as D7210 $172.88 $162.88 $10.00 tooth, and including elevation necessary. Treatment notes of mucoperiosteal flap if must include documentation indicated that a surgical extraction was done per tooth.

Occlusal surface of tooth covered by soft tissue;

Removal of impacted tooth- requires mucoperiosteal D7220 $207.25 $187.25 $20.00 soft tissue flap elevation. Teeth 1-32 One of D7220 per 1 lifetime per patient per tooth Part of crown covered by bone; requires mucoperiosteal flap Removal of impacted tooth- D7230 $255.53 $235.53 $20.00 elevation and bone partially bony removal. Teeth 1-32 One of D7230 per 1 lifetime per patient per tooth Most or all of crown covered by bone; requires mucoperiosteal flap Removal of impacted tooth- D7240 $296.38 $276.38 $20.00 elevation and bone completely bony removal. Teeth 1-32 One of D7240 per 1 lifetime per patient per tooth.

Most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve Removal of impacted tooth- dissection required, completely boney, with D7241 $389.20 $369.20 $20.00 separate closure of unusual surgical complications maxillary sinus required or aberrant tooth position.

Teeth 1-32 One of D7241 per lifetime per patient per tooth.

Includes removal of bone, and/or sectioning of residual tooth roots, smoothing of socket bone and closure as necessary. Treatment notes must include documentation Surgical removal of residual D7250 $182.30 $172.30 $10.00 that a surgical extraction tooth roots (cutting procedure)

was done per tooth. Can only be charged once per tooth. Cannot be charged for removal of broken off roots for recently extracted tooth.

Removing tissue for histologic evaluation.

Incisional biopsy of oral tissue- Treatment notes must D7286 $381.00 $381.00 $0.00 soft include documentation and proof that biopsy was sent for evaluation.

Substantially reshaping the Alveoloplasty in conjunction bone after an extraction with extractions - four or more procedure, much more than D7310 $150.00 $140.00 $10.00 teeth or tooth spaces, per minor smoothing of the quadrant bone. Reported per quadrant.

Substantially reshaping the Alveoloplasty in conjunction bone after an extraction with extractions - one to three D7311 $139.42 $129.42 $10.00 procedure, much more than teeth or tooth spaces, per minor smoothing of the quadrant bone. Reported per quadrant.

Substantially reshaping the Alveoloplasty not in bone after an extraction conjunction with extractions - D7320 $200.47 $190.47 $10.00 procedure, correcting four or more teeth or tooth anatomical irregularities.

spaces, per quadrant Reported per quadrant.

Substantially reshaping the Alveoloplasty not in bone after an extraction conjunction with extractions - D7321 $200.47 $190.47 $10.00 procedure, correcting one to three teeth or tooth anatomical irregularities.

spaces, per quadrant Reported per quadrant.

Removal of a benign bony outgrowth (bone spur) for Removal of lateral exostosis D7471 $290.11 $280.11 $10.00 proper prosthesis (maxilla or mandible)

fabrication. Reported per arch.

To remove a malformation Removal of torus palatinus D7472 $341.08 $331.08 $10.00 of bone for proper prosthesis fabrication.

To remove a malformation Removal of torus mandibularis D7473 $332.69 $322.69 $10.00 of bone for proper prosthesis fabrication.

Incision through mucosa, Incision & drainage of abscess D7510 $193.00 $183.00 $10.00 including periodontal - intraoral soft tissue origins.

Emergency treatment to alleviate pain/discomfort.

This code cannot be used for filing claims or writing or calling in a prescription to the pharmacy or to address situations that arise during Palliative (emergency) multi-visit treatments treatment of dental pain - D9110 $78.23 $53.23 $25.00 covered by a single fee minor procedure such as surgical or endodontic treatment.

Report per visit, no procedure. Frequency: Limit 1 time per year. Maintain documentation that specifies problem and treatment.

Evaluation for moderate One of D9219 or D9310 per sedation, deep sedation or D9219 $40.90 $40.90 $0.00 12 month(s) per provider or general anesthesia location Deep sedation/general Ten of D9223 per 1 day per anesthesia-each 15 minute D9223 $103.40 $93.40 $10.00 patient. Not allowed with increment D9243 Intravenous moderate Fourteen of D9243 per 1 (conscious)sedation/analgesia- D9243 $103.40 $93.40 $10.00 day per patient. Not allowed each 15 minute increment with D9223 EXPLANATION OF RESTORATIONS Location Number Characteristics of Surfaces 1 Placed on one of the following five surface classifications – Mesial, Distal, Incisal, Lingual, or Labial.

2 Placed, without interruption, on two of the five surface classifications – e.g., Mesial–Lingual.

Anterior 3 Placed, without interruption, on three of the five surface classifications – e.g., Lingual–Mesial–Labial.

4 or more Placed, without interruption, on four or more of the five surface classifications – e.g., Mesial-Incisal-Lingual-Labial.

1 Placed on one of the following five surface classifications – Mesial, Distal, Occlusal, Lingual, or Buccal.

2 Placed, without interruption, on two of the five surface classifications – e.g., Mesial-Occlusal.

Posterior 3 Placed, without interruption, on three of the five surface classifications – e.g., Lingual-Occlusal-Distal.

4 or more Placed, without interruption, on four or more of the five surface classifications – e.g., Mesial-Occlusal-Lingual-Distal. NOTE: Tooth surfaces are reported using the letters in the following table. Surface Code Buccal B Distal D Facial (or Labial) F Incisal I Lingual L Mesial M Occlusal O _________________________________________________________________________ EDITOR’S NOTES 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 03/04/2007, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.

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