10 CCR 2505-3
DEPARTMENT OF HEALTH CARE POLICY AND FINANCING FINANCIAL MANAGEMENT OF THE CHILDREN’S BASIC HEALTH PLAN 10 CCR 2505-3 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] 50 DEFINITIONS 50.1 “Applicant” shall mean a person applying or re-applying for benefits on behalf of a child and/or themselves.
50.2 “CBMS” shall mean Colorado Benefits Management System is the computer
system that determines an applicant’s eligibility for public assistance in the state of Colorado.
50.3 “Child” means a person who is less than nineteen years of age.
50.4 “Cost sharing” shall mean payments, such as copayments that are due on behalf of the enrollee.
50.5 “Department” shall mean the Colorado Department of Health Care Policy and
Financing which is responsible for administering the Colorado Medical Assistance Program and Children’s Basic Health Plan as well as other State- funded health care programs.
50.6 “Dependent child” shall mean a child who lives with a parent, legal guardian, caretaker relative or foster parent and is under the age of 18, or, is age 18 and a full-time student, and expected to graduate by age 19 50.7 “Effective Date” shall mean the first day of eligibility which is the date the application is received and date-stamped by the Eligibility site or the date the application was received and date-stamped by an Application Assistance site or Presumptive Eligibility site. In the absence of a date-stamp, the application date is the date that the application was signed by the client.
50.8 “Eligibility Site” shall mean a location outside of the Department that has been deemed by the Department as eligible to accept applications and determine eligibility for applicants.
50.9 “Enrollee” shall mean an eligible person who is enrolled in the Children’s Basic Health Plan.
50.10 “Essential Community Provider” means a healthcare provider that:
A. Has historically served medically needy or medically indigent patients and demonstrates a commitment to serve low-income and medically indigent populations who make up a significant portion of its patient population, or in the case of a sole community provider, serves medically indigent patients within its medical capability; and B. Waives charges or charges for services on a sliding scale based on income and does not restrict access or services because of a client's financial limitations.
50.11 “Evidence of Coverage” or “EOC” shall mean any certificate, agreement, or
contract issued to an enrollee from time-to-time by a Managed Care Organization (MCO) setting out the coverage to which the enrollee is or was entitled under the Children’s Basic Health Plan.
50.12 “Grievance Committee” shall mean a conference with the Department or its
Designee in which a contested decision regarding an applicant or enrollee is reexamined.
50.13 “Household” shall be determined by relationships to the tax filer as declared on the Single Streamlined Application and as required in 10 CCR 2505-10- 8.100.4.E.
50.14 “Income” shall be any compensation from participation in a business, including wages, salary, tips, commissions and bonuses. The Modified Adjusted Gross Income is a methodology used to determine eligibility as required in 10 CCR 2505-10-8.100.4.C.
50.15 “Managed Care Organization” or “MCO” shall mean:
A. A carrier which meets the definition in §10-16-102 (8), C.R.S. with which the Department contracts to provide health care or dental services covered by the Children’s Basic Health Plan; or, B. Essential community providers and other health care and dental service providers with whom the Department contracted to provide health care services under the Children’s Basic Health Plan using a managed care model.
50.16 “Presumptive Eligibility” shall mean children and pregnant women who have
applied and appear to be eligible for the Children’s Basic Health Plan shall be presumed eligible and may receive immediate temporary medical coverage.
50.17 “Qualified Hospital Presumptive Eligibility Site” is a hospital that has voluntarily elected to serve as a Presumptive Eligibility site. Qualified Hospital Presumptive Eligibility Sites agree to make determinations in accordance with State policies and assist individuals with completing Medical Assistance applications and understanding documentation requirements.
50.18 “Unearned Income” shall be the gross amount received in cash or kind that is not earned from employment or self-employment.
50.19 “Woman” shall mean a female who is 19 years in age or older.
100 ELIGIBILITY 110 INDIVIDUALS ASSISTED UNDER THE PROGRAM 110.1 To be eligible for the Children’s Basic Health Plan, an eligible person shall: A.
1. Be less than 19 years of age; or 2. Be a pregnant woman B. Fall into one of the following categories:
1. Be a citizen or national of the United States, the District of Columbia, Puerto Rico, Guam, the United States Virgin Islands, the Northern Mariana Islands, American Samoa, or Swain's Island; or 2. Be a lawfully admitted non-citizen who entered the United States prior to August 22, 1996, or 3. Be a non-citizen who entered the United States on or after August 22, 1996 and is applying for Medical Assistance who falls into one of the following categories:
4. Be a non-citizen who arrived in the United States on any date, who falls into one of the following categories:
5. Be a lawfully admitted non-citizen in the United States who falls into one of the categories:
C. For determinations of eligibility for the Children’s Basic Health Plan, legal immigration status must be verified. This requirement applies to a non- citizen individual who meets the criteria of any category defined at 110.1.B and has declared that he or she has a legal immigration status.
1. The Verify Lawful Presence (VLP) interface will be used to verify immigration status as required in 10 CCR 2505-10-8.100.3.G.2 2. If the state cannot verify immigration status the individual will receive a Reasonable Opportunity Period as required in 10 CCR 2505-10-8.100.3.H.9 3. This requirement does not apply to the following groups:
D. Be a resident of Colorado; and residence shall be retained until abandoned. A person temporarily absent from the state, inside or outside the United States, retains Colorado residence. Temporarily absent means that at the time he/she leaves, the person intends to return.
E. Have a household income greater than 142% but not exceeding 260% of the Federal Poverty Level, adjusted for household size for children under the age of 19; or F. Have a household income greater than 195% but not exceeding 260% of the Federal Poverty Level, adjusted for household size for pregnant women.
G. Failure to complete an application or to provide required documentation in Section 130 will result in the denial of the incomplete application or individual applicant (s).
120 INSUFFICIENT ACCESS TO OTHER HEALTH COVERAGE 120.1 To be eligible for the Children’s Basic Health Plan, an eligible person shall not:
A. Be covered under a group health plan or under health insurance coverage excluding Consolidated Omnibus Budget Reconciliation Act (COBRA) at the time of application or at redetermination; or B. Be eligible to receive assistance under Title XIX of the Social Security Act; or C. Be an inmate of a public institution or a patient in an institution for mental diseases, except that Reentry Demonstration Initiative Services authorized by the 1115 Demonstration Waiver titled Colorado Expanding the Substance Use Disorder (SUD) Continuum of Care and described in Attachment G to the Center for Medicare & Medicaid Services’ (“CMS”) Demonstration Approval dated October 14, 2025 are available to inmates of public institutions 90 days prior to their release. Reentry Demonstration Initiative Services are only available while approved by CMS. CMS’s Demonstration Approval dated October 14, 2025 is hereby incorporated by reference. This incorporation 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 303 E. 17 Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.medicaid.gov.
120.2 The Department shall not require that applicants be uninsured for any period of time prior to becoming eligible for the Children’s Basic Health Plan. 130 VERIFICATION REQUIREMENTS 130.1 To be eligible for the Children’s Basic Health Plan, an applicant shall provide minimal verification as required in 10 CCR 2505-10-8.100.4.B. 140 REDETERMINATION 140.1 “Redetermination of eligibility” is a case review and/or the request for necessary verification to determine whether a member enrolled in a Medical Assistance Program continues to be eligible. Eligibility shall be redetermined at least every twelve months since the last eligibility determination. Eligibility may be redetermined through telephone, mail, or online electronic means. Prior to making a determination of ineligibility, the eligibility site must review on all bases of Medical Assistance eligibility for a member.
A. “Ex Parte Review” is a redetermination of eligibility for a member without requesting verification by utilizing available information from the member’s account, electronic sources and other assistance programs.
1. If verified information is available for any of the six months prior to the redetermination month, and the member meets all other eligibility requirements, then an approval notice will be sent to eligible members of the household who are requesting assistance. This approval notice shall include directions on how to view the information used to determine eligibility.
2. If all required information is not available and/or the information on file does not support a finding of eligibility, a redetermination form,as described in Section 140.1.A.3, and/or a verification form will be issued to the household at least 30 days before the end of the eligibility period. The household will be sent a prepopulated redetermination form with the current information on file and a notice of required verifications to determine eligibility at least 30 days prior to the end of the eligibility period.
3. The redetermination form shall direct members to verify that the information provided is accurate or to report any changes to the information. Members must complete and return the redetermination form with the necessary verifications and the signature form. If a member fails to sign the signature form or comply with any of these requirements, the member will be terminated from the program for failure to complete the redetermination process.
4. If the member submits the redetermination form and/or verification information before the end of the eligibility period, the member must maintain coverage until the eligibility site can make a final determination.
5. If the member submits the redetermination form and/or verification information after the end of the eligibility period, the member will not maintain coverage.
6. If incomplete information is submitted or a member reports new changes, the eligibility site must contact the member by telephone or in writing to provide required documents or requested verifications.
B. “Reconsideration period” is the 90-day time period allowed after a member's eligibility is terminated due to failure to return the redetermination with the necessary verifications and the signature. The member’s eligibility must be reconsidered if the member submits the requested information within 90 days following termination of eligibility.
1. Members who return properly completed redetermination forms and requested information during the reconsideration period will not be required to submit a new application for eligibility. If redetermination forms and requested information are not returned within 90 days after the termination, the member must submit a new application for enrollment in the program.
2. For members who are determined to be eligible for Medical Assistance within the reconsideration period, the effective date of coverage will be the first day of the month in which the redetermination form was returned. If the member has a gap in coverage due to submitting the redetermination within the reconsideration period, the member can request up to three months in retro coverage.
150 CALCULATION OF HOUSEHOLD INCOME 150.1 Calculation of income for the Children’s Basic Health Plan shall be determined as required in 10 CCR 2505-10-8.100.4.C 150.2 Income disregards for the Children’s Basic Health Plan shall be determined as required in 10 CCR 2505-10-8.100.4.D 160 [Repealed eff. 12/30/2012] 170 PRESUMPTIVE ELIGIBILITY
170.1 A pregnant woman or a child under the age of 19 may apply for presumptive
eligibility for immediate temporary medical services through designated presumptive eligibility sites or a qualified hospital presumptive eligibility site that provides presumptive eligibility determinations.
A. To qualify for presumptive eligibility, a child under the age of 19 shall have a declared household income that shall be greater than 142% but not exceed 260% of Federal Poverty Level; or B. To qualify for presumptive eligibility, a pregnant woman shall have an attested pregnancy, declare that her household's income shall be greater than 195% but not exceed 260% of the Federal Poverty Level; and C. The applicant must be a United States citizen or a lawfully residing immigrant as defined in Section 110 or meet the exceptions outlined in 110.1.C.3.a.
170.2 Presumptive eligibility sites and qualified hospital presumptive eligibility sites must be certified by the Department of Health Care Policy and Financing to make presumptive eligibility determinations. Presumptive eligibility sites and qualified hospital presumptive eligibility sites must be re-certified by the Department of Health Care Policy and Financing every year to remain approved as presumptive eligibility sites.
A. The presumptive eligibility site or qualified hospital presumptive eligibility site shall forward the medical assistance application to the County Department of Human Services within five business days of the received date.
170.3 The presumptive eligibility period begins on the date the applicant(s) is
determined eligible and ends with the day an eligibility determination for Medical Assistance is made for the applicant(s).
170.4 The County Department of Human Services or Medical Assistance site must
make an eligibility determination within 45 days from the date of the medical assistance application.
A. Medical Assistance applicants may appeal if a County Department of Human Services is unable to act within 45 days of the medical assistance application date or the denial of a medical assistance application. Appeal procedures are outlined in Section 600.
B. A presumptively eligible member may not appeal the end of a presumptive eligibility period.
170.5 Applicants who already receive another medical assistance program cannot
receive presumptive eligibility.
170.6. An applicant may only receive presumptive eligibility once every 12 months with the exception of pregnant women who may receive presumptive eligibility once every pregnancy.
180 Express Lane Eligibility Express Lane Eligibility shall allow for automatic initiation of Medical Assistance enrollment by using available data and findings from other programs as listed below.
180.1 Free/Reduced Lunch Program
A. Recipients of the Free/Reduced Lunch Program who have submitted a Free/Reduced Lunch application at a participating school district 1. Families will be given the option to opt into Medical Assistance coverage for their potentially eligible child.
2. Children who meet all necessary eligibility requirements as outlined in this volume will be automatically enrolled.
3. Children who meet all necessary eligibility requirements except verification of U.S. citizenship and identity will receive 90 days of eligibility while awaiting this verification.
4. Any additionally required verification will be requested from the client through CBMS prior to being automatically enrolled.
5. Eligibility is based on income declared on the Free/Reduced Lunch application as well as eligibility requirements outlined in section 150.
6. If it would be found that a child does not satisfy an eligibility requirement for Medical Assistance, the child’s eligibility will be evaluated using the application for Medical Assistance.
B. Recipients of the Free/Reduced Lunch Program who were not required to submit a Free/Reduced Lunch application at a participating school district 1. Families who are automatically enrolled Free/Reduced Lunch recipient children will not be forwarded to the Department for Express Lane Eligibility in compliance USDA confidentiality guidelines.
2. These families must apply for Medical Assistance in order to give consent for request of benefits.
180.2 Direct Certification
A. When an application for Supplemental Nutrition Assistance Program (SNAP) or Colorado Works (Temporary Assistance for Needy Families Program (TANF)) has been submitted, families will be given the option to opt into Medical Assistance coverage for their potentially eligible children.
1. Children who meet all necessary eligibility requirements as outlined throughout sections 100 through 180 will be automatically enrolled, 2. Children who are only missing verification of U.S. citizenship and identity will receive 90 days of coverage while waiting for this verification.
3. Any additionally required verification will be requested from the client through CBMS prior to being automatically enrolled.
4. Eligibility is determined based on income declared on the Food Stamp or Colorado Works application as well as eligibility requirements outlined throughout this volume.
5. If it would be found that a child does not satisfy an eligibility requirement for Medical Assistance, the child’s eligibility will be evaluated using the Single Streamlined application for Medical Assistance.
6. Individuals whose eligibility is not determined through Express Lane Eligibility may also submit a separate Single Streamlined Application for Medical Assistance to determine eligibility. 200 BENEFITS PACKAGE 210 The following are covered benefits including any applicable limitations:
A. Emergency Care and Urgent/After Hours Care;
B. Emergency Transport/Ambulance Services;
C. Hospital/Other Facility Services Including:
1. Inpatient;
2. Physician;
3. Outpatient/Ambulatory;
D. Medical Office Visits Including:
1. Physician;
2. Mid-Level Practitioner;
3. Specialist;
E. Diagnostic Services;
F. Preventative, Routine and Family Planning Services Including:
1. Immunizations;
2. Well-child visits;
3. Health maintenance visits;
4. Abortion (Effective January 1, 2026)
G. Maternity Care Including:
1. Prenatal;
2. Delivery and inpatient well-baby care;
3. Postpartum care 4. Lactation Services & Support H. Mental Illness Treatments such as:
1. Neurobiologically-based mental illness 2. Mental disorders 3. All other mental illness;
I. Physical Therapy, Speech Therapy and Occupational Therapy shall be limited to 30 visits per diagnosis per year. Effective November 1, 2007, Physical, Speech and Occupational Therapy services shall be unlimited for children from birth up to the child’s third birthday.
J. Durable Medical Equipment shall be limited to the lesser of the purchase price or rental price for medically necessary durable medical equipment that shall not exceed two thousand dollars per year.
K. Transplants must be medically necessary and are limited to:
1. Liver;
2. Heart;
3. Heart/lung;
4. Cornea;
5. Kidney;
6. Bone marrow which shall be limited to the following conditions:
7. Peripheral stem cell support which shall be limited to the following conditions:
L. Home health care;
M. Hospice care;
N. Prescription medication;
O. Kidney dialysis shall be excluded only if the member is also eligible for Medicare;
P. Skilled nursing facility care must be provided only when there is a reasonable expectation of measurable improvement in the members' health status.
Q. Vision services shall be limited to:
1. Vision screenings for age appropriate preventative care;
2. Referral required for refraction services;
3. Minimum fifty dollar benefit for eyeglasses;
R. Audiology services shall be limited to:
1. Hearing screenings for age appropriate preventative care;
2. Hearing aids without financial limitation for enrollees age 18 and under no more than once every five years unless medically necessary including:
S. Intractable pain;
T. Gender-affirming care (see 10 CCR 2505-10, 8.735)
U. Case management is covered only when medically necessary; except that Targeted Case Management authorized by the 1115 Demonstration Waiver titled Colorado Expanding the Substance Use Disorder (SUD) Continuum of Care and described in Attachment G to the Center for Medicare & Medicaid Services’ (“CMS”) Demonstration Approval dated October 14, 2025 is available to inmates of public institutions 90 days prior to their release. Targeted Case Management is only available while approved by CMS. CMS’s Demonstration Approval dated October 14, 2025 is hereby incorporated by reference. This incorporation 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 303 E. 17 Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.medicaid.gov.
V. Dietary counseling/nutritional services shall be limited to:
1. Formula for metabolic disorders;
2. Total parenteral nutrition;
3. Enterals and nutrition products;
4. Formulas for gastrostomy tubes;
W. Dental services are limited to:
1. Those dental services described in the Children’s Basic Health Plan dental Evidence of Coverage booklet provided to enrollees, who are less than nineteen years of age. Beginning October 1, 2019, the dental services listed below are covered benefits for enrolled pregnant women of any age, excepting Limited Orthodontic services under Section 210.W.1.h for pregnant women age nineteen and above. Children’s Basic Health Plan dental services are provided by the dental MCO (or its designee) with which the Department has contracted for the applicable plan year to provide the following dental services;
2. Orthodontic and prosthodontic treatment for cleft lip or cleft palate in newborns (covered as a medical service in accordance with section 10-16-104, C.R.S.); and 3. Treatment of teeth or periodontium required due to accidental injury to naturally sound teeth (covered as a medical service in accordance with section 10-16-104, C.R.S.). A physician or legally licensed dentist must perform treatment within 72 hours of the accident.
X. Therapies covered shall include:
1. Chemotherapy;
2. Radiation;
Y. The following are not covered benefits:
1. Acupuncture;
2. Artificial conception;
3. Biofeedback;
4. Storage Costs for umbilical blood;
5. Chiropractic care;
6. Convalescent care or rest cures;
7. Cosmetic surgery;
8. Custodial care;
9. Domiciliary care;
10. Duplicate coverage;
11. Government institution or facility services;
12. Hair loss treatments;
13. Hypnosis;
14. Infertility services;
15. Maintenance therapy;
16. Nutritional therapy unless specified otherwise;
17. Personal comfort items;
18. Physical exams for employment or insurance;
19. Private duty nursing services;
20. Routine foot care;
21. Taxes;
22. Temporomandibular joint (TMJ) treatment, unless it has a medical basis;
23. Other therapies and treatments which are not medically necessary;
24. Vision services unless specified otherwise;
25. Vision therapy;
26. War-related conditions;
27. Weight-loss programs;
28. Work-related conditions;
300 ENROLLMENT FEES AND COPAYMENTS 310 [Repealed eff. 10/30/2022] 320 COPAYMENTS 320.1 The following copayments shall be due for enrollees at the time of service:
A. For families with income, at the time of eligibility determination, less than 101% of the Federal Poverty Level (MAGI-equivalent), all copayments shall be waived, except for emergency and care, which shall be $3.00 per use and urgent/after hours care, which shall be $1.00 per use.
B. For families with income, at the time of eligibility determination, between 101% and 150% of the Federal Poverty Level (MAGI-equivalent), the copayment shall be:
1. Effective July 1, 2012:
C. For families with income, at the time of eligibility determination, between 151% and 200% of Federal Poverty Level (MAGI-equivalent), the copayment shall be:
1. Effective July 1, 2012:
3. Due to the Coronavirus COVID-19 Public Health Emergency, members who are eligible for Children’s Basic Health Plan will have waived laboratory copayments, specifically as it relates to laboratory copayments associated with COVID-19 testing. Copayments will continue to be waived after May 11,2023 the ending of Coronavirus COVID-19 Public Health Emergency.
D. For families with income, at the time of eligibility determination, between 201% and 260% of Federal Poverty Level (MAGI-equivalent), the copayment shall be:
1. Effective July 1, 2012:
3. Due to the Coronavirus COVID-19 Public Health Emergency, members who are eligible for Children’s Basic Health Plan will have waived laboratory copayments, specifically as it relates to laboratory copayments associated with COVID-19 testing. Copayments will continue to be waived after May 11,2023 the ending of Coronavirus COVID-19 Public Health Emergency. 330 COST SHARING LIMITATIONS
330.1 American Indians and Alaskan Natives shall be exempt from cost sharing
requirements. American Indian shall mean a member of a federally recognized Indian tribe, band, or group, or a descendant in the first or second degree of any such member. Alaskan Native shall mean an Eskimo or Aleut or other Alaska Native enrolled by the Secretary of the Interior.
330.2 The maximum yearly cost sharing requirements for families of enrollees shall be 5% of income.
330.3 No copayments shall apply to preventive services. For the purpose of this
section, preventive services shall mean:
A. All healthy newborn and newborn inpatient visits, including routine screening whether provided on an inpatient or outpatient basis;
B. Routine examinations;
C. Immunizations and related office visits; and D. Routine preventive and diagnostic dental services.
330.4 Prenatal Care Program clients shall be exempt from cost sharing requirements. 400 ENROLLMENT 400.1 An applicant found eligible for Children’s Basic Health Plan can elect to be enrolled the Children’s Basic Health Plan.
410 SELECTION OF A MANAGED CARE ORGANIZATION
410.1
A. Once eligibility has been determined, an eligible person shall have the opportunity to select a participating MCO in the county of the eligible person’s residence. If there is only one participating MCO available in the county of the eligible person’s residence, the eligible person shall be enrolled in that MCO.
B. In the event the Department contracts with an MCO to provide dental services to Children’s Basic Health Plan enrollees, an enrollee automatically will be enrolled with such MCO. No separate MCO election will be required.
410.2 MCO SELECTION
A. Upon determination of eligibility for the Children’s Basic Health Plan program, if the eligible person has notified the Department or its designee of his/her chosen MCO prior to the last business day of the month in which eligibility was determined, the Department or its designee shall enroll the eligible person in that MCO.
B. Upon determination of eligibility for the Children’s Basic Health Plan program, if the eligible person has not chosen an MCO, the Department or its designee shall enroll the eligible person in an MCO selected by the Department or its designee. In areas of the state where there is only one participating MCO available, the Department or its designee shall select that MCO and enroll the eligible person.
C. The Department or its designee shall notify the enrollee of the MCO selected. If the enrollee wants to change MCOs, the enrollee shall contact the Department or its designee within 90 days from the effective date of the MCO enrollment. An enrollee may also change a pending MCO enrollment before the effective date.
D. For renewal applications, the Department or its designee shall reassign the eligible person to the participating MCO the applicant approved for the previous enrollment period. If the eligible person wishes to change MCO enrollment, he/she shall notify the Department or its designee within his/her re-enrollment period.
410.3 In counties in which a participating MCO as defined in section 50.14.A is not available, the eligible person shall be enrolled in an MCO as defined in section 50.14.B.
410.4 Once an enrollee has selected an MCO or upon expiration of the timeframe to change, the enrollee shall remain enrolled in that MCO for the remainder of his/her eligibility period, unless the eligible person meets any of the disenrollment criteria set forth in section 440.
410.5 An eligible person shall have an opportunity to change to a different MCO serving the eligible person’s geographic region, if one is available, during the applicant’s annual redetermination period.
420 ENROLLMENT OF ALL ELIGIBLE PERSONS IN A FAMILY 420.1 If one eligible child from a family is enrolled in the Children’s Basic Health Plan, all eligible children in that family must be enrolled in the Children’s Basic Health Plan.
420.2 All eligible children in a family must be enrolled in the same MCO.
430 ENROLLMENT DATE 430.1 Eligibility for the Children’s Basic Health Plan shall be effective on the latter of:
A. The first day of the month of application for Medical Assistance; or B. The first day of the month the person becomes eligible for the Children’s Basic Health Plan program.
430.2 Upon being enrolled in the Children’s Basic Health Plan, continuous eligibility applies to children under the age of 19, who through an eligibility determination, reassessment or redetermination are found eligible for the Children’s Basic Health Plan program. The continuous eligibility period may last for up to 12 months and will begin on the month of application or from the authorization date.
A. The continuous eligibility period applies without regard to changes in income or other factors that would otherwise cause the child to be ineligible.
i) If the reported income decreases, a member may transition to the MAGI Medical Assistance program specified in section 10 CCR 2505-10-8.100.4.G.2, and a new 12-month continuous eligibility period will begin on the first day of the month of the transition.
B. A child’s continuous eligibility period will end effective the earliest possible month, if any of the following occur:
i) Child is deceased;
iii) The child states that she/he has moved out of the household permanently;
iv) Is no longer a Colorado resident;
v) Is unable to be located based on evidence or reasonable assumption;
vi) Requests to be withdrawn from continuous eligibility;
vii) Fails to provide documentation during a reasonable opportunity period as specified in section 10 CCR 2505-10-8.100.3.H.9; or viii) Eligibility was erroneously granted at the most recent determination, redetermination, or renewal of eligibility because of agency error, or a finding of fraud or perjury attributed to the child or the child's responsible party.
430.3. If determined eligible, the enrollment date of a pregnant woman shall be effective as of the first of the month of the date of application or the first day of the month the pregnant woman becomes eligible. The enrollment span shall end on the last day of the month 12 months after the birth of the child or termination of the pregnancy. Once eligibility has been approved, coverage must be provided regardless of changes in the woman's financial circumstances, once the income verification requirements are met.
A. A pregnant women’s eligibility period will end effective the earliest possible month, if any of the following occur:
i) Fails to provide a reasonable explanation or paper documentation when self-attested income is not reasonably compatible with income information from an electronic data source, by the end of the 90-day reasonable opportunity period. This exception only applies the first-time income is verified following an initial eligibility determination or an annual redetermination.
430.4 An eligible person’s enrollment date in the selected MCO shall be no later than:
A. The first of the month following eligibility determination and MCO selection if eligibility is determined before the 17th of the month.
B. The first of the second month following eligibility determination and MCO selection if eligibility is determined on or after the 17th of the month.
430.5 A child born to a mother who is enrolled in the Children’s Basic Health Plan at the time of the child’s birth is guaranteed coverage for one year.
A. To receive Medical Assistance under the Children’s Basic Health Plan, the birth must be reported verbally or in writing to the County Department of Human Services or Eligibility site. Information provided shall include the baby’s name, date of birth, and mother’s name or Medical Assistance number. A newborn can be reported at any time by any person. Once reported, a newborn meeting the above criteria shall be added to the mother’s Medical Assistance case, or his or her own case if the newborn does not reside with the mother, according to timelines defined by the Department. If adopted, the newborn’s agent does not need to file an application or provide a Social Security Number or proof of application for a Social Security Number for the newborn.
440 DISENROLLMENT
440.1 An enrollee shall be disenrolled from an MCO for the following reasons:
A. Administrative error on the part of the Department, the Department’s designee, or the MCO, including but not limited to enrollment of a person who does not reside in the MCO’s service area; or, B. A change in the enrollee’s residence to an area not in the MCO’s service area; or, C. When an enrollee’s coverage is terminated as described in section 440.1A.
440.2 If an enrollee is disenrolled from an MCO for any of the reasons stated in section440.1 and there is another participating MCO available in the enrollee’s county of residence, the enrollee shall be allowed to select a new MCO.
440.3 If the enrollee is enrolled in a MCO as defined in section 50.15B and a MCO as defined in section 50.15A becomes available in the child’s county of residence, the enrollee will be disenrolled from the MCO as defined in section 50.15 B and enrolled in the MCO as defined in section 50.15A.
440.4 An enrollee may be disenrolled from both an MCO and/or the Children’s Basic Health Plan for the following reasons:
A. Fraud or intentional misconduct, including but not limited to knowing misuse of covered services, knowing misrepresentation of membership status; or, B. An enrollee’s receipt of other health care coverage will terminate a member’s coverage at renewal; or, C. The admission of an enrollee into any federal, state, or county institution for the treatment of mental illness, substance use disorder, or into any correctional facility; or, D. Ineligibility for the program, based on the guidelines set forth in the Children’s Basic Health Plan eligibility rules; or, E. Failure to comply with cost sharing requirements (copayments) set forth in the Children’s Basic Health Plan cost sharing rules; or, F. There is not another participating MCO as defined in section 50.14 available in the enrollee’s county of residence.
440.5 If an eligible person or an eligible person’s family displays an ongoing pattern of behavior that is abusive to provider(s), staff or other patients; or, disruptive to the extent that the provider’s ability to furnish services to the child or other patients is impaired, the eligible person may be disenrolled from his/her managed care organization. If there is another participating MCO available in the eligible person’s county of residence, the Department may allow the eligible person to select a new MCO. If there is not another MCO available in the eligible person’s county, the eligible person may be disenrolled from the Children’s Basic Health Plan.
500 FINANCIAL MANAGEMENT The Children’s Basic Health Plan, being a non-entitlement program, must manage to its legislative appropriation. The Department shall track expenditures, caseload, and other financial information to make informed decisions on spending its appropriation. Expenditures may exceed State appropriations with approval of the Governor, but any General Fund over expenditure shall be limited to $250,000. 510 The Department shall make quarterly assessments of projected expenditures. If it appears the program may overspend its appropriation due to changes in enrollment, health care costs, funding, legislation, or other factors, the Department shall consider if adjustments to the program are necessary. The program may use, but is not limited to, any of the following financial management tools: waiting lists, adjustments of eligibility criteria and/or levels, instituting open enrollment periods, or temporary closure of the program. 600 APPEALS PROCESS 600.1 Applicants shall be notified of any action regarding the eligibility and enrollment status and cost sharing requirements for the enrollees’ participation in the Children’s Basic Health Plan and appeal rights regarding those actions by the Department or its designee.
600.2 The Department or its designee shall notify the applicant within ten (10) business days of a decision regarding eligibility, enrollment and cost sharing. The notice shall:
A. Be in writing;
B. Be in his/her primary language, to the extent practicable;
C. Describe to the applicant the reasons for the decision;
D. Document the authority for the decision (e.g. rule citation); and E. Inform the applicant of his/her rights and responsibilities regarding the decision.
600.3 An applicant who disagrees with a denial regarding eligibility, enrollment, or cost sharing requirements may appeal in writing to the Children’s Basic Health Plan Eligibility Vendor within thirty (30) calendar days of the date of the notification of denial of eligibility, enrollment, or cost sharing. The appeal shall be reviewed and processed within thirty (30) calendar days of receipt and the results of the appeal shall be communicated to the applicant within ten (10) business days of the review. The following guidelines shall apply to the appeal process:
A. The Children’s Basic Health Plan Eligibility Vendor will coordinate the appeals process with the county or Eligibility site that determined the initial eligibility, enrollment, or cost sharing decision within ten (10) business days after receipt of the appeal.
B. The county or Eligibility site that determined the initial eligibility, enrollment, or cost sharing decision shall:
1. Review the data entry of the application in the Department’s eligibility system for accuracy and completeness within ten (10) business days after receipt of the appeal from the Children’s Basic Health Plan Eligibility Vendor;
2. Correct or complete information in the Department’s eligibility system if it is found to be incomplete or incorrect and re-run eligibility;
3. Maintain the original denial, if the information in the Department’s eligibility system is complete and correct; and 4. Notify the applicant and the Children’s Basic Health Plan Eligibility Vendor in writing once the review is complete with the results of the data entry review and the option of forwarding the appeal to the Grievance Committee.
600.4 If the applicant disagrees with the results of the appeal, the applicant may have their appeal reviewed by the Grievance Committee. The Grievance Committee’s decision shall be final.
A. The Grievance Committee shall be conducted by an independent panel appointed by the Executive Director of the Department. The panel shall include at least three people from the Department or its designee not previously involved with the grievance. A person previously involved with the grievance may be present at the conference and appear before the panel to present information and answer questions, but shall not have a vote. The Department shall ensure that those appointed to the panel have sufficient experience to make an informed decision regarding the grievance under review.
B. The applicant may attend the Grievance Committee in person or by telephone.
C. The applicant may be represented by the person of the applicant’s choice (i.e. legal counsel, friend, family member, etc.) during the Grievance Committee.
D. The applicant may have access to documents that were used by the Department or its designee in making the decision under appeal.
600.5 An enrollee who disagrees with a denial of benefits shall submit an appeal to the MCO he/she is enrolled in and shall follow the MCO’s appeal process. 610 [Repealed eff.12/30/2012] ______________________________________________________________________ Editor’s Notes History Entire rule eff. 07/30/2007.
Rule 210 emer. rule eff. 11/01/2007.
Rule 210 eff. 12/30/2007.
Rules 50.17-50.21, 100-110.1E, 150.3-150.3E, 170-170.2 emer. rules eff. 01/01/2008. Rules 50.17-50.21; 100-110.1E; 150.3-150.3E; 170-170.2 eff. 03/30/2008. Rules 500-510 eff. 11/30/2008.
Rule 210 eff. 12/30/2008.
Rule 110 eff. 03/30/2009.
Rule 150 emer. rule eff. 04/10/2009.
Rule 150 eff. 06/30/2009.
Rules 110.1 B 4-5, 150.1 Q-R eff. 11/30/2009.
Rule 130.1 B emer. rule eff. 01/01/2010; expired 03/11/2010. Rule 130.1 B eff. 03/30/2010.
Rules 110.1 D, 150.3, 170.1, 310.1 B, 320.1 D emer. rules eff. 05/01/2010. Rule 110.1 D expired 08/07/2010.
Rule 140.1 emer. rule eff. 06/11/2010.
Rules 150.3, 170.1, 310.1 B, 320.1 D eff. 06/30/2010.
Rules 110.1 D, 140.1 eff. 08/30/2010.
Rules 110.1 B 4-5 eff. 10/30/2010.
Rules 130.1 A, 150.2 eff. 12/30/2010.
Rule 140.1 B emer. rule eff. 09/09/2011.
Rule 180 emer. rule eff. 10/14/2011.
Rule 140 1B eff. 11/30/2011.
Rules 180, 430 eff. 12/30/2011.
Rules 300-330 eff. 01/01/2012.
Rules 430.1-430.2 emer. rules eff. 01/13/2012.
Rules 170, 430 eff. 04/01/2012.
Rules 410.1 A, 410.2-410.4 eff. 11/30/2012.
Rules 50.9, 50.15-50.16, 120, 150.1 O-Q, 400.1 eff. 12/30/2012. Rules 160, 220, 340, 450, 610 repealed eff. 12/30/2012.
Rules 170.5, 330.4 eff. 01/30/2013.
Rules 180.1 A.1, 180.1 A.6, 180.2 eff. 04/30/2013.
Rule 120 emer. rule eff. 05/10/2013.
Rule 120 eff. 07/30/2013.
Rules 50, 110.1.D-110.1.F, 130, 150, 170.1, 430 eff. 10/01/2013. Rules 430.2-430.5 eff. 04/30/2014.
Rules 110.1 B.2, 170.1 C eff. 07/01/2015.
Rules 50-600.5 eff. 03/02/2017.
Rule 110 eff. 09/30/2017.
Rule 430.4 eff. 10/30/2017.
Rules 430.2-430.3 eff. 10/30/2018.
Rule 210 W emer. rule eff. 10/01/2019.
Rule 210 W eff. 12/30/2019.
Rules 110.1 D, 140.1 C, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 05/08/2020. Rules 110.1 D, 140.1 C, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 09/04/2020. Rules 110.1 D, 140.1 C, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 12/11/2020. Rules 110.1 C.2, 110.1 D, 140.1 C, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 04/11/2021; expired 08/07/2021.
Rules 110.1 C.2, 110.1 D, 140.1 C, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 08/09/2021.
Rules 110.1 C.2, 110.1 D, 140.1 C, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 11/12/2021.
Rules 140.1, 430 eff. 03/10/2022.
Rules 110.1 C.2, 110.1 D, 140.1 D, 310.6, 320.1 C.3, 320.1 D.3 emer. rules eff. 03/11/2022.
Rules 110.1 E-F, 170.1 A-B, 170.3, 310.1, 430.2 B.ii, 430.3 eff. 06/30/2022. Rules 50.4, 110.1 C.2, 110.1 D, 140.1 D, 320.1 C.3, 320.1 D.3, 440.4 E emer. rules eff. 07/08/2022. Rule 310 repealed emer. rule eff. 07/08/2022. Rules 50.4, 110.1 C.2, 110.1 D, 140.1 D, 320.1 C.3, 320.1 D.3, 440.4 E emer. rules eff. 10/14/2022. Rule 310 repealed emer. rule eff. 10/14/2022. Rules 50.4, 440.4 E, repealed rule 310 eff. 10/30/2022. Rule 140.1 A emer. rule eff. 01/13/2023.
Rules 110.1 C.2, 110.1 D, 140.1 D, 320.1 C.3, 320.1 D.3 emer. rules eff. 02/10/2023. Rules 140.1 A eff. 04/30/2023.
Rules 110.1 C.2, 110.1 D, 140.1 D, 320.1 C.3, 320.1 D.3 emer. rules eff. 05/12/2023; expired 09/09/2023.
Rules 110.1 C.2, 110.1 D, 140.1 D, 180.2 A, 210, 320.1, 440.4 C eff. 10/30/2023. Rules 110.1 B.5.p, 110.1 C.3 eff. 12/30/2024.
Rules 1.20.1 A, 430.2 A.i), 430.2 B, 440.4 B eff. 03/02/2025. Rule 140 eff. 06/30/2025.
Rules 50.17-19, 170 eff. 11/30/2025.
Rules 210 F.4, 210 Y.17-28 emer. rules eff. 01/01/2026. Rules 1.20.1, 2.10.U eff. 03/02/2026.
Rules 1.20.1, 2.10.U eff. 04/14/2026.
Annotations Rule 170.5 (adopted 12/14/2012) was repealed by Senate Bill 13-079 effective 05/15/2013.