STATEMENT OF BASIS AND PURPOSE, REGULATORY ANALYSIS AND SPECIFIC STATUTORY AUTHORITY The addition of a new section to the Mental Health Services rules was adopted as emergency on 6/4/99 by the State Board of Human Services, with an effective date of 7/1/99 (CSPR# 99-5-5-1). Statement of Basis and Purpose, Regulatory Analysis, and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of Extemal Affairs. Department of Human Services. Revisions to the Mental Health Services rules were adopted emergency and final on 8/6/99 by the State Board of Human Services, with an effective date of 7/1/99 and 8/6/99 (CSPR# 99-5-5-1). Statement of Basis and Purpose. Regulatory Analysis and specific statutory authority for these revisions were incorporated by reference into the rule. These materials are available for review by the public during normal working hours at the Office of Extemal Affairs, Department of Human Services.

20.100 INTRODUCTION

These rules are intended to implement the mental health treatment services defined in the Child Mental Health Treatment Act, Sections 27-10.3-101 through 27-10.3-107, C.R.S., subject to available appropriations. The Child Mental Health Treatment Act includes children who are Medicaid eligible as well as those who are at risk of out-of-home placement, as defined below. In addition, the rules are intended to provide a sliding fee scale for responsible parties to offset the cost of care provided under the Child Mental Health Treatment Act. Gnevance procedures for denial of merital health treatment are established in the rules as well as a dispute resolution process for county departments and mental health agencies.

20.200 DEFINITIONS

“Ability to Pay” is the amount of income and assets of the legally responsible person(s) available to pay for the individual cost of mental health treatment and room and board for a child in residential treatment. “Child at Risk of Out-of-Home Placement” means a child who has been diagnosed with a mental illness (as a mentally ill person, as defined in Section 27-10-102(7), C.R.S.) and who requires the level of care provided in a residential child care facility pursuant to Section 26-4-527, C.R.S., and who, although not otherwise categorically eligible for Medicaid, is determined to be eligible for Supplemental Security Income and therefore Medicaid-eligible because of the child's need for mental health services and for whom it is not appropriate or warranted to file an action in dependence or neglect pursuant to Title 19, Article 3, C.R.S.

“Children who are Medicaid Eligible” means a child who, with a covered mental health diagnosis, is eligible for services through the Medicaid Mental Health Capitation Program. “Community Mental Health Center” means either a physical facility or a group of service providers under unified administration or otherwise affiliated with one another that provides, at a minimum, the following services for the prevention and treatment of mental illness in persons residing in a particular community in or near the facility or group so situated: ● Inpatient services;

● Outpatient services;

● Partial hospitalization;

● Residential treatment;

● Emergency services; and, ● Consultative and educational services.

“Cost of Care” includes mental health treatment not covered by Medicaid, and room and board. “County Department” means the county or district department of social services. “Mental Health Agency” means the community mental health center serving children in a particular geographic area or the Mental Health Assessment and Services Agency (MHASA) serving children in a particular geographic area who are receiving Medicaid.

“Resident” means a child receiving residential mental health treatment under the Child Mental Health Treatment Act.

“Residential Treatment Center” means a residential child care facility licensed pursuant to Section 26- 4-527, C.R.S., which has been approved by the State Department to provide mental health treatment. “Responsible Persons” means parent(s) or legal guardian(s) of a minor. “State Department” means the Colorado Department of Human Services.

20.300 APPLICATION FOR MENTAL HEALTH TREATMENT FOR CHILDREN (applies to both

1. children who are Medicaid eligible and those that are at risk of out-of-home placement, as defined in Section 20.200)

A. A parent or guardian may apply to a mental health agency on behalf of his or her minor child for mental health treatment.

B. The mental health agency will evaluate the child and clinically assess the child's need for mental health services. When warranted, treatment services will be provided as may be necessary and in the best interests of the child and the child's family.

C. The mental health agency shall be responsible for providing the treatment services, including any in- home family mental health treatment, other family preservation services, residential treatment or any post-residential follow-up services that may be appropriate for the child's or family's needs.

20.400 PROCESS OF DETERMINING ABILITY TO PAY AND ADJUSTED CHARGE FOR

1. RESIDENTIAL TREATMENT SERVICES (applies only to children at risk of out-of-home placement, as defined in Section 20.200)

A. The mental health agency shall determine the cost of care for children in this residential program. Insurance and other benefits shall be applied first to the cost of care. Medicaid is the payor of last resort and will be provided if other insurance coverage is not available. Insurance and other benefits for any resident shall be billed at the full cost of care. A responsible person(s) who fails to cooperate in making existing insurance and other benefits available for payment will nevertheless be considered as having benefits available for payment.

B. The responsible person(s)' ability to pay shall be calculated using the “Colorado Child Support Guideline” and the “Schedule of Basic Child Support Obligations,” as found in Section 14-10-115, C.R.S., and the Department's Child Support Enforcement rules (9 CCR 2504-1).

C. The charge to the responsible person(s) shall be the balance of the cost of care after insurance and other benefits have been deducted, or the ability to pay, whichever is less. If the responsible person(s) does not cooperate in making insurance and other benefits available, the responsible person(s) will be billed for the amount equal to the dollar value of the insurance or benefits in addition to the lesser of the balance of the cost of care or the ability to pay. If the dollar value of insurance and other benefits cannot be determined, the legally responsible person(s) will be billed the full cost of care.

20.500 DISPUTE RESOLUTION FOR DENIAL OF MENTAL HEALTH TREATMENT (applies to both children who are Medicaid eligible and those that are at risk of out-of-home placement, as defined in Section 20.200)

A. Except as provided below, the mental health agency shall use the formalized grievance process that the agency has established pursuant to the requirements of the Mental Health Services Clients Rights and Advocacy Rules, Section RA.2 (2 CCR 502-2) and the Capitated Medicaid Mental Health Care grievance process found at Section 8.212.10 of the Colorado Department of Health Care Policy and Financing's Medical Assistance Manual (10 CCR 2505-10).

B. An assessment and decision regarding requests for residential treatment shall be performed by the mental health agency within the following time periods after a request for residential treatment has been made:

1. 1. Emergency situations, defined as a condition which appears to require unscheduled, immediate or special mental health intervention in response to a crisis situation involving the risk of imminent harm to the person or others: Evaluation shall be completed within six (6) hours of the initial assessment request.
2. 2. Urgent situations, defined as a condition which appears to, if not addressed within twenty-four
   1. (24) hours, be likely to escalate to an emergency situation: Evaluation shall be completed within twenty-four (24) hours of the initial assessment request.
3. 3. Routine situations, defined as all other situations: Evaluation shall be completed within three
   1. (3) days of the initial assessment request.

C. The mental health agency decision shall be communicated orally and in writing to the parent or guardian within the time allowed above for the completion of the evaluation. Oral notice shall be face to face with the parent or guardian when possible. The written decision shall contain notice of the applicable criteria for residential treatment, the factual basis for any denial, the alternative services being offered including a time limited plan for assessing the need for residential treatment, notice of the grievance procedures contained in this section; and, shall contain a paragraph for the parent or guardian to sign, indicating that they either agree with the decision, or that they disagree and wish to file a grievance.

D. If the parent or guardian requests a grievance of a denial of residential treatment, either in writing or orally, the mental health agency shall have two (2) working days within which to complete the internal grievance review process and communicate a decision to the parent in writing and orally, in person when possible. Said notice shall contain the information required in paragraph C, above, along with the process for clinical review in E, below. If the mental health agency requires more than two days to complete its internal review and the parent is agreeable, then the mental health agency may take up to but no more than 5 days to complete the review. If the parent is not agreeable, the two (2) working day timeline discussed above remains in effect.