Statutes, codes, and regulations
Colorado Administrative Code
Department 2505 - Department of Health Care Policy and FinancingDivision 2505 - Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)
Rule 10 CCR 2505-10-8.200 - MEDICAL ASSISTANCE - SECTION 8.200 Physician Services, Dental, Vision Services, Medicaid Managed Care Program, EPSDT
Section 10 CCR 2505-10-8.205 - MEDICAID STATEWIDE MANAGED CARE SYSTEM

10 Colo. Code Regs. § 2505-10-8.205

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Current through Register Vol. 47, No. 16, August 25, 2024
Section 10 CCR 2505-10-8.205 - MEDICAID STATEWIDE MANAGED CARE SYSTEM
8.205.1DEFINITIONS
8.205.1.A. Attribution means the process by which the Department enrolls a Member with a Primary Care Medical Provider or Managed Care Organization.
8.205.1.B. Covered Services means the health care services defined in the contract between the Department and a Managed Care Organization or Prepaid Inpatient Health Plan that are paid through a Monthly Capitation Payment.
8.205.1.C,. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention or behavioral health services to result in the following:
1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) or the health of another in serious jeopardy.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
8.205.1.D. Emergency services means covered inpatient and outpatient services that are as follows:
1. Furnished by a provider that is qualified to furnish these services.
2. Needed to evaluate or stabilize an emergency medical condition.
8.205.2.E. Managed Care Organization (MCO) shall mean an entity that has, or is seeking to qualify for, a comprehensive risk contract under 42 CFR 438.2, and that is:
1. A Federally qualified HMO that meets the advance directives requirements of subpart I of 42 CFR 489; or
2. Any public or private entity that meets the advance directives requirements and is determined by the Secretary of the U.S. Department of Health and Human Services to also make the services it provides to its Medicaid members as accessible (in terms of timelines, amount, duration, and scope) as those services are to other Medicaid beneficiaries within the area served by the entity; and meets the solvency standards of 42 CFR 438.116.
8.205.1.F. Medicaid Statewide Managed Care System, also known as the Accountable Care Collaborative, means any Managed Care Organization, Primary Care Case Management Entity, or Prepaid Inpatient Health Plan established under the State authorities established in Title 25.5, Article 5, Part 4, C.R.S. and under the federal authority established in 42 C.F.R. Part 438 and approved by the Centers for Medicare and Medicaid Services (CMS).
8.205.1.G. Member means any person enrolled in the Medicaid Statewide Managed Care System.
8.205.1.H. Prepaid Inpatient Health Plan (PIHP) shall mean an entity that provides medical services to members under contract with the State agency, and on the basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates; provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its members; and does not have a comprehensive risk contract.
8.205.1.I. Primary Care Case Management Entity (PCCM Entity) means an entity contracted with the state department to furnish case management services, including the coordination and monitoring of primary health care services, as defined in 42 CFR § 438.2.
8.205.1.J. Primary Care Medical Provider (PCMP) means a primary care provider contracted with PCCM Entity to serve as a medical home for members.
8.205.1.K. Utilization Management means the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.
8.205.2CLIENT ELIGIBILITY
8.205.2.A. A Medicaid Client with full Medicaid benefits must be enrolled into the Medicaid Statewide Managed Care System, with the exception of the individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE) as defined in Section 8.497.
8.205.2.B. The following individuals are not eligible for enrollment in the Medicaid Statewide Managed Care System:
1. Qualified Medicare Beneficiary only (QMB-only).
2. Qualified Disabled and Working Individuals (QDWI)
3. Qualified Individuals 1 (QI 1).
4. Special Low Income Medicare Beneficiaries (SLMB).
5. Undocumented immigrants.
6. Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE).
7. Individuals between ages 21 and 64 who are inpatient at the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan.
8. Individuals who are incarcerated.
9. Individuals while determined presumptively eligible for Medicaid.
8.205.3MEMBER RIGHTS AND PROTECTIONS
8.205.3.A. A Member enrolled in a PCCM Entity, MCO, or PIHP has the following rights and protections:
1. To be treated with respect and with due consideration for the Member's dignity and privacy.
2. To receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee's condition and ability to understand.
3. To participate in decisions regarding the Member's health care, including the right to refuse treatment and the right to a second opinion.
4. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
5. To obtain family planning services and family planning-related services directly from any provider duly licensed or certified to provide such services without regard to enrollment in a PCCM Entity, MCO, or PIHP, without referral.
6. To request and receive a copy of the Member's medical records and to request that they be amended or corrected, as specified in 45. CFR Part 164.
7. To select a PCMP from those available in the PCCM Entity or MCO network.
8. To request any change of PCMP in a PCCM Entity network from the Department or its designee.
9. To select or request a change of a provider from those providers available in the MCO or PIHP provider network.
10. To have access to written materials that are critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices available in the prevalent non-English languages. All materials shall be written in English and Spanish, or any other prevalent language, as directed by the Department or as required by 42 CFR 438.10.
11. To have oral interpretation available in all languages and written translation available in each prevalent non-English language at no cost to any Member.
12. To exercise the Member's rights without any adverse effect on the way the Member is treated.
8.205.4MEMBER ENROLLMENT AND DISENROLLMENT
8.205.4.A. Enrollment in the Medicaid Statewide Managed Care System is mandatory for eligible Members.
8.205.4.B. Members enrolled into the Medicaid Statewide Managed Care System are attributed to a PCMP or MCO.
1. Members may be attributed to an MCO in accordance with the Department's member enrollment policy that takes into consideration the following:
a. County of residence.
i. Members residing in Garfied, Gunnison, Mesa, Montrose, Pitkin, and Rio Blanco counties may be attributed to the MCO operated by or under the control of Rocky Mountain Health Plans.
ii. Members residing in Adams, Arapahoe, Denver, and Jefferson Counties may be attributed to the MCO operated by or under the control of Denver Health and Hospital Authority.
b. Member's age.
c. Member's Medicaid aid category.
2. Members will be attributed to a PCMP based on factors that include Member choice, Member utilization history, provider capacity, and geographic location in accordance with the Department's member enrollment policy in the following instances:
a. The Member resides in a county that is not covered by an MCO.
b. The Member opts out of enrollment in an MCO.
3. Members may change their attribution to a PCMP by contacting the Department or its designee. Any change in attribution to a PCMP is effective the first day of the month following the member's formal submission of the change request to the Department or its designee.
4. Members may change their attribution to an MCO as specified in 8.205.5. H, I, J, and K.
8.205.4.C. Members attributed to a PCMP are assigned to a PCCM Entity/PIHP based on the PCMP's contract with a PCCM Entity/PIHP.
8.205.4.D. Members attributed to an MCO are assigned to the PIHP contracted with the MCO.
8.205.4.E Child and youth Members determined eligible for Medicaid as a result of a dependency and neglect action resulting in out-of-home placement pursuant to article 2 of title 19 C.R.S. must be assigned to the PCCM Entity and PIHP that cover the county with jurisdiction over the action.
1. The Department or its designee may change the child or youth Member's PCCM Entity and PIHP assignment only at the request of the county with jurisdiction over the action or by the child's or youth's legal guardian.
8.205.4.F. Members who are disenrolled from a PCCM Entity, MCO, or PIHP for a period of two (2) months or less due to loss of eligibility shall be reenrolled into the same program upon regaining eligibility within the two (2) month period.
8.205.4.G. A Member who is enrolled with an MCO remains assigned to that MCO for a period of twelve (12) months except as otherwise provided in these rules.
8.205.4.H. A Member may request disenrollment from their MCO without cause during the ninety (90) days following the date of their initial enrollment or the date the Department or its designee sends the notice of enrollment, whichever is later.
8.205.4.I. A Member may request disenrollment without cause at least every twelve (12) months after the date of initial enrollment with an MCO.
8.205.4.J. A Member may request disenrollment when the Department imposes intermediate sanctions as set forth in the Department's contract with the MCO.
8.205.4.K. A Member may request disenrollment from an MCO for cause at any time. Cause shall be defined as any of the following:
1. The Member moves out of the MCO service area.
2. The MCO does not, because of moral or religious objections, cover the service the Member needs.
3. The Member needs related services to be performed at the same time and not all related services are available within the MCO network, and the Member's provider determines that receiving the services separately would subject the Member to unnecessary risk.
4. The Department or its designee unintentionally enrolls a Member into the wrong plan.
5. Poor quality of care, as documented by the Department.
6. Lack of access to covered services, as documented by the Department.
7. Lack of access to providers experienced in dealing with the Member's health care needs, as documented by the Department.
8. The Member's primary care provider leaves the MCO.
9. Other reasons satisfactory to the Department.
8.205.4.L. For Members who are unable to make decisions for themselves, a family member, legal guardian or designated advocate shall be included in all decision-making concerning enrollment and disenrollment of the Member.
8.205.5DISMISSAL OF MEMBER BY A PROVIDER
8.205.5.A. Providers, excluding safety net providers, participating in a PCCM Entity, MCO, or PIHP may dismiss an enrolled Member from their practice for cause at any time. Cause shall be defined as any of the following:
1. A documented, ongoing pattern of failure on the part of the Member to keep scheduled appointments or meet any other Member responsibilities.
2. A documented ongoing pattern of failure to follow the recommended treatment plan or medical instructions.
3. The provider cannot provide the level of care necessary to meet the Member's needs.
4. The Member and /or Member's family is abusive to provider and/or staff.
5. The provider moves out of the service area.
6. Other reasons approved by the Department.
8.205.5.B. Providers must take the following steps prior to dismissing a Member from their practice:
1. The provider shall give no less than 45 days notice to both the Member and the PCCM Entity, MCO or PIHP.
2. For Members with behavioral health needs who are at risk of dismissal, the provider must make a referral for care coordination to the Member's MCO, PIHP, or PCCM Entity prior to giving written notice of dismissal.
3. The provider shall give the Member a reasonable opportunity to find substitute care and information necessary to obtain the patient's medical records;
8.205.5.C. The PCCM Entity, MCO or PIHP shall respond within 48 hours of any request to coordinate Member access to a new provider.
8.205.6ESSENTIAL COMMUNITY PROVIDERS
8.205.6.A In order to be eligible for designation as an Essential Community Provider, the following health care providers shall be determined to have historically served medically needy or medically indigent patients and demonstrated a commitment to serve low-income and medically indigent populations who make up a significant portion of their patient population or, in the case of a sole community provider, serve the medically indigent patients within their medical capability:
1. Disproportionate share hospitals.
2. Local county and district health departments, county nursing services and regional health department operating pursuant to Title 25, C.R.S., as amended.
3. Federally Qualified Health Centers (FQHCs).
4. School based health centers that can verify that 25% of students enrolled in the school are at or below 185% of the Federal Poverty Level and that services are offered to the entire student population enrolled in the school without regard to the patient's ability to pay.
5. Family Medicine Residency Training Programs that can verify that 25 % of the patients served are at or below 185% of the Federal Poverty Level.
6. Rural Health Clinics that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
7. State certified Title X Family. Planning Agencies that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
8. Sole community providers that are not located within a metropolitan statistical area, as designated by the U.S. Office of Management and Budget, and in whose community there is no other similar type of health care and the provider can verify that it provides health care services to patients below 185% of the Federal Poverty Level within its medical capability.
9. New health care providers operating under a sponsoring or participating entity that qualifies as an Essential Community Provider.
10. Health care providers that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
8.205.6.B. In order to be eligible for designation as an Essential Community Provider, the provider shall waive charges or charge for services on a sliding scale for patients/families at or below 185% of the Federal Poverty Level.
8.205.6.C. Health care providers, except those set forth a 8.206.1(1) through (3), who seek to be designated as an Essential Community Provider, shall submit their application, including a copy of their sliding fee scale to the Department.
8.205.7QUALIFIED PHARMACY PROVIDERS
8.205.7.A. An MCO shall contract with qualified pharmacy providers in a manner permitting a nursing facility to continue to comply with federal Medicaid requirements of participation.
8.205.7.B. A qualified pharmacy provider shall meet all of the following requirements:
1. Employ, on a full-time basis, a pharmacist licensed by the State of Colorado.
2. Demonstrate a capability of procuring, preparing, dispensing and distributing pharmaceutical products in an institutional setting.
3. Demonstrate a capability of monitoring Members on an ongoing basis to identify, prevent and resolve drug-related problems including, but not limited to, the monitoring of drug-drug interactions and drag-allergy interactions.
4. Provide pharmaceutical consulting services twenty-four (24) hours per day.
5. Perform medication-use assessments with the assistance of a pharmacist licensed by the State of Colorado at least once each month. Such assessments shall be Member-centered, ensuring that the Member's medication regimen meets his or her needs.
6. Participate with the Member's physicians, nurses, dieticians and other health care professionals in inter-disciplinary care planning.
7. Provide continuous pharmaceutical care and services to Members twenty-four (24) hours per day every day.
8. Reasonably respond to emergency situations and maintain an emergency kit registered with the. Colorado. State Board of Pharmacy at each nursing home.
9. Utilize appropriate unit dose or unit of issue distribution systems to ensure that Members receive proper medications, at the proper time, and at the proper dosage.
10. Demonstrate its capability to provide physician orders and medication administration records on a monthly basis.
8.205.8PERSONS WITH SPECIAL HEALTH CARE NEEDS
8.205.8.A. Persons with Special Health Care Needs shall mean persons having ongoing health conditions that
1. Have a biologic, psychologic or cognitive basis;
2. Have lasted or are virtually certain to last for at least one year; and
3. Produce one or more of the following sequelae:
a. Significant limitation in areas of physical, cognitive or emotional function;
b. Dependency on medical or assistive devices to minimize limitation of function or activities;
c. In addition, for children:
(i) Significant limitation in social growth or developmental function;
(ii) Need for psychologic, educational, medical or related services over and above the usual for the child's age; or
(iii) Special ongoing treatments such as medications, special diets, interventions or accommodations at home or at school.
8.205.9STATEWIDE SYSTEM OF COMMUNITY BEHAVIORAL HEALTH CARE
8.205.9.A The Medicaid Statewide Managed Care System must include PIHPs to administer a statewide system of community behavioral health care.
8.205.9.B. The following are required services of the statewide system of community behavioral health care:
1. Inpatient Behavioral Health Services-- A program in which the Member receives services in a hospital or health care facility 24 hours a day.
a. Inpatient Psychiatric Services-- A program of psychiatric care in which the Member remains 24 hours a day in a psychiatric hospital, State Institute for Mental Disease (IMD), or other facility licensed as a hospital or Psychiatric Residential Treatment Facility by the State.
i. Members under age 21 and members 65 years of age or older may receive services in an IMD.
ii. Members ages 21-64 are excluded from receiving services in an IMD for more than 15 days within a month.
b. Residential and Inpatient Substance Use Disorder Services
i. Inpatient Substance Use Disorder Services- Substance use disorder services that provide a planned and structured regimen of 24-hour professionally directed evaluation, observation, medical monitoring and addiction treatment in an inpatient setting. American Society of Addiction Medicine level 4 services are reimbursed fee for service and are not covered by the PIHP as part of the statewide system of community behavioral health care.
ii. Residential Substance Use Disorder Services- Substance use disorder services that are delivered in settings that provide 24-hour structure, support and clinical interventions for patients. These services are appropriate for Members who require time and structure to practice and integrate their recovery and coping skills in a residential, supportive environment. Higher levels of residential treatment provide safe, stable living environments for Members who need them to establish or maintain their recovery apart from environments that promote continued use in the community.
2.Outpatient Services-- A program of care in which the Member receives services in a hospital or other health care facility, but does not remain in the facility 24 hours a day, including:
a.Physician Services, including psychiatric care- Behavioral health services provided within the scope of practice of medicine as defined by State law.
b.Rehabilitative Services- Any remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of behavioral/emotional disability and restoration of a Member to the Member's best possible functional level, including:
i.Individual Behavioral Health Therapy- Therapeutic contact with one Member of more than 30 minutes, but no more than two (2) hours.
ii.Individual Brief Behavioral Health Therapy- Therapeutic contact with one Member of up to and including 30 minutes.
iiiGroup Behavioral Health Therapy- Therapeutic contact with more than one Member, of up to and including two (2) hours.
iv.Family Behavioral Health Therapy- Therapeutic contact with a Member and family member(s), or other persons significant to the Member, for improving Member-family functioning. Family behavioral health therapy is appropriate when intervention in the family interactions is expected to improve the Member's emotional/behavioral health. The primary purpose of family behavioral health therapy is treatment of the Member.
v.Behavioral Health Assessment- Clinical assessment of a Member by a behavioral health professional that determines the nature of the Member's problem(s), factors contributing to the problem(s), a Member's strengths, abilities and resources to help solve the problem(s), and any existing diagnoses.
vi.Pharmacologic Management- Monitoring of medications prescribed and consultation provided to Members by a physician or other medical practitioner authorized to prescribe medications as defined by State law, including associated laboratory services, as indicated.
vii.Outpatient Day Treatment- Therapeutic contact with a Member in a structured, non-residential program of therapeutic activities lasting more than four (4) hours but less than twenty-four (24) hours per day. Services include assessment and monitoring; individual/group/family therapy; psychological testing; medical/nursing support; psychosocial education; skill development and socialization training focused on improving functional and behavioral deficits; medication management; expressive and activity therapies; and coordination of needed services with other agencies. When provided in an outpatient hospital program, may be called "partial hospitalization."
viii. Intensive Outpatient Substance Use Disorder Services- Therapeutic contact with a member to help the member achieve changes in their alcohol and/or other drug use. Intensive outpatient treatment services are delivered with greater frequency than standard outpatient services. This level of care is appropriate for patients who have more complex needs. Allowable services include substance use disorder assessment, individual and family therapy, group therapy, and alcohol/drug screening counseling.
ix.Emergency/Crisis Services- Services provided during a behavioral health emergency which involve unscheduled, immediate, or special interventions in response to crisis situation with a Member, including associated laboratory services, as indicated.
3.Targeted Case Management- Case management services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services.
4.School-Based Behavioral Health Services- Behavioral health services provided to school-aged children and adolescents on-site in their schools, with the cooperation of the schools.
5.Drug Screening and Monitoring- Substance use disorder counseling services provided along with screening results to be discussed with client.
6.Detoxification Services- Services relating to detoxification including all of the following: Physical assessment of detox progression including vital signs monitoring; level of motivation assessment for treatment evaluation; provision of daily living needs (includes hydration, nutrition, cleanliness and toiletry); safety assessment, including suicidal ideation and other behavioral health issues.
7.Medication-Assisted Treatment- Administration of Methadone or another approved controlled substance to an opiate-dependent person for the purpose of decreasing or eliminating dependence on opiate substances.
8. Alternative behavioral health services-Administration of non-traditional, community-based services not available through the State Plan but authorized through the Department's 1915(b) waiver with the Centers for Medicare and Medicaid Services.
a.Assertive Community Treatment (ACT)- Comprehensive, locally-based, individualized treatment for adults with serious behavioral health disorders, that is available 24 hours a day, 365 days a year. The ACT team actively engages Members in their community to develop skills and monitor status, rather than function as an office-based team. Services include case management, initial and ongoing behavioral health assessment, psychiatric services, employment and housing assistance, family support and education, and substance use disorders services.
b.Clubhouse and Drop-in Center services- Peer support services for people who have behavioral health disorders, provided in a Clubhouse or Drop-In Center setting. Clubhouse participants may use their skills for clerical work, data input, meal preparation, providing resource information and outreach to clients. Drop-in Centers offer planned activities and opportunities for individuals to interact socially, promoting and supporting recovery.
c.Intensive Case Management-- Community-based services averaging more than one hour per week, provided to adults with serious behavioral health disorders who are at risk of a more intensive 24 hour placement and who need extra support to live in the community. Services are assessment, care plan development, multi-system referrals, assistance with wraparound and supportive living services, monitoring and follow-up. Intensive case management may be provided to children/youth under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program.
d. Mental Health Residential Services- Twenty-four (24) hour care, excluding room and board, provided in a non-hospital, non-nursing home setting, appropriate for Members whose mental health issues and symptoms are severe enough to require a 24-hour structured program but do not require hospitalization. Services are provided in the setting where the client is living, in real-time, with immediate interventions available as needed. Clinical interventions are assessment and monitoring of mental and physical health status; assessment and monitoring of safety; assessment of/support for motivation for treatment; assessment of ability to provide for daily living needs; observation and assessment of group interactions; individual, group and family therapy; medication management; and behavioral interventions. Residential services may be provided to children/youth under EPSDT.
e.Prevention/Early Intervention Services- Proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive behavioral health. Services include behavioral health screenings; educational programs promoting safe and stable families; senior workshops related to aging disorders; and parenting skills classes.
f.Recovery Services- Community-based services that promote self-management of behavioral health symptoms, relapse prevention, treatment choices, mutual support, enrichment, rights protection, social supports. Services are peer counseling and support services, peer-run drop-in centers, peer-run employment services, peer mentoring, consumer and family support groups, warm lines, and advocacy services.
g.Respite Care- Temporary or short-term care of a child, youth or adult client provided by adults other than the birth parents, foster/adoptive parents, family members or caregivers that the Member normally resides with. Respite is designed to give the caregivers some time away from the Member to allow them to emotionally recharge and become better prepared to handle normal day-today challenges. Respite care providers are specially trained to serve individuals with behavioral health issues.
h.Vocational-- Services designed to help adult and adolescent clients who are ineligible for state vocational rehabilitation services to gain employment skills and employment. Services are skill and support development interventions, educational services, vocational assessment, and job coaching.
8.205.9.C. The PIHPs must offer Members an initial or subsequent nonurgent behavioral health care visit where medically necessary and at appropriate therapeutic intervals in compliance with C.R.S. § 25.5-5-402(3)(g).
8.205.10UTILIZATION MANAGEMENT
8.205.10.A. The MCOs and PIHPs must ensure Covered Services delivered to Members are Medically Necessary as defined in Section 8.076.1.8 as well as Section 8.280 for Members under 21 years of age, delivered in the least restrictive setting, and most likely to address the Member's health care needs by employing Utilization Management best practices.
1. If it is determined that the Member does not meet criteria of Medical Necessity or the Member has a diagnosis not covered by the capitated payment arrangement, MCOs and PIHPs must inform the Member about how other appropriate Medicaid State Plan services may be obtained and coordinate referrals to appropriate providers within the region within 48 hours of request from the Member, a family member, legal guardian or designated advocate.
8.205.10.B. Utilization Management practices shall align with the following guidelines:
1. Establish and regularly update Utilization Management policies and procedures for evaluating the clinical appropriateness, efficacy, or efficiency of Covered Services, referrals, procedures or settings in accordance with the most recent national and industry standards or guidelines and with federal and department rules and regulations.
2. Ensure Utilization Management policies and procedures are designed in compliance with 42 CFR 438. Part 2.
3. Design and implement Utilization Management policies and procedures in compliance with the federal Mental Health Parity and Addiction Equity Act requirements defined in 42 CFR 438 Subpart K, including the application of financial requirements, treatment limitations, and non-quantitative treatment limitations, as well as the process for determining access to out-of-network providers.
4 Appropriately incorporate use of prior authorization and continued stay reviews for residential and inpatient behavioral health services that are not for treatment of an Emergency Medical Condition to ensure that the services requested or furnished are medically necessary and sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished.
a. Utilize the American Society of Addiction Medicine criteria to determine medical necessity for residential and inpatient substance use disorder treatment services.
b. Engage in care coordination and discharge planning to appropriately transition members across the continuum of care.
5. Make Utilization Management decision-making criteria available to members and providers upon request.
6. Designate an appropriately licensed medical professional to provide oversight and evaluation of the Utilization Management policies and activities.
7. Establish standards for Utilization Management personnel to consult with the ordering provider prior to denial or limitation of requested/provided services.
8. Ensure Utilization Management processes do not impede timely access to services.
8.205.10.C. The MCOs and PIHPs must ensure that the services requested or furnished are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished.
8.205.10.D. The PIHPs must cover all medically necessary Covered Services for covered behavioral health diagnoses under the Capitated Behavioral Health Benefit, regardless of any co-occurring conditions.
8.205.10.E. The MCOs and PIHPs must not deny a Covered Service based solely on the Member having a diagnosis of a co-occurring intellectual or developmental disability, a neurological or neurocognitive disorder, or a traumatic brain injury.
8.205.10.F. The MCOs and PIHPs must not require prior authorization for the non-pharmaceutical components of medication-assisted treatment.
8.205.10.G. The MCOs must not impose any prior authorization requirements or step therapy requirements as a prerequisite to authorizing coverage for any prescription medication approved by the Food and Drug Administration for the treatment of substance use disorders.
8.205.10.H. The MCOs and PIHPs must coordinate State Plan covered services that are paid fee-for-service.
8.205.10.I. The MCOs and PIHPs must have a grievances and appeals process as specified in Section 8.209.
8.205.11EMERGENCY SERVICES
8.205.11.A. The MCOs and PIHPs must cover and pay for emergency services regardless of whether the provider that furnishes the services has a contract with the MCO or PIHP, to the extent that services required to treat an emergency medical condition fall within the scope of services for which the MCO or PIHP is responsible.
8.205.11.B. The MCOs and PIHPs may not deny payment for treatment obtained under either of the following circumstances:
1. A Member had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of emergency medical condition in 8.205.1.C of this section.
2. A representative of the MCO or PIHP instructs the Member to seek emergency services.
8.205.11.C. The MCOs and PIHPs may not:
1. Limit what constitutes an emergency medical condition with reference to of the definition in 8.205.1.C of this section, on the basis of lists of diagnoses or symptoms, except to the extent that services required to treat an emergency medical condition fall outside the scope of the services for which the MCO and PIHP is responsible; and
2. Refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent not notifying the Member's primary care provider, MCO, PIHP, or applicable State entity of the Member's screening and treatment within 10 calendar days of presentation for emergency services.
8.205.11.D. A Member who has an emergency medical condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the Member.

10 CCR 2505-10-8.205