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 2505-10-8.700 - MEDICAL ASSISTANCE - SECTION 8.700 Federally Qualified Health Centers, Women's Health Services
Section 10 CCR 2505-10-8.715 - BREAST AND CERVICAL CANCER PROGRAM

10 Colo. Code Regs. § 2505-10-8.715

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Current through Register Vol. 47, No. 24, December 25, 2024
Section 10 CCR 2505-10-8.715 - BREAST AND CERVICAL CANCER PROGRAM
8.715.1DEFINITIONS

Breast and Cervical Cancer Program (BCCP) means the Medicaid program established, operated and monitored by the Department.

Colorado Women's Cancer Control Initiative (CWCCI) means the program administered by the Colorado Department of Public Health and Environment and funded by the Centers for Disease Control and the National Breast and Cervical Cancer Early Detection Program.

In Need of Treatment means services necessary to determine the extent and proper course of cancer or precancerous treatment as well as definitive cancer treatment itself. Treatment can include surgery, radiation, chemotherapy and approved medications following treatment as determined by the client's physician and the Department.

National Breast and Cervical Cancer Early Detection Program (NBCCEDP) means the program where the Centers for Disease Control (CDC) provides breast and cervical screening services to underserved women. In Colorado, the CDC provider is the Department of Public Health and Environment's Colorado Women's Cancer Control Initiative.

Presumptive Eligibility for BCCP means the temporary eligibility for benefits that begin on the date a Qualified Entity determines the client meets eligibility requirements for the BCCP and the client signs the presumptive eligibility form. Women identified by the CWCCI as being In Need of Treatment for breast or cervical cancer or a precancerous condition shall apply for presumptive eligibility on a simplified Medicaid application.

Qualified Entity means a provider contracted with the Department of Public Health and Environment under a cooperative agreement with the CDC to support activities related to the NBCCEDP. A qualified entity shall provide breast and cervical cancer assessment services for the CWCCI.

State Designated Entity means an agency acting on behalf of and at the direction of the Department and whose function may include, but is not limited to, processing eligibility determinations and assisting clients with the application process.

8.715.2ELIGIBILITY REQUIREMENTS
8.715.2.A. Clients shall meet all requirements of the CWCCI program.
8.715.2.B. Clients shall enroll for screening at participating Breast and Cervical Cancer assessment sites through the CWCCI.
8.715.2.C. Clients shall:
1. Be a woman who has not yet attained the age of 65.
2. Be a resident of Colorado.
3. Be a citizen of the United States or a qualified alien as described in 8.100.53(A)(2) through 8.100.53(A)(4).
4. Have been screened by a Qualified Entity and found to be In Need of Treatment for breast or cervical cancer, including precancerous conditions as determined through pathological tests.
5. Not have creditable coverage as described in 8.715.3.
6. Not be eligible under another Medicaid program.
7. Be a client who has previously qualified and enrolled in a NBCCED program in another state and chooses to transfer her enrollment to CWCCI.
8.715.2.D. Clients shall not have been previously screened or received treatment for breast or cervical cancer prior to July 1, 2002.
8.715.2.E. Clients shall not be considered to be In Need of Treatment if it is determined she only requires routine follow-up monitoring services.
8.715.2.F. Clients shall be willing to seek Medicaid approved breast or cervical cancer or precancerous treatment within three months of the date of eligibility. If a client does not seek such treatment within three months of the date of presumptive eligibility, the client shall be removed from the program on the last day of the third month. The client will be re-entered in the BCCP program at such time as treatment is scheduled to begin. If treatment has not been started within one month of the scheduled date, the client will be disenrolled.
8.715.3CREDITABLE COVERAGE
8.715.3.A. Creditable coverage shall include coverage of any individual as defined at 10-16-102, C.R.S. (2002).
8.715.3.B. The following are not considered creditable coverage:
1. Limited scope coverage such as that which covers only dental, vision or long term care;
2. Coverage only for a specific disease or illness (unless the specific disease or illness includes breast or cervical cancer); or
3. A medical care program run by the Indian Health Services or a tribal organization.
8.715.3.C. An individual who otherwise has creditable coverage may qualify for the program if:
1. The individual is in a period of exclusion for treatment of breast or cervical cancer; or
2. The individual has exhausted her lifetime limits on benefits under the plan for breast or cervical cancer.
8.715.3.D. Individuals who have coverage that contains yearly limited drug benefits, yearly limits on outpatient visits or high deductibles shall be considered to have creditable coverage.
8.715.4PRESUMPTIVE ELIGIBILITY
8.715.4.A. Presumptive eligibility shall be determined by Qualified Entities.
8.715.4.B. The Department shall make available to Qualified Entities:
1. Information on the BCCP presumptive eligibility form and card;
2. Information on how to obtain the Medicaid application; and
3. Information on how to assist CWCCI personnel and individuals on application completion and filing.
8.715.4.C. Qualified Entities shall determine presumptive eligibility based on verbal confirmation by the potential client that she meets CWCCI criteria and shall enroll the clients who appear to be eligible.
8.715.4.D. Presumptive eligibility shall begin on the date the client completes the BCCP presumptive eligibility form and the Qualified Entity determines the client meets all eligibility criteria.
8.715.4.E. All potential clients shall be required to complete the BCCP presumptive eligibility form and the Medicaid application at the same time.
8.715.4.F. The Qualified Entity shall submit the presumptive eligibility form, a copy of the presumptive eligibility card, the CWCCI history and physical, the diagnosis pathology report and the signed consent form to the Department.
8.715.4.G. The Designated Entity shall process the Medicaid application within thirty calendar days of receipt.
8.715.4.H. The presumptive eligibility period shall end on the following:
1. The date on which a formal determination is made on the client's Medicaid application; or
2. If a full determination cannot be made on the basis of the BCCP presumptive eligibility form and the client fails to complete the Medicaid application, then eligibility will end on last day of the month following the month in which the client was determined to be presumptively eligible.
8.715.5ELIBILITY PERIOD
8.715.5.A. Eligibility shall begin on the date the client is determined to be presumptively eligible.
8.715.5.B. The client shall be eligible to receive services for up to one year from the date of initial eligibility unless she is no longer In Need of Treatment or no longer meets program eligibility requirements.
8.715.5.C. If the client remains in treatment beyond one year, renewed eligibility shall be determined consistent with BCCP and Medicaid requirements.
8.715.5.D. A period of renewed eligibility begins each time the client is screened under the CWCCI program and is found to be In Need of Treatment for breast or cervical cancer and meets all other eligibility criteria.
8.715.5.E. A client may be determined no longer eligible for the program if:
1. She does not complete the Medicaid application; or
2. She is no longer In Need of Treatment for breast or cervical cancer or qualified precancerous conditions when the client's provider notifies the Department; or
3. She reaches the age of 65; or
4. She obtains other creditable coverage describe in 8.715.3.
8.715.5.F. Clients who are determined no longer eligible shall be notified in writing as described in 8.715.6(B).
8.715.6NOTIFICATION
8.715.6.A. The BCCP presumptive eligibility form shall include a statement of the applicant's rights and responsibilities.
8.715.6.B. The Department shall notify clients who are no longer In Need of Treatment for the BCCP

in writing thirty days prior to their disenrollment date. This notice will be provided only to those clients who have completed their course of treatment per their provider.

1. Copies of the notice shall be sent to the client, her designated representative if applicable, the CWCCI site, the State Designated Entity and the client's provider.
2. The notification shall include information regarding appeal rights described in 10 C.C.R. 2505-10, Section 8.057.
8.715.6.C. The Department shall notify clients who no longer meet the BCCP eligibility criteria at least ten days prior to program termination.
8.715.7BENEFITS
8.715.7.A. Eligible clients shall receive all Medicaid benefits included in the State Plan.
8.715.7.B. Breast reconstructive surgery shall be a covered benefit when completed up to seven months following a mastectomy.
8.715.7.C. Breast or cervical cancer or precancerous treatment provided prior to the NBCCED program implementation or client enrollment into the BCCP is not a covered benefit.
8.715.7.D. Clients eligible for this program shall receive all mental health services through the Mental Health Assessment Service Agency of the county in which the client resides.
8.715.8ROLES/RESPONSIBILITIES
8.715.8.A. County Departments of Human/Social Services shall:
1. Assist in providing information to the client about services and benefits available through the program;
2. Assist the client in accessing health care services or contact the appropriate agencies for services, such as the enrollment broker, mental health provider and transportation provider;
3. Assist the client in applying for and accessing other benefits for which she may qualify, such as home care allowance, food stamps and financial assistance; and
4. Assist the Department by notifying the Department when a client's eligibility status changes.
8.715.8.B. Clients shall notify the Department and healthcare providers if the client receives creditable coverage or if a third party is responsible for illness or injury to the client.
8.715.8.C. Providers shall respond to inquiries from the Department and provide information required to verify the client's In Need of Treatment status within ten calendar days of the Department's request.
8.715.8.D. Provider's shall follow Medicaid billing instructions and obtain prior authorizations when necessary.
8.715.8.E. The State Designated Entities shall have the following responsibilities:
1. To determine whether a client is eligible for Medicaid in any other eligibility group;
2. To complete review of the Medicaid application form within fifteen days of receipt;
3. To notify the client she has thirty days to submit addition information if needed and if the information is not received the client will be found ineligible;
4. To inform the client of her appeal rights if eligibility is denied; and
5. To disenroll the client from the BCCP when notified the client is no longer in Need of Treatment.

10 CCR 2505-10-8.715