10 Colo. Code Regs. § 2505-10-8.731
Current through Register Vol. 47, No. 24, December 25, 2024
Section 10 CCR 2505-10-8.731 - WOMEN'S HEALTH SERVICES8.731.1DefinitionsBRCA means a mutation in breast, ovarian, tubal, or peritoneal cancer susceptibility genes. The mutation may be either BRCA1 or BRCA2.
BRCA Screening means to assess whether a client has a documented biological family history of breast, ovarian, tubal, or peritoneal cancer that may be associated with an increased risk for potential mutation in breast cancer susceptibility genes (BRCA1 and BRCA2).
Sterile/Sterility means permanently rendered incapable of reproducing.
8.731.2Client Eligibility8.731.2.A. All female and transgender Medicaid clients are eligible for women's health services.8.731.3.Provider Eligibility8.731.3.A. All Colorado Medicaid enrolled providers are eligible to provide women's health services when it is within the scope of the provider's practice.8.731.4.Covered Services8.731.4.A. Women's Health Services are covered when medically necessary, as defined at Section 8.076.1.8, and within the limitations described in this section 8.731 and under 10 CCR 2505-10 as applicable.8.731.4.B. All services are covered as often as clinically indicated, unless otherwise restricted under this rule.8.731.4.C. The following services are covered: 1. Annual gynecological exam2. Cervical cancer screening and follow-upa. Cervical cancer screenings are only covered once per state fiscal year, unless clinical indication requires additional screening. b. Further diagnostic and treatment procedures are covered as clinically indicated.3. Sexually transmitted disease/infection testing, risk counseling, and treatment4. Human Papillomavirus (HPV) vaccination a. HPV vaccination is only covered for clients ages 9 through 26. b. For clients ages 9 through 18 who are covered through the Vaccines for Children program, only the administration of the vaccine is covered in accordance with 8.200.3.C.2.c. For clients ages 19 through 26, the administration of the vaccine and the vaccine are covered in accordance with 8.200.3.C.2.5. BRCA screening, genetic counseling, and testing a. BRCA screening, genetic counseling, and testing is only covered for clients over the age of 18.b. BRCA screening is covered and must be conducted prior to any BRCA-related genetic testing.c. The provider shall make genetic counseling available to clients with a positive screening both before and after genetic testing, if the provider is able, and genetic counseling is within the provider's scope of practice. If the provider is unable to provide genetic counseling, the provider shall refer the client to a genetic counselor.d. Genetic testing for breast cancer susceptibility genes BRCA1 and BRCA2 is covered for clients with a positive screening.6. Mammographya. Mammography is covered for clients who are age 40 and older; or, have been clinically assessed as at high risk for, or have a history of, breast disease.7. Mastectomy a. Mastectomy is covered for women who have a positive genetic test as a BRCA mutation carrier. b. Bilateral mastectomy is a covered benefit when there is a known breast disease in either breast.c. Prophylactic bilateral mastectomy is a covered benefit for women who have tested positive for the BRCA1 or BRCA2 mutation or have a personal history of breast disease.d. For clients who have undergone a mastectomy, a maximum of two mastectomy brassieres are covered per year.8. Breast reconstruction is covered within five years of a mastectomy.9. Breast reduction procedures are covered for clients with macromastia and there is a documented failure of alternative treatment for macromastia.10. Hysterectomya. Hysterectomy is covered when performed solely for medical reasons and when all of the following conditions are met: i) The client is over the age of 20, or is a BRCA1 or BRCA2 carrier over the age of 18;ii) The person who secures the authorization to perform the hysterectomy has informed the client, or the client's authorized representative, as defined in Section 8.057.1, orally and in writing that the hysterectomy will render the client Sterile;iii) The client, or the client's authorized representative, as defined in Section 8.057.1, has acknowledged in writing, that the client or representative has been informed the hysterectomy will render the client Sterile; andiv) The Department or its designee has been provided with a copy of the written acknowledgment under 8.731.4.C.10.a.iii. The acknowledgement must be received by the Department or its designee before reimbursement for any services related to the procedure will be made. b. A written acknowledgment of Sterility from the client is not required if either of the following circumstances exist: i) The client is already Sterile at the time of the hysterectomy; or,ii) The client requires a hysterectomy because of a life-threatening emergency in which the physician determines prior acknowledgement is not possible.c. If an acknowledgement of Sterility is not required because of the 8.731.4.C.10.b exceptions, the physician who performs the hysterectomy shall certify in writing that either: i) The client was already Sterile, stating the cause of that sterility; or,ii) The hysterectomy was performed under a life-threatening emergency situation in which the physician determined prior acknowledgement was not possible. The physician must include a description of the emergency.d. The Department or its designee must be provided with a copy of the physician's written certificate under 8.731.4.C.10.c. The acknowledgement must be received by the Department or its designee before reimbursement for any services related to the procedure will be made.8.731.5Non-Covered Services8.731.5.A. Prophylactic bilateral mastectomy is not covered when: 1. There is no known breast disease present or personal history of breast disease, or,2. The client does not test positive for the BRCA1 or BRCA2 mutation.8.731.5.B. Hysterectomy for the sole purpose of sterilization. 1. If more than one purpose for the hysterectomy exists, but the purpose of sterilization is primary, the hysterectomy is not a covered service.8.731.5.C. Routine BRCA genetic testing for clients whose family history is not associated with an increased risk of BRCA gene mutation is not covered.8.731.6.Prior Authorization8.731.6.A. All breast reconstruction and reduction procedures require prior authorization.8.731.6.B. All BRCA genetic testing requires prior authorization.