10 Colo. Code Regs. § 2505-10-8.754

Current through Register Vol. 47, No. 11, June 10, 2024

Section 10 CCR 2505-10-8.754 - CLIENT CO-PAYMENT

8.754.1CLIENT RESPONSIBILITY

Clients shall be responsible for the following co-payments:

8.754.1.A. Hospital outpatient, $0.00 per visit, effective July 1, 2023.

8.754.1.B. Physician (M.D. or D.O) office or home visit, $0.00 per visit, effective July 1, 2023.

8.754.1.C. Rural health clinic, $0.00 per visit, effective July 1, 2023.

8.754.1.D. Brief, individual, group and partial care community mental health center visits except services which fall under Home and Community Based Service programs, $0.00 per visit, effective July 1, 2023.

8.754.1.E. Pharmacy, $0.00 per prescription or refill, effective July 1, 2023.

8.754.1.F. Optometrist, $0.00 per visit, effective July 1, 2023.

8.754.1.G. Podiatrist, $0.00 per visit, effective July 1, 2023.

8.754.1.H. Inpatient hospital, $0.00 per admission, July 1, 2023.

8.754.1.I. Durable medical equipment/disposable supply services, $0.00 per date of service, effective July 1, 2023.

8.754.1.J. Laboratory services, $0.00 per date of service, July 1, 2023.

8.754.1.K. Radiology services, $0.00 per date of service, July 1, 2023.

8.754.1.L. Emergency services, $0.00 co-pay.

1. For services that continue to have a co-pay under Section 8.754.2, it is the provider's responsibility to identify emergency on the claim form so that the fiscal agent can exempt the service from co-payment.

8.754.2NON-EMERGENCY SERVICES

Effective July 1, 2022, non-emergency services rendered in the hospital outpatient emergency room are subject to a $8.00 co-payment, in compliance with 42 U.S.C. 1396o (2021), per visit.

8.754.2.A. Providers may not assess a $6.00 co-payment for non-emergency services provided in the emergency room unless they have first:

1. Determined that the medical condition does not meet the threshold for emergency care services, as defined at 10 C.C.R. 2505-10, Section 8.300.1.I;

2. Informed the client that the condition does not require emergency care services;

3. Informed the client of the amount of their cost sharing obligation for non-emergency services provided in the emergency room;

4. Provided the client with the name and location of an available and accessible alternative non-emergency services provider; and

5. Determine that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is otherwise exempt from cost sharing; and

6. Provide a referral to coordinate scheduling for treatment by the alternative provider.

8.754.3EMERGENCY TREATMENT

Prescription drugs administered during emergency treatment shall be considered part of the treatment and are not subject to co-payment.

8.754.4PRESCRIPTIONS

All prescriptions written in the emergency room or elsewhere are subject to the co-payment set forth in Paragraph 8.754.1.E. above.

8.754.5EXEMPTIONS

The following clients and services are exempt from co-payment requirements:

8.754.5.A. Children under the age of 19.

8.754.5.B. All services to women in the maternity cycle.

1. The maternity cycle means pregnancy, labor, birth and the immediate postpartum period not to exceed six weeks.

2. The client must inform the provider of her pregnancy or postpartum condition at the time of service, and all providers must indicate pregnancy on the claim form in order to claim this exemption.

3. In the case of prescription drugs, the prescribing physician should note pregnancy or postpartum on the prescription.

4. Providers may request oral or written verification of pregnancy or postpartum condition by contacting the physician.

5. If the provider questions the client's statement that she is pregnant or postpartum and the provider is unable to obtain verification of the pregnancy or postpartum condition, then the provider may collect the co-payment amount imposed by this regulation from the recipient.

6. If the recipient feels that she has been wrongly denied an exemption due to an unverified pregnancy or postpartum condition, she has the right of appeal through the recipient appeal process set forth at 10 C.C.R. 2505-10, Section 8.057.

8.754.5.C. All services to institutionalized clients, including those in skilled nursing facilities, intermediate care facilities (ICF's), ICF's for the mentally retarded, recipients under age 21 in inpatient psychiatric hospitals, and recipients 65 and over in institutions for mental diseases.

8.754.5.D. Family planning services and supplies furnished to clients of child-bearing age. The fiscal agent shall identify the family planning services and supplies exempted on the Medicaid claim form.

8.754.5.E. All emergency care services.

1. Emergency care services is defined in Section 8.300.1.I.

2. Emergency treatment can be given in the emergency room, the outpatient department, or a physician's office.

3. The attending medical personnel shall define the emergent nature of the recipient's condition.

4. For cases where it is not clear if an emergency exists, a triage of the member will be conducted to determine if the member's condition meets the threshold for emergency care services, as defined in Section 8.300.1.I.

5. There shall be no co-payment charge for the triage.

8.754.5.F. All services provided under the Community Mental Health Services program and Managed Care programs.

8.754.5.G All preventive and vaccine services as required by the Affordable Care Act (42 USC § 1396d(a)(13) (2010)) and described in the United States Preventive Services Task Force (USPSTF) A and B recommendations and the Advisory Committee for Immunization Practices (ACIP) recommended vaccines and their administration which are hereby incorporated by reference. The incorporation of the USPSTF A and B recommendations and the ACIP recommended vaccines excludes later amendments to, or editions of, the referenced material. The USPSTF A and B recommendations is available from the US Preventive Services Task Force web page at http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm. The ACIP recommended vaccines is available at the Centers for Disease Control and Prevention webpage at http://www.cdc.gov/vaccines/hcp/acip-recs/. 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: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

8.754.6PROVIDERS

8.754.6.A. The co-payment amount charged by a provider shall not vary depending on the cost of the specific service being rendered.

8.754.6.B. A provider may not deny services to an individual when such clients are unable to immediately pay the co-payment amount. However, the client remains liable for the co-payment at a later date.

8.754.6.C. Providers shall bill their usual and customary charge. For any service for which a co-payment amount is imposed, the fiscal agent shall deduct the appropriate co-payment amount from the payment to the provider.

8.754.6.D. Physicians providing laboratory or radiology services in their office shall be responsible for collecting co-payments for the office visit and for the laboratory or radiology services provided.

10 CCR 2505-10-8.754

46 CR 06, March 25, 2023, effective 2/10/2023

46 CR 10, May 25, 2023, effective 6/15/2023

46 CR 13, July 10, 2023, effective 6/9/2023 (EMRGENCY)

46 CR 17, September 10, 2023, effective 9/30/2023