10 Colo. Code Regs. § 2505-10-8.900-A
A. Client Copayments - General Policies
A Client is responsible for paying a portion of his or her medical bills. The Client's portion is called the Client Copayment. Qualified Health Care Providers are responsible for charging the Client a copayment. Qualified Health Care Providers may require Clients to pay their copayment prior to receiving care (except for Emergency Care). Qualified Health Care Providers may charge copayments in accordance with the Standard Client Copayment Table or an alternate sliding fee scale that is submitted by the provider with the annual application for the CICP and approved by the Department.
Percent of FPL | 0 - 40% and Homeless | 0 -40% | 41 -62% | 63 -81% | 82 - 100% | 101 -117% | 118 -133% | 134 - 159% | 160 - 185% | 186 -200% | 201 -250% |
Ambulatory Surgery | $0 | $15 | $65 | $105 | $155 | $220 | $300 | $390 | $535 | $600 | $630 |
Inpatient Facility | $0 | $15 | $65 | $105 | $155 | $220 | $300 | $390 | $535 | $600 | $630 |
Hospital Physician | $0 | $7 | $35 | $55 | $80 | $110 | $150 | $195 | $270 | $300 | $315 |
Emergency Room | $0 | $15 | $25 | $25 | $30 | $30 | $35 | $35 | $45 | $45 | $50 |
Emergency Transportation | $0 | $15 | $25 | $25 | $30 | $30 | $35 | $35 | $45 | $45 | $50 |
Outpatient Hospital Services | $0 | $7 | $15 | $15 | $20 | $20 | $25 | $25 | $35 | $35 | $40 |
Clinic Services | $0 | $7 | $15 | $15 | $20 | $20 | $25 | $25 | $35 | $35 | $40 |
Specialty Outpatient | $0 | $15 | $25 | $25 | $30 | $30 | $35 | $35 | $45 | $45 | $50 |
Prescription | $0 | $5 | $10 | $10 | $15 | $15 | $20 | $20 | $30 | $30 | $35 |
Laboratory | $0 | $5 | $10 | $10 | $15 | $15 | $20 | $20 | $30 | $30 | $35 |
Basic Radiology & Imaging | $0 | $5 | $10 | $10 | $15 | $15 | $20 | $20 | $30 | $30 | $35 |
High-Level Radiology & Imaging | $0 | $30 | $90 | $130 | $185 | $250 | $335 | $425 | $580 | $645 | $680 |
There are different copayments for different service charges. The following information explains the different types of medical care charges and the related Client Copayments under the Standard Client Copayment Table.
1. Inpatient facility charges are for all non-physician (facility) services received by a Client while receiving care in the hospital setting for a continuous stay of 24 hours or longer.
2. Ambulatory Surgery charges are for all non-physician (facility) Ambulatory Surgery operative procedures received by a Client who is admitted to and discharged from the hospital setting on the same day. The Client is also responsible for the corresponding Hospital Physician charges.
3. Hospital Physician charges are for services provided directly by a physician in the hospital setting, including inpatient, ambulatory surgery, and emergency room care.
4. Clinic Services charges are for all non-physician (facility) and physician services received by a Client while receiving care in the outpatient clinic setting. Outpatient charges include primary and preventive medical care. This charge does not include radiology or laboratory services performed at the clinic.
5. Emergency Room charges are for all non-physician (facility) services received by a Client while receiving Emergency Care or Urgent Care in the hospital setting for a continuous stay less than 24 hours (i.e., emergency room care).
6. Specialty Outpatient charges are for all non-physician (facility) and physician services received by a Client while receiving care in the specialty outpatient setting. These services can be provided in standalone clinics and outpatient hospital settings. Specialty Outpatient charges include distinctive medical care (i.e., oncology, orthopedics, hematology, pulmonary) that is not normally available as primary and preventive medical care. Specialty Outpatient charges do not include radiology, laboratory, emergency room, or ambulatory surgery services provided in a hospital setting.
7. Emergency Transportation charges are for transportation provided by an ambulance.
8. Laboratory Service charges are for all laboratory tests received by a Client while receiving care in the outpatient hospital or clinic setting. Laboratory Service charges may not be charged in addition to charges for emergency room or inpatient services provided in the hospital setting.
9. Basic Radiology and Imaging Service charges are for all radiology and imaging services received by a Client while receiving care in the outpatient hospital or clinic setting. Basic Radiology and Imaging Service charges may not be charged in addition to charges for emergency room or inpatient services provided in the hospital setting.
10. Prescription charges are for prescription drugs received by a Client at a Qualified Health Care Provider's pharmacy as an outpatient service. To encourage the availability of discounted prescription drugs, providers are allowed to modify (increase or decrease) the Prescription Copayment with the written approval of the Department.
11. High-Level Radiology and Imaging Service charges are for Clients receiving a Magnetic Resonance Imaging, Computed Tomography, Positron Emission Tomography or other Nuclear Medicine services, Sleep Studies, or Catheterization Laboratory in the outpatient hospital, emergency room, or clinic setting.
12. Outpatient Hospital Service charges are for all non-physician (facility) and physician services received by a Client while receiving non-Emergency Care or non-Urgent Care in the outpatient clinic setting. Outpatient Hospital Services charges include primary and preventive medical care. This charge does not include radiology, laboratory, emergency room, or ambulatory surgery services provided in a hospital setting.
13. Clients who are seen in the hospital setting in an observation bed should be charged the emergency room copay if their stay is less than 24 hours and the inpatient facility copay if their stay is 24 hours or longer.
B. Homeless Clients, Clients living in transitional housing, "doubled-up" Clients, or recipients of Colorado's Aid to the Needy Disabled financial assistance program, who are at or below 40% of the federal poverty guideline are exempt from Client Copayments.
1. Homeless Clients are exempt from Client Copayments, the income verification requirement, and providing proof of residency when completing the CICP application.
2. Transitional housing is designed to assist individuals in becoming self-supporting. Clients living in transitional housing must provide a written statement from their counselor or program director asserting that they are participating in a transitional housing program. Transitional housing Clients are exempt from the income verification requirement when completing the CICP application.
3. Clients who have no permanent housing of their own and who are temporarily living with a person who has no legal obligation to financially support the Client are considered doubled-up. The individual allowing the Client to reside with him or her may be asked to provide a written statement confirming that the Client is not providing financial assistance to the household and that the living arrangement is not intended to be permanent.
4. Recipients of Colorado's Aid to the Needy Disabled financial assistance program are exempt from Client Copayments, and the income verification requirement when completing the CICP application.
C. Client Annual Copayment Cap
1. Homeless Clients whose financial determination is between 0 and 40% of the federal poverty guideline are exempt from copayments, so their copayment cap is $0. Clients whose financial determination is between 0 and 40% of the federal poverty guideline who are not homeless have a copayment cap that is the lesser of 10% of the family's net income or $120. Clients who are also Old Age Pension Health and Medical Care Program clients have a copayment cap of $300 as mandated by Section 8.941.10. For all other CICP Clients, annual copayments shall not exceed 10% of the family's financial determination.
2. Clients who are also Old Age Pension Health and Medical Care Program clients have annual copayment caps based on a calendar year. All other Client annual copayment caps (annual caps) are based on the Client's date of eligibility.
3. Clients are responsible for any charges incurred prior to the determination of the Client's financial eligibility.
4. Clients are responsible for tracking their CICP copayments and informing the provider in writing, including documentation, within 90 days after meeting or exceeding their annual cap. If a Client overpays the annual cap and informs the Qualified Health Care Provider of that fact in writing, the Qualified Health Care Provider shall reimburse the Client for the overpayment.
5. A CICP Client is eligible to receive a new determination if his or her financial or family situation has changed since the initial financial determination. CICP copayments made under the prior financial determination will not count toward a new CICP copayment cap and the Client's annual copayment cap resets when the Client completes a new application.
6. An annual cap applies only to charges incurred after a Client is eligible to receive discounted health care services and applies only to discounted services incurred at a CICP Qualified Health Care Provider, including services discounted under Hospital Discounted Care.
D. The Client must pay the lower of the copayment listed, the patient responsibility portion if the Client is insured, or actual charges. Payment plans must be offered to Clients and must follow the requirements set forth in Section 8.923 of the Hospital Discounted Care rule.
E. Clients shall be notified at or before time of services rendered of their copayment responsibility and available payment plan option.
F. Grants from foundations to Clients from non-profit, tax exempt, charitable foundations specifically for Client copayments are not considered other medical insurance or income. The provider shall honor these grants and may not count the grant as a resource or income.
10 CCR 2505-10-8.900-A