10 Colo. Code Regs. § 2505-10-8.902
Current through Register Vol. 47, No. 24, December 25, 2024
Section 10 CCR 2505-10-8.902 - PROVISIONS APPLICABLE TO QUALIFIED HEALTH CARE PROVIDERSA. Requirements for Qualified Health Care Providers 1. Agreements will be made annually between the Department and Qualified Health Care Providers through an application process.2. Agreements may be executed with Hospital Providers throughout Colorado that meet the following requirements: a. Licensed or certified as a general hospital or birth center by the Department of Public Health and Environment.b. Hospital Providers shall provide Emergency Care to all Clients throughout the Program year at discounted rates.c. Hospital Providers shall have at least two obstetricians with staff privileges at the Hospital Provider who agree to provide obstetric services to individuals under Medicaid. In the case where a Hospital Provider is located in a rural area (that is, an area outside of a metropolitan statistical area, as defined by the Executive Office of Management and Budget), the term "obstetrician" includes any physician with staff privileges at the Hospital Provider to perform non-emergency obstetric procedures. This requirement does not apply to a Hospital Provider in which the inpatients are predominantly under 18 years of age or which does not offer non-emergency obstetric services as of December 21, 1987.
d. Using the information submitted by an Applicant and the Uniform Application developed and distributed by the Department, the Qualified Health Care Provider shall determine whether the Applicant meets all requirements to receive discounted health care services under the Program. Eligibility shall be determined at the time of application, unless required documentation is not available, in which case the Applicant will be notified of the missing documentation within three business days. An eligibility determination shall be made within 14 calendar days of receipt of the missing documents. Hospital Providers shall determine Client financial eligibility using the following information: I. Income from each Applicant age 18 and older;II. Household size, where all non-spouse or civil union partner, non-student adults ages 18 to 64 included on the application must have financial support demonstrated or attested to.i. An applicant must include their spouse or civil union partner in their household for purposes of the application.ii. Any additional person living at the same address as the applicant may also be included in the household.iii. An applicant may include household members who live in other states or countries if the applicant attests that they provide at least 50% of the household member's support.e. Hospital Providers shall use the Sliding Fee Scale developed by the Department or submit for Department approval with their annual application a Sliding Fee Scale that shows copayments for different service categories divided into at least three income tiers covering 0 to 250% of the federal poverty guideline. Copayments shall be expressed in dollar amounts and shall not exceed the copayments in the Standard Client Copayment Table found in Appendix A. Hospital Providers shall inform Applicants and Clients of their copayment responsibilities at the time their application is approved.f. Hospital Providers shall submit Program utilization and charge data in a format and timeline determined by the Department.3. Agreements may be executed with Clinic Providers throughout Colorado that meet the following minimum criteria:a. Licensed or certified as a community health clinic by the Department of Public Health and Environment or certified by the U.S. Department of Health and Human Services as a federally qualified health center or rural health clinic.b. Using the information submitted by an Applicant, the provider shall use the application developed and distributed by the Department to determine whether the Applicant meets all requirements to receive discounted health care services under the Program. Clinic Providers may develop their own application and submit it to the Department for approval. Eligibility shall be determined at the time of application, unless required documentation is not available, in which case the Applicant will be notified of the missing documentation within three business days. An eligibility determination shall be made within 14 calendar days of receipt of the missing documents. Clinic Providers who are federally qualified health centers shall determine Client financial eligibility as required under federal regulations and guidelines. Clinic Providers who are not federally qualified health centers shall determine Client financial eligibility using the following information: I. Income from each Applicant age 18 and older, andc. Clinic Providers shall submit a Sliding Fee Scale for Department approval with their annual application that shows copayments for different service categories. Copayments for Clients between 0 and 100% of the federal poverty guideline shall be nominal or $0. Sliding Fee Scales shall have at least three tiers between 101 and 250% of the federal poverty guideline. I. Sliding fee scales used by federally qualified health centers approved by the federal government meet all requirements of the Program.II. Copayments for Clients between 101 and 250% of the federal poverty guideline may not be less than the copayments for Clients between 0 and 100% of the federal poverty guideline.III. The same sliding fee scale shall be used for all Clients eligible for the Program.IV. Sliding fee scales shall be reviewed by the Qualified Health Care Provider on a regular basis to ensure there are no barriers to care.d. Clinic Providers shall inform Applicants and Clients of their copayment responsibilities at the time their application is approved.4. Qualified Health Care Providers shall provide the Applicant and/or representative a written notice in the Applicant's preferred language of the provider's determination as to the Applicant's eligibility to receive discounted services under the Program. If eligibility to receive discounted health care services is granted by the Qualified Health Care Provider, the notice shall include the dates of eligibility and the Applicant's copay responsibilities. If eligibility to receive discounted health care services is denied, the notice shall include a brief, plain language explanation of the reason(s) for the denial. Every notice of the Qualified Health Care Provider's decision, whether an approval or a denial, shall include an explanation of the Applicant's appeal rights found at Section 8.902.B in these regulations.5. Qualified Health Care Providers shall screen all Applicants for eligibility for Medicaid and the Children's Basic Health Plan and refer Applicants to those programs if they appear eligible. The Qualified Health Care Provider shall refer Applicants to Colorado's health insurance marketplace for information about private health insurance.6. Qualified Health Care Providers shall not discriminate against Applicants or Clients based on race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or disability.B. Client Appeals 1. If an Applicant or Client feels that a financial determination or denial is in error, he or she shall only challenge the financial determination or denial by filing an appeal with the Qualified Health Care Provider who determined eligibility to receive discounted health care services under the CICP pursuant to this Section 8.902. There is no appeal process available through the Office of Administrative Courts.2. Instructions for Filing an Appeal The Qualified Health Care Provider shall inform the Applicant or Client that he or she has the right to appeal the financial determination or denial if he or she is not satisfied with the Qualified Health Care Provider's decision.
An Applicant or Client who wishes to appeal a denial must:
a. Submit a letter requesting appeal within 30 calendar days of the date of the denial notice. Appeals submitted after the deadline may be denied for being submitted untimely;b. Enclose any supporting documentation; If no denial notice is received earlier, an appeal letter may be submitted within 45 calendar days of the date the application was completed. The deadline for an appeal letter may be extended for good cause.
3. Appeals a. An Applicant or Client may file an appeal if he or she wishes to challenge the accuracy of his or her initial financial determination.b. Each Qualified Health Care Provider must designate a manager to review appeals and supporting documentation.c. If the initial financial determination is found to be inaccurate, the financial determination will be corrected, with eligibility effective retroactive to the initial effective date of application.d. A decision shall be issued to the Applicant or Client and the Department in writing within 15 calendar days following receipt of the appeal request.4. Provider Management Exceptiona. An Applicant or Client may request a provider management exception simultaneously with an appeal, or within 15 calendar days of the date of the Qualified Health Care Provider's decision regarding an appeal.b. A provider management exception may be granted at the Qualified Health Care Provider's discretion if the Applicant or Client can demonstrate that there are circumstances that should be taken into consideration when establishing the household financial status.c. Each Qualified Health Care Provider must designate a manager to review provider management exceptions and supporting documents. I. The facility shall notify the Client in writing of the Qualified Health Care Provider's findings within 15 calendar days of receipt of the Client's written request.II. The Qualified Health Care Provider must note provider management exceptions on the application.d. A financial determination from a provider management exception is effective as of the initial effective date of application.e. Qualified Health Care Providers are not required to honor provider management exceptions granted by other Qualified Health Care Providers.C. Financial Eligibility General Rule: An Applicant shall be financially eligible for discounted health care services under the CICP if their household income is no more than 250% of the current federal poverty guidelines for a household of that size.
1. Qualified Health Care Providers determine eligibility for the CICP and shall maintain auditable files of applications for discounted health care services under the CICP until June 30 of the seventh state fiscal year following the eligibility determination.2. The determination of financial eligibility process looks at the financial circumstances of a household as of the date that an application is started.3. All Qualified Health Care Providers must accept each other's CICP financial determinations unless the Qualified Health Care Provider believes that the financial determination was determined incorrectly, the Qualified Health Care Provider's financial determination process is materially different from the process used by the issuing Qualified Health Care Provider, or that the financial determination was a result of a provider management exception.4. CICP eligibility is retroactive for services received from a Qualified Health Care Provider up to 181 days prior to application.5. Documentation concerning the Applicant's financial status shall be maintained by the provider until June 30 of the seventh state fiscal year following the eligibility determination.6. Beyond the distribution of available funds made by the CICP, allowable Client copayments, and other third-party sources, a provider shall not seek payment from a Client for the provider's CICP discounted health care services to the Client.7. Emergency Application for Providers a. In emergency circumstances, an Applicant may be unable to provide all of the information or documentation required by the usual application process. For emergency situations, the Qualified Health Care Provider shall follow these steps in processing the application: I. Use the regular application to receive discounted health care services under the CICP but indicate emergency application on the application.II. Ask the Applicant to give spoken answers to all questions and apply the federal poverty guideline based on the spoken information provided. If the Applicant appears eligible for Medicaid or CHP+, the Applicant will need to apply for the applicable program prior to being placed on CICP.III. Ask the Applicant to sign the application indicating their understanding of their \ eligibility determination in relationship to the federal poverty guideline made using their spoken information.b. An emergency application is good for only one episode of service in an emergency room and any subsequent service related to the emergency room episode. If the Client receives any care other than the emergency room visit, the Hospital Provider must request the Client to submit documentation to support all figures on the emergency application or complete a new application. If the documentation submitted by the Client does not support the earlier, spoken information, the Hospital Provider must obtain a new application from the Client. If the Client does not submit any supporting documentation or complete a new application upon the request of the provider, the provider shall use the information contained in the emergency application.D. Audit Requirements The Department will conduct audits of Qualified Health Care Providers. Qualified Health Care Providers shall comply with requests for data and other information from the Department. Qualified Health Care Providers shall complete corrective actions when required by the Department. The Department's intention is to audit one-third of the participating Qualified Health Care Providers each year. After any Qualified Health Care Provider discontinues participation in the program, the provider must maintain compliance with audit requirements for the records created during the period during which the Qualified Health Care Provider was participating.
E. HIPAA The CICP does not meet the definition of a covered entity or business associate under the Health Insurance Portability and Accountability Act of 1996 at 45 C.F.R. sec. 160.103. The CICP is not a part of the Colorado Medical Assistance Program, nor of Health First Colorado, Colorado's Medicaid program. CICP's principal activity is the making of grants to providers who serve eligible persons who are uninsured or underinsured. The state personnel administering the CICP will provide oversight in the form of procedures and conditions to ensure funds provided are being used to serve the target population, but they will not be significantly involved in any health care decisions or disputes involving a Qualified Health Care Provider or Client.
47 CR 11, June 10, 2024, effective 6/30/2024