10 Colo. Code Regs. § 2505-3-210

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Current through Register Vol. 47, No. 18, September 25, 2024

Section 10 CCR 2505-3-210 - The following are covered benefits including any applicable limitations:

A. Emergency Care and Urgent/After Hours Care;

B. Emergency Transport/Ambulance Services;

C. Hospital/Other Facility Services Including:

1. Inpatient;

2. Physician;

3. Outpatient/Ambulatory;

D. Medical Office Visits Including:

1. Physician;

2. Mid-Level Practitioner;

3. Specialist;

E. Diagnostic Services;

F. Preventative, Routine and Family Planning Services Including:

1. Immunizations;

2. Well-child visits;

3. Health maintenance visits;

G. Maternity Care Including:

1. Prenatal;

2. Delivery and inpatient well-baby care;

3. Postpartum care

4. Lactation Services & Support

H. Mental Illness Treatments such as:

1. Neurobiologically-based mental illness

2. Mental disorders

3. All other mental illness;

I. Physical Therapy, Speech Therapy and Occupational Therapy shall be limited to 30 visits per diagnosis per year. Effective November 1, 2007, Physical, Speech and Occupational Therapy services shall be unlimited for children from birth up to the child's third birthday.

J. Durable Medical Equipment shall be limited to the lesser of the purchase price or rental price for medically necessary durable medical equipment that shall not exceed two thousand dollars per year.

K. Transplants must be medically necessary and are limited to:

1. Liver;

2. Heart;

3. Heart/lung;

4. Cornea;

5. Kidney;

6. Bone marrow which shall be limited to the following conditions:

a. Aplastic anemia;

b. Leukemia;

c. Immunodeficiency disease;

d. Neuroblastoma;

e. Lymphoma;

f. High risk stage II and III breast cancer;

g. Wiskott aldrich syndrome;

7. Peripheral stem cell support which shall be limited to the following conditions:

a. Aplastic anemia;

b. Leukemia;

c. Immunodeficiency disease;

d. Neuroblastoma;

e. Lymphoma;

f. High risk stage II and III breast cancer;

g. Wiskott aldrich syndrome;

L. Home health care;

M. Hospice care;

N. Prescription medication;

O. Kidney dialysis shall be excluded only if the member is also eligible for Medicare;

P. Skilled nursing facility care must be provided only when there is a reasonable expectation of measurable improvement in the members' health status.

Q. Vision services shall be limited to:

1. Vision screenings for age appropriate preventative care;

2. Referral required for refraction services;

3. Minimum fifty dollar benefit for eyeglasses;

R. Audiology services shall be limited to:

1. Hearing screenings for age appropriate preventative care;

2. Hearing aids without financial limitation for enrollees age 18 and under no more than once every five years unless medically necessary including:

a. A new hearing aid when alterations to the existing hearing aid cannot adequately meet the needs of the child

b. Services and supplies including, but not limited to, the initial assessment, fitting, adjustments, and auditory training that is provided according to accepted professional standards.

S. Intractable pain;

T. Gender-affirming care (see 10 CCR 2505-10, 8.735)

U. Case management is covered only when medically necessary;

V. Dietary counseling/nutritional services shall be limited to:

1. Formula for metabolic disorders;

2. Total parenteral nutrition;

3. Enterals and nutrition products;

4. Formulas for gastrostomy tubes;

W. Dental services are limited to:

1. Those dental services described in the Children's Basic Health Plan dental Evidence of Coverage booklet provided to enrollees, who are less than nineteen years of age. Beginning October 1, 2019, the dental services listed below are covered benefits for enrolled pregnant women of any age, excepting Limited Orthodontic services under Section 210.W.1.h for pregnant women age nineteen and above. Children's Basic Health Plan dental services are provided by the dental MCO (or its designee) with which the Department has contracted for the applicable plan year to provide the following dental services;

a. Diagnostic

b. Preventive

c. Restorative

d. Endodontic

e. Periodontic

f. Prosthodontic

g. Oral and Maxillofacial Surgery

h. Limited Orthodontic, excepting pregnant women age nineteen and above.

i. Adjunctive General Services

2. Orthodontic and prosthodontic treatment for cleft lip or cleft palate in newborns (covered as a medical service in accordance with section 10-16-104, C.R.S.); and

3. Treatment of teeth or periodontium required due to accidental injury to naturally sound teeth (covered as a medical service in accordance with section 10-16-104, C.R.S.). A physician or legally licensed dentist must perform treatment within 72 hours of the accident.

X. Therapies covered shall include:

1. Chemotherapy;

2. Radiation;

Y. The following are not covered benefits:

1. Acupuncture;

2. Artificial conception;

3. Biofeedback;

4. Storage Costs for umbilical blood;

5. Chiropractic care;

6. Convalescent care or rest cures;

7. Cosmetic surgery;

8. Custodial care;

9. Domiciliary care;

10. Duplicate coverage;

11. Government institution or facility services;

12. Hair loss treatments;

13. Hypnosis;

14. Infertility services;

15. Maintenance therapy;

16. Nutritional therapy unless specified otherwise;

17. Elective termination of pregnancy, unless the elective termination is to save the life of the mother or if the pregnancy is the result of an act of rape or incest;

18. Personal comfort items;

19. Physical exams for employment or insurance;

20. Private duty nursing services;

21. Routine foot care;

22. Taxes;

23. Temporomandibular joint (TMJ) treatment, unless it has a medical basis;

24. Other therapies and treatments which are not medically necessary;

25. Vision services unless specified otherwise;

26. Vision therapy;

27. War-related conditions;

28. Weight-loss programs;

29. Work-related conditions;

10 CCR 2505-3-210

38 CR 11, June 10, 2015, effective 7/1/2015

40 CR 03, February 10, 2017, effective 3/2/2017

40 CR 17, September 10, 2017, effective 9/30/2017

40 CR 19, October 10, 2017, effective 10/30/2017

41 CR 19, October 10, 2018, effective 10/30/2018

42 CR 18, October 10, 2019, effective 10/1/2019

42 CR 23, December 10, 2019, effective 12/30/2019

43 CR 11, June 10, 2020, effective 5/8/2020

43 CR 17, September 10, 2020, effective 9/4/2020

44 CR 01, January 10, 2021, effective 12/11/2020

44 CR 17, September 10, 2021, effective 8/9/2021

44 CR 23, December 10, 2021, effective 11/12/2021

45 CR 03, February 10, 2022, effective 3/10/2022

45 CR 07, April 10, 2022, effective 3/11/2022

45 CR 11, June 10, 2022, effective 6/30/2022

45 CR 15, August 10, 2022, effective 7/8/2022

45 CR 22, November 25, 2022, effective 10/14/2022

45 CR 19, October 10, 2022, effective 10/30/2022

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

46 CR 07, April 10, 2023, effective 4/30/2023

46 CR 11, June 10, 2023, effective 5/12/2023

46 CR 19, October 10, 2023, effective 10/30/2023