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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

3 Blindness is defined in this volume as the total lack of vision or vision in the better eye of 20/200 or less with the use of a correcting lens and/or tunnel vision to the extent that the field of vision is no greater than 20 degrees. Burial Spaces are burial plots, gravesites, crypts, mausoleums, urns, niches and other customary and traditional repositories for the deceased's bodily remains provided such spaces are owned by the individual or are held for his or her use, including necessary and reasonable improvements or additions to or upon such burial spaces such as: vaults, headstones, markers, plaques, or burial containers and arrangements for opening and closing the gravesite for burial of the deceased. Burial Trusts are irrevocable pre-need funeral agreements with a funeral director or other entity to meet the expenses associated with burial for Medical Assistance applicants/recipients. The agreement can include burial spaces as well as the services of the funeral director. Caretaker Relative is a person who is related to the dependent child or any adult with whom the dependent child is living and who assumes responsibility for the dependent child’s care. Case Management Services are services provided by community mental health centers, clinics, community centered boards, and EPSDT case managers to assist in providing services to Medical Assistance clients in gaining access to needed medical, social, educational and other services. Cash Surrender Value is the amount the insurer will pay to the owner upon cancellation of the policy before the death of the insured or before maturity of the policy. Categorically Eligible means persons who are eligible for Medical Assistance due to their eligibility for one or more Federal categories of public assistance. CBMS - Colorado Benefits Management System is the computer system that determines an applicant’s eligibility for public assistance in the state of Colorado. CDHS -Colorado Department of Human Services is the state department responsible for administering the social service and financial assistance programs for Colorado.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

4 Children MAGI Medical Assistance group provides Medical Assistance coverage to tax dependents or otherwise eligible applicants through the end of the month that the individual turns 19 years old. Child Support Services is a CDHS program that assures that all children receive financial and medical support from each parent. This is accomplished by locating each parent, establishing paternity and support obligations, and enforcing those obligations. Citizen is a person who was born in the United States or who has been naturalized. Client is a person who is eligible for the Medical Assistance Program. “Client” is used interchangeably with “recipient” when the person is eligible for the program. CMS - Centers for Medicare and Medicaid Services is the Federal agency within the US Department of Health and Human Services that partners with the states to administer Medicaid and CHP+ via State Plans in effect for each State. Colorado is in Region VIII. CHP+ - Child Health Plan Plus is low-cost health insurance for Colorado's uninsured children and pregnant women. CHP+ is public health insurance for children and pregnant women who earn too much to qualify for The Medical Assistance Program, but cannot afford private health insurance. COLA - Cost of Living Adjustment is an annual increase in the dollar value of benefits made automatically by the United States Department of Health and Human Services or the state in OASDI, SSI and OAP cases to account for rises in the cost of living due to inflation. Colorado State Plan is a written statement which describes the purpose, nature, and scope of the Colorado’s Medical Assistance Program. The Plan is submitted to the CMS and assures that the program is administered consistently within specific requirements set forth in both the Social Security Act and the Code of Federal Regulations (CFR) in order for a state to be eligible for Federal Financial Participation (FFP). Common Law Marriage is legally recognized as a marriage in the State of Colorado under certain circumstances even though no legally recognized marriage ceremony is performed or civil marriage contract is executed. Individuals declaring or publicly holding

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

5 themselves out as a married couple through verbal or written methods may be recognized as legally married under state law. C.R.S. § 14-2-104(3). Community Centered Boards are private non-profit organizations designated in statute as the single entry point into the long-term service and support system for persons with developmental disabilities. Community Spouse is the spouse of an institutionalized spouse. Community Spouse Resource Allowance is the amount of resources that the Medical Assistance regulations permit the spouse staying at home to retain. Complete Application means an application in which all questions have been answered, which is signed, and for which all required verifications have been submitted. The Department is defined in this volume as the Colorado Department of Health Care Policy and Financing which is responsible for administering the Colorado Medical Assistance Program and Child Health Plan Plus programs as well as other State-funded health care programs. Dependent Child is a child who lives with a parent, legal guardian, caretaker relative or foster parent and is under the age of 18, or, is age 18 and a full-time student, and expected to graduate by age 19. Dependent Relative for purposes of this rule is defined as one who is claimed as a dependent by an applicant for federal income tax purposes. Difficulty of Care Payments is a payment to an applicant or member as compensation for providing live-in home care to an individual who qualifies for foster care or Home and Community Based Services (HCBS) waiver program and lives in the home of the care recipient. This additional care must be required due to a physical, mental, or emotional handicap. Disability means the inability to do any substantial gainful activity (or, in the case of a child, having marked and severe functional limitations) by reason of a medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of l2 months or more.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

6 Dual Eligible clients are Medicare beneficiaries who are also eligible for Medical Assistance. Earned Income is defined for purposes of this volume as any compensation from participation in a business, including wages, salary, tips, commissions and bonuses. Earned Income Disregards are the allowable deductions and exclusions subtracted from the gross earnings. Income disregards vary in amount and type, depending on the category of assistance. Electronic Data Source is an interface established with a federal or state agency, commercial entity, or other data sources obtained through data sharing agreements to verify data used in determining eligibility. The active interfaces are identified in the Department’s verification plan submitted to CMS. Eligibility Site is defined in this volume as a location outside of the Department that has been deemed by the Department as eligible to accept applications and determine eligibility for applicants. Employed means that an individual has earned income and is working part time, full time or is self-employed, and has proof of employment. Volunteer or in-kind work is not considered employment. EPSDT- Early Periodic Screening, Diagnosis and Treatment is the child health component of the Medical Assistance Program. It is required in every state and is designed to improve the health of low-income children by financing appropriate, medically necessary services and providing outreach and case management services for all eligible individuals. Equity Value is the fair market value of land or other asset less any encumbrances. Ex Parte Review is an administrative review of eligibility during a redetermination period in lieu of performing a redetermination from the client. This administrative review is performed by verifying current information obtained from another current aid program. Face Value of a Life Insurance Policy is the basic death benefit of the policy exclusive of dividend additions or additional amounts payable because of accidental death or other special provisions.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

7 Fair Market Value is the average price a similar property will sell for on the open market to a private individual in the particular geographic area involved. Also, the price at which the property would change hands between a willing buyer and a willing seller, neither being under any pressure to buy or to sell and both having reasonable knowledge of relevant facts. FBR - The Federal Benefit Rate is the monthly Supplemental Security Income payment amount for a single individual or a couple. The FBR is used by the Aged, Blind and Disabled Medical Assistance Programs as the eligibility income limits. FFP - Federal Financial Participation as defined in this volume is the amount or percentage of funds provided by the Federal Government to administer the Colorado Medical Assistance Program. FPL - Federal Poverty Level is a simplified version of the federal poverty thresholds used to determine financial eligibility for assistance programs. The thresholds are issued each year in the Federal Register by the Department of Health and Human Services (HHS). Good Cause is the client’s justification for needing additional time due to extenuating circumstances, usually used when extending deadlines for submittal of required documentation. Good Cause for Child Support is the specific process and criteria that can be applied when a client is refusing to cooperate in the establishment of paternity or establishment and enforcement of a child support order due to extenuating circumstances. HCBS are Home and Community Based Services are also referred to as “waiver programs”. HCBS provides services beyond those covered by the Medical Assistance Program that enable individuals to remain in a community setting rather than being admitted to a Long-Term Care institution. In-Kind Income is income a person receives in a form other than money. It may be received in exchange for work or service (earned income) or a non-cash gift or contribution (unearned income).

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

8 Inpatient is an individual who has been admitted to a medical institution on recommendation of a physician or dentist and who receives room, board and professional services for 24 hours or longer, or is expected to receive these services for 24 hours or longer. Institution is an establishment that furnishes, in single or multiple facilities, food, shelter and some treatment or services to four or more persons unrelated to the proprietor. Institutionalization is the commitment of a patient to a health care facility for treatment. Institutionalized Individual is a person who is institutionalized in a medical facility, a Long-Term Care institution, or applying for or receiving Home and Community Based Services (HCBS) or the Program of All Inclusive Care for the Elderly (PACE). Institutionalized Spouse is a Medicaid eligible client who begins a stay in a medical institution or nursing facility on or after September 30, 1989, or is first enrolled as a Medical Assistance client in the Program of All Inclusive Care for the Elderly (PACE) on or after October 10, 1997, or receives Home and Community Based Services (HCBS) on or after July 1, 1999; and is married to a spouse who is not in a medical institution or nursing facility. An institutionalized spouse does not include any such individual who is not likely to be in a medical institution or nursing facility or to receive HCBS or PACE for at least 30 consecutive days. Irrevocable means that the contract, trust, or other arrangement cannot be terminated, and that the funds cannot be used for any purpose other than outlined in the document. Insurance Affordability Program (IAP) refers to Medicaid, Child Health Plan Plus (CHP+), and premium and cost-sharing assistance for purchasing private health insurance through state insurance marketplace. Legal Immigrant is an individual who is not a citizen or national and has been permitted to remain in the United States by the United States Citizenship and Immigration Services (USCIS) either temporarily or as an actual or prospective permanent resident or whose extended physical presence in the United States is known to and allowed by USCIS.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

9 Legal Immigrant Prenatal is a medical program that provides medical coverage for pregnant legal immigrants who have been legal immigrants for less than five years. Limited Disability for the Medicaid Buy-In Program for Working Adults with Disabilities means that an individual has a disability that would meet the definition of disability under SSA without regard to Substantial Gainful Activity (SGA). Long-Term Care is Medical Assistance services that provides nursing-home care, home- health care, personal or adult day care for individuals aged at least 65 years or with a chronic or disabling condition. Long-Term Care Institution means class I nursing facilities, intermediate care facilities for intellectual and developmental disabilities (ICF/IDD) and swing bed facilities. Long- Term Care institutions can include hospitals. Long-Term Services and Supports Level of Care Eligibility Determination is the determination using the state prescribed assessment instrument that an individual does or does not meet institutional level of care. Long-Term Services and Supports Level of Care Eligibility Determination Screen is a comprehensive evaluation with an individual seeking services and appropriate collaterals (such as family members, friends, and/or caregivers) to determine the individual’s eligibility for long-term services and supports based on their need for institutional level of care as determined using the state prescribed assessment instrument. Managed care system is a system for providing health care services which integrates both the delivery and the financing of health care services in an attempt to provide access to medical services while containing the cost and use of medical care. Medical Assistance is defined as all medical programs administered by the Department of Health Care Policy and Financing. Medical Assistance/Medicaid is the joint state/federal health benefits program for individuals and families with low income and resources. It is an entitlement program that is jointly funded by the states and federal government and administered by the state. This program provides for payment of all or part of the cost of care for medical services.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

10 Medical Assistance Required Household is defined for purposes of this volume as all parents or caretaker relatives, spouses, and dependent children residing in the same home. Minimal Verification is defined in this volume as the minimum amount of information needed to process an application for benefits. No other verification can be requested from clients unless the information provided is questionable or inconsistent. Minimum Essential Coverage is the type of coverage one must maintain to be in compliance with the Affordable Care Act in order to avoid paying a penalty for being uninsured. Minimum essential coverage may include but not limited to: Medicaid; CHP+; private health plans through Connect for Health Colorado; Medicare; job-based insurance, and certain other coverage. MMMNA - Minimum Monthly Maintenance Needs Allowance is the calculation used to determine the amount of institutionalized spouse’s income that the community spouse is allowed to retain to meet their monthly living needs. MAGI - Modified Adjusted Gross Income refers to the methodology by which income and household composition are determined for the MAGI Medical Assistance groups under the Affordable Care Act. These MAGI groups include Parents and Caretaker Relatives, Pregnant Women, Children, and Adults. For a more complete description of the MAGI categories and pursuant rules, please refer to section 8.100.4. MIA - Monthly Income Allowance is the amount of institutionalized spouse’s income that the community spouse is allowed to retain to meet their monthly living needs. MSP - Medicare Savings Program is a Medical Assistance Program to assist in the payment of Medicare premium, coinsurance and deductible amounts. There are four groups that are eligible for payment or part-payment of Medicare premiums, coinsurance and deductibles: Qualified Medicare Beneficiaries (QMBs), Specified Low- Income Medicare Beneficiaries (SLIMBs), Qualified Disabled and Working Individuals (QDWIs), and Qualifying Individuals – 1 (QI-1s). Non-Filer is an individual who neither files a tax return nor is claimed as a tax dependent. For a more complete description of how household composition is

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

11 determined for the MAGI Medical Assistance groups, please refer to the MAGI household composition section at 8.100.4.E. Nursing Facility is a facility or distinct part of a facility which is maintained primarily for the care and treatment of inpatients under the direction of a physician. The patients in such a facility require supportive, therapeutic, or compensating services and the availability of a licensed nurse for observation or treatment on a twenty-four-hour basis. OAP - Old Age Pension is a financial assistance program for low income adults age 60 or older. OASDI - Old Age, Survivors and Disability Insurance is the official term Social Security uses for Social Security Act Title II benefits including retirement, survivors, and disability. This does not include SSI payments. Outpatient is a patient who is not hospitalized overnight but who visits a hospital, clinic, or associated facility for diagnosis or treatment. Is a patient who does not require admittance to a facility to receive medical services. PACE - Program of All-inclusive Care for the Elderly is a unique, capitated managed care benefit for the frail elderly provided by a not-for-profit or public entity. The PACE program features a comprehensive medical and social service delivery system using an interdisciplinary team approach in an adult day health center that is supplemented by in- home and referral services in accordance with participants' needs. Parent and Caretaker Relative is a MAGI Medical Assistance group that provides Medical Assistance to adults who are parents or Caretaker Relatives of dependent children. Patient is an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health, or lessening of illness, disability, or pain. PEAK – the Colorado Program Eligibility and Application Kit is a web-based portal used to apply for public assistance benefits in the State of Colorado, including Medical Assistance.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

12 PNA - Personal Needs Allowance means moneys received by any person admitted to a nursing care facility or Long-Term Care Institution which are received by said person to purchase necessary clothing, incidentals, or other personal needs items which are not reimbursed by a Federal or state program. Pregnant Women is a MAGI Medical Assistance group that provides Medical Assistance coverage to pregnant women whose MAGI-based income calculation is less than 195% FPL, including women who are in their 12 months post-partum. Premium means the monthly amount an individual pays to participate in a Medicaid Buy-In Program. Provider is any person, public or private institution, agency, or business concern enrolled under the state Medical Assistance program to provide medical care, services, or goods and holding a current valid license or certificate to provide such services or to dispense such goods. Psychiatric Facility is a facility that is licensed as a residential care facility or hospital and that provides inpatient psychiatric services for individuals under the direction of a licensed physician. Public Institution means an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. Qualified Hospital Presumptive Eligibility Sites are hospitals that have voluntarily elected to serve as Presumptive Eligibility sites. Qualified Hospital Presumptive Eligibility Sites agree to make determinations in accordance with State policies and assist individuals with completing Medical Assistance applications and understanding documentation requirements. Questionable is defined as inconsistent or contradictory tangible information, statements, documents, or file records. Reasonable Compatibility refers to an allowable difference or discrepancy between the income an applicant self attests and the amount of income reported by an electronic data source. For a more complete description of how reasonable compatibility is used to

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

13 determine an applicant’s financial eligibility for Medical Assistance, please refer to the MAGI Income section at 8.100.4.C Reasonable Explanation refers to the opportunity afforded an applicant to explain a discrepancy between self-attested income and income as reported by an electronic data source, when the difference is above the threshold percentage for reasonable compatibility. Recipient is any person who has been determined eligible to receive benefits. Resident is any individual who is living within the state and considers the state as their place of residence. Residents include any unemancipated child whose parent or other person exercising custody lives within the state. RRB - Railroad Retirement Benefits is a benefit program under Federal law 45 U.S.C. § 231 et seq that became effective in 1935. It provides retirement benefits to retired railroad workers and families from a special fund, which is separate from the Social Security fund. Secondary School is a school or educational program that provides instruction or training towards a high school diploma or an equivalent degree such as a High School Equivalency Diploma (HSED). SGA – Substantial Gainful Activity is defined by the Social Security Administration. SGA is the term used to describe a level of work activity and earnings. Work is “substantial” if it involves performance of significant physical or mental activities or a combination of both, which are productive in nature. For work activity to be substantial, it does not need to be performed on a full-time basis. Work activity performed on a part-time basis may also be substantial gainful activity. “Gainful” work activity is work performed for pay or profit; or work of a nature generally performed for pay or profit; or work intended for profit, whether or not a profit is realized. Single Entry Point Agency means the organization selected to provide case management functions for persons in need of Long-Term Care services within a Single Entry Point District.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

14 Single Streamlined Application or “SSAp” is the general application for health assistance benefits through which applicants will be screened for Medical Assistance programs including Medicaid, CHP+, or premium and cost-sharing assistance for purchasing private health insurance through a state insurance marketplace. SISC- Supplemental Income Status Codes are system codes used to distinguish the different types of state supplementary benefits (such as OAP) a recipient may receive. Supplemental Income Status Codes determine the FFP for benefits paid on behalf of groups covered under the Medical Assistance program. SSA - Social Security Administration is an agency of the United States federal government that administers Social Security, a social insurance program consisting of retirement, disability, and survivors' benefits. SSI - Supplemental Security Income is a Federal income supplement program funded by general tax revenues (not Social Security taxes) that provides income to aged, blind or disabled individuals with little or no income and resources. SSI Eligible means an individual who is eligible to receive Supplemental Security Income under Title XVI of the Social Security Act, and may or may not be receiving the monetary payment. TANF - Temporary Assistance to Needy Families is the Federal assistance program which provides supportive services and federal benefits to families with little or no income or resources. It is the Block Grant that was established under the Personal Responsibility and Work Opportunity Reconciliation Act in Title IV of the Social Security Act. Tax Dependent is anyone expected to be claimed as a dependent by a Tax-Filer. Tax-Filer is an individual, head of household or married couple who is required to and who files a personal income tax return. Third Party is an individual, institution, corporation, or public or private agency which is or may be liable to pay all or any part of the medical cost of an injury, a disease, or the disability of an applicant for or recipient of Medical Assistance.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

15 Title XIX is the portion of the federal Social Security Act which authorizes a joint federal/state Medicaid program. Title XIX contains federal regulations governing the Medicaid program. TMA - Transitional Medical Assistance is a Medical Assistance category for families that lost Medical Assistance coverage due to increased earned income or loss of earned income disregards. Unearned Income is the gross amount received in cash or kind that is not earned from employment or self-employment. VA - Veterans Affairs is The Department of Veterans Affairs which provides patient care and Federal benefits to veterans and their dependents. 8.100.2 Legal Basis Constitution of Colorado, Article XXIV, Old Age Pensions, section 7, established a health and medical care fund for persons who qualify to receive old age pensions. Colorado Revised Statutes, Title 25.5, Article 4, Colorado Medical Assistance Act, section 102, provides for a program of Medical Assistance for individuals and families, whose income and resources are insufficient to meet the costs of necessary medical care and services, to be administered in cooperation with the federal government. The Social Security Act, Title XIX, Grants to States for Medical Assistance Programs, and the consequent Federal regulations, Title 42, CFR (Code of Federal Regulations), Chapter IV, Subchapter C, set forth the conditions for states to obtain Federal Financial Participation in Medical Assistance expenditures. Under the Colorado Medical Assistance Program, the Medicaid program provides coverage of certain groups specified in Title XIX of the Social Security Act. The OAP State Only Medical Assistance Program provides coverage to certain old age pension clients entitled to health and medical care under the Colorado Constitution. The Department of Health Care Policy and Financing is the single State agency designated to administer the Colorado Medical Assistance Program under Title XIX of the Social Security Act and Colorado statutes. The Office of Medical Assistance of the

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

16 Department is delegated the duties and responsibilities for administration of the Colorado Medical Assistance Program. 8.100.3. Medical Assistance General Eligibility Requirements 8.100.3.A. Application Requirements 1. The eligibility site shall advise individuals concerning the benefits of the Medical Assistance Program and determine or redetermine eligibility for Medical Assistance in accordance with rules and regulations of the Department. A person who is applying for the Medical Assistance Program or a client who is determined ineligible for the Medical Assistance Program in one category shall be evaluated under all other categories of eligibility. There is no time limit for Medical Assistance coverage as long as the client remains categorically eligible. 2. If the applicant applied for Medical Assistance on the Single Streamlined Application and was found ineligible, this application shall be reviewed for all other Medical Assistance eligibility programs, the Child Health Plan Plus (CHP+) program and premium and cost-sharing assistance for purchasing private health insurance through the state insurance marketplace. a. The application data and verifications shall be automatically transferred to the state insurance marketplace through a system interface when applicants are found ineligible for Medical Assistance eligibility programs. If an individual is pending for a Non-MAGI Medical Assistance eligibility program but has been found financially ineligible for MAGI Medical Assistance eligibility programs, the application data and verifications shall be transferred to the state insurance marketplace. 3. Persons applying for assistance need complete only one application form to apply for both Medical Assistance and Financial Assistance under the Federal or State Financial Assistance Programs administered in the county. The application will be the Application for Public Assistance. 4. If an applicant is found to be ineligible for a particular program, the Application for Public Assistance shall be reviewed and processed for other financial programs

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

18 10. During normal business hours, eligibility sites shall not restrict the hours in which applicants may file an application. The eligibility site must afford any individual wishing to do so the opportunity to apply for Medical Assistance without delay. 11. The applicant has the right to withdraw his or her application at any time. 8.100.3.B. Residency Requirements 1. Individuals shall make application in the county in which they live. Individuals who reside in a county but who do not reside in a permanent dwelling nor have a fixed mailing address shall be considered eligible for the Medical Assistance Program, provided all other eligibility requirements are met. In no instance shall there be a durational residency requirement imposed upon the applicant, nor shall there be a requirement for the applicant to reside in a permanent dwelling or have a fixed mailing address. If an individual without a permanent dwelling or fixed mailing address is hospitalized, the county where the hospital is located shall be responsible for processing the application to completion. If the individual moves prior to completion of the eligibility determination the origination eligibility site completes the determination and transfers the case as applicable. a. For applicants in Long Term Care institutions - The county of domicile for all Long Term Care clients is the county in which they are physically located and receiving services. 2. A resident of Colorado is defined as a person that is living within the state of Colorado and considers Colorado to be their place of residence at the time of application. For institutionalized individuals who are incapable of indicating intent as to their state of residence, the state of residence shall be where the institution is located unless that state determines that the individual is a resident of another state, by applying the following criteria: a. for any institutionalized individual who is under age 21 or who is age 21 or older and incapable of indicating intent before age 21, the state of residence is that of the individual's parent(s) or legally appointed guardian at the time of placement;

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

20 Assistance or for any other reason is a non-resident, so long as they consider their permanent place of residence to be outside of the state of Colorado. 8.100.3.C. Transferring Requirements 1. When a family or individual moves from one county to another within Colorado, the client shall report the change of address to the eligibility site responsible for the current active Medical Assistance Program case(s). If a household applies in the county in which they live and then moves out of that county during the application determination process, the originating eligibility site shall complete the processing of that application before transferring the case. The originating eligibility site shall electronically transfer the case to the new county of residence in CBMS. 2. The originating eligibility site must notify the receiving eligibility site of the client's transfer of Medical Assistance. The originating eligibility site may notify the receiving eligibility site by telephone that a client has moved to the receiving county. If the family or individual wishes to apply for other types of assistance, they shall submit a new application to the receiving eligibility site. 3. If the household is transferring the current Medical Assistance case, the receiving eligibility site cannot mandate a new application, verification, or an office visit to authorize the transfer. The receiving eligibility site can request copies of specific case documents to be forwarded from the originating eligibility site to verify the data contained in CBMS. 4. If the originating eligibility site closes a case for the discontinuation reason of “unable to locate,” the applicant shall reapply at the receiving eligibility site for the Medical Assistance Program. 5. If a case is closed for any other discontinuation reason than “unable to locate” and the client provides appropriate information to overturn the discontinuation with the originating eligibility site, then, upon transfer, the receiving eligibility site shall reopen the case with case comments in CBMS. These actions shall be performed according to timeframes defined by the Department.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

22 d. In unusual circumstances, documented in the case record and in CBMS case comments, the eligibility site may delay its decision on the application beyond the applicable deadline at its discretion. Examples of such unusual circumstances are a delay or failure by the applicant or an examining physician to take a required action such as submitting required documentation, or an administrative or other emergency beyond the agency's control. e. Due to the Coronavirus COVID-19 Public Health Emergency, required through the Federal CARES Act for the Maintenance of Effort (MOE), the Department will continue eligibility for all Medical Assistance categories, regardless of changes made for a redetermination or additional documentation for current Medicaid enrollees. The Department will allow these individuals to continue eligibility through the period of the COVID-19 pandemic federal emergency declaration. Once the federal emergency declaration has concluded, the Department will process eligibility redeterminations and /or changes for all members whose eligibility was maintained during the emergency declaration. Effective May 11, 2023 the coronavirus COVID-19 pandemic federal emergency has been declared to end. To ensure the Department Maintains access to State and Federal funding provided by the Federal ‘Families First Coronavirus Response Act” Pub.L. 116-127, and the Federal “Consolidated Appropriations Act, 2023”, the Department will process eligibility redeterminations and take appropriate action for all members whose eligibility was maintained during the emergency declaration. By May 2024 all members whose eligibility has been maintained due to the Public Health Emergency will have completed the renewal process. A member’s eligibility may no longer be maintained after May 31, 2023 if they have completed the renewal process and/or a change is reported, and they are found ineligible. Members whose eligibility has been maintained during the Public Health Emergency and whose renewal is not due yet will remain in their current

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

24 iii) Make any statement to the applicant or take any action, the purpose or effect of which is to discourage the applicant from registering to vote; and iv) Make any statement to an applicant which is to lead the applicant to believe that a decision to register or not to register has any bearing on the availability of services or benefits. c. The eligibility site shall ensure the confidentiality of individuals registering and declining to register to vote. d. Records concerning registration and declination to register to vote shall be maintained for two years by the eligibility site. These records shall not be part of the public assistance case record. e. A completed voter registration application shall be transmitted to the county clerk and recorder for the county in which the eligibility site is located not later than ten (10) days after the date of acceptance; except that if a registration application is accepted within five (5) days before the last day for registration to vote in an election, the application shall be transmitted to the county clerk and recorder for the county not later than five (5) days after the date of acceptance. 7. Individuals who transfer from one Colorado county to another shall be provided the same opportunity to register to vote in the new county of residence. The new county of residence shall follow the above procedure. The new county of residence shall notify its county clerk and recorder of the client's change in address within five (5) days of receiving the information from the client. 8.100.3.E. Retroactive Medical Assistance Coverage 1. An applicant for Medical Assistance shall be provided such assistance any time during the three months preceding the date of application, or as of the date the person became eligible for Medical Assistance, whichever is later. That person shall have received medical services at any time during that period and met all applicable eligibility requirements.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

25 2. An explanation of the conditions for retroactive Medical Assistance shall be given to all applicants. Those applicants who within the three months period prior to the date of application or as of the date the person became eligible for Medical Assistance, whichever is later, have received medical services which would be a benefit under the Colorado State Plan, can request retroactive coverage on the application form. The determination of eligibility for retroactive Medical Assistance shall be made as part of the application process. An applicant does not have to be eligible in the month of application to be eligible for retroactive Medical Assistance. The applicant or client may verbally request retroactive coverage at any time following the completion of an application. Verification required to determine Medical Assistance Program eligibility for the retroactive period shall be secured by the eligibility site to determine retroactive eligibility. Proof of the declared medical service shall not be required. 8.100.3.F. Groups Assisted Under the Program 1. The Medical Assistance Program provides benefits to the following persons who meet the federal definition of categorically needy at the time they apply for benefits: a. Parents and Caretaker Relatives, Pregnant Women, Children, Adults, and Family Planning Medical Assistance as defined under the Modified Adjusted Gross Income (MAGI)Medical Assistance section 8.100.4. b. Persons who meet legal immigrant requirements as outlined in this volume, who were or would have been eligible for SSI but for their alien status, if such persons meet the resource, income and disability requirements for SSI eligibility. c. Persons who are receiving financial assistance; and who are eligible for a SISC Code of A or B. See section 8.100.3.M for more information on SISC Codes. d. Persons who are eligible for financial assistance under Old Age Pension (OAP) and SSI, but are not receiving the money payment.

(10-ccr-2505-10-8-100)(page-26)Page 26#

CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

26 e. Persons who would be eligible for financial assistance from OAP or SSI, except for the receipt of Social Security Cost of Living Adjustment (COLA) increases, or other retirement, survivors, or disability benefit increases to their own or a spouse's income. This group also includes persons who lost OAP or SSI due to the receipt of Social Security Benefits and who would still be eligible for the Medical Assistance Program except for the cost of living adjustments (COLA's) received. These populations are referenced as Pickle and Disabled Widow(er)s. f. Persons who are blind, disabled, or aged individuals residing in the medical institution or Long Term Care Institution whose income does not exceed 300% of SSI. g. Persons who are blind, disabled or aged receiving HCBS whose income does not exceed 300% of the SSI benefit level and who, except for the level of their income, would be eligible for an SSI payment. h. A disabled adult child who is at least 18 years of age and who was receiving SSI as a disabled child prior to the age of 22, and for whom SSI was discontinued on or after May 1, 1987, due to having received of OASDI drawn from a parent(s) Social Security Number, and who would continue to be eligible for SSI if the above OASDI and all subsequent cost of living adjustments were disregarded. This population is referenced as Disabled Adult Child (DAC). i. Children age 18 and under who would otherwise require institutionalization in an Long Term Care Institution, Nursing Facility (NF), or a hospital but for which it is appropriate to provide care outside of an institution as described in 1902(e)(3) of the Act Public Law No. 97-248 (Section 134). j. Persons receiving OAP-A, OAP-B, and OAP Refugees who do not meet SSI eligibility criteria but do meet the state eligibility criteria for the OAP State Only Medical Assistance Program. These persons qualify for a SISC Code C.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

65 i) Providing verbal or written statements describing the individual’s effort at obtaining the required documentation; ii) Providing copies of emails, letters, applications, checks, receipts, or other materials sent or received in connection with a request for documentation; or iii) Providing verbal or written statements of the individuals’ efforts at identifying people who could attest to the individual’s citizenship or identity, if citizenship and/or identity are included in missing documentation. An individual’s verbal statement describing his or her efforts at securing the required documentation should be accepted without further verification unless the accuracy or truthfulness of the statement is questionable. The individual’s good faith efforts should be documented in the case file and are subject to all record retention requirements. 8.100.3.I. Additional General Eligibility Requirements 1. Each person for whom Medical Assistance is being requested shall furnish a Social Security Number (SSN); or, if one has not been issued or is unknown, shall apply for the number and submit verification of the application, unless an exception below applies. The application for an SSN shall be documented in the case record by the eligibility site. Upon receipt of the assigned SSN, the client shall provide the number to the eligibility site. This requirement does not apply to those individuals who are not requesting Medical Assistance yet appear on the application, nor does it apply to individuals applying for emergency medical services, limited reproductive health services, or eligible newborns born to a Medical Assistance eligible mother. a. An applicant's or client's refusal to furnish or apply for a Social Security Number affects the family's eligibility for assistance as follows: i) that person cannot be determined eligible for the Medical Assistance Program; and/or

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

68 3. An individual receiving Aid to the Needy Disabled (AND) may also receive MAGI Medical Assistance, if the recipient meets the eligibility requirements for MAGI Medical Assistance. For these individuals, eligibility sites shall not include the applicant’s AND payment when calculating income to determine the household’s financial eligibility for MAGI Medical Assistance. 8.100.3.K. Consideration of Income 1. Income or resources of an alien sponsor or an alien sponsor’s spouse shall be countable to the sponsored alien effective December 19, 1997. Forms used prior to December 19, 1997, including but not limited to forms I-134 or I-136 are legally unenforceable affidavits of support. The attribution of the income and resources of the sponsor and the sponsor's spouse to the alien will continue until the alien becomes a U.S. citizen or has worked or can be credited with 40 qualifying quarters of work, provided that an alien crediting the quarters to the applicant/client has not received any public benefit during any creditable quarter for any period after December 31, 1996. a. Exception: When the sponsored alien is a pregnant woman or a child the income or resources of an alien sponsor or an alien sponsor’s spouse will not be countable to the sponsored alien. 2. Income, in general, is the receipt by an individual of a gain or benefit in cash or in kind during a calendar month. Income means any cash, payments, wages, in- kind receipt, inheritance, gift, prize, rents, dividends, interest, etc., that are received by an individual or family. 3. Earned income is payment in cash or in kind for services performed as an employee or from self-employment. 4. Earned in kind income shall be income produced as a result of the performance of services by the applicant/client, for which he/she is compensated in shelter or other items in lieu of wages. 5. Received means “actually” received or legally becomes available, whichever occurs first; the point at which the income first is available to the individual for

(10-ccr-2505-10-8-100)(page-74)Page 74#

CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

74 available in expenditures for medical care and services which are benefits of the Medical Assistance program but not for SMIB premium payments; b. Code B - for persons eligible to receive financial assistance under SSI; persons eligible to receive financial assistance under OAP “A” who, except for the level of their income, would be eligible for an SSI payment; persons who are receiving mandatory State supplementary payments; and persons who continue to be eligible for Medical Assistance after disregarding certain Social Security increases; code B signifies that FFP is available in expenditures for medical care and services which are benefits of the Medical Assistance program and also for SMIB premium payments; c. Code C - for persons eligible to receive assistance under OAP “A”, OAP “B”, or OAP Refugee Assistance for financial assistance only; who do not receive SSI payment and do not otherwise qualify under SISC code B as described in item B. above; code C signifies that no FFP is available in Medical Assistance program expenditures. d. Code D1 – for persons eligible to receive assistance under AwDC from program implementation through 12/31/2013; Code D1 signifies 50% FFP is available in expenditures for medical care and services which are benefits of the Medical Assistance program. e. Code E1 - for persons eligible to receive assistance under the Medicaid Buy-In Program for Working Adults with Disabilities and whose annual adjusted gross income, as defined under IRS statute, is less than or equal to 450% of FPL – after SSI earned income deductions; as well as for children eligible to receive assistance under the Medicaid Buy-In Program for Children with Disabilities and whose household income is less than or equal to 300% of FPL after income disregards. Code E1 signifies that FFP is available in expenditures for medical care and services which are benefits of the Medical Assistance program but not for SMIB premium payments.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

75 3. Recipients of financial assistance under State AND, State AB, or OAP “C” are not automatically eligible for Medical Assistance and the SISC code which shall be entered on the eligibility reporting form is C. 8.100.3.N. Confidentiality 1. All information obtained by the eligibility site concerning an applicant for or a recipient of Medical Assistance is confidential information. 2. A signature on the Single Streamlined Application and the Application for Public Assistance allows an eligibility site worker to consult banks, employers, or any other agency or person to obtain information or verification to determine eligibility. The identification of the worker as an eligibility site employee will, in itself, disclose that an application for the Medical Assistance Program has been made by an individual. In this type of contact, as well as other community contacts, the eligibility site should strive to maintain confidentiality. The signature on the Single Streamlined Application and the Application for Public Assistance also provides permission for the release of the client's medical information to be provided by health care providers to the State and its agents for purpose of administration of the Medical Assistance Program. 3. Eligibility site staff may release a client's Medical Assistance state identification number and approval eligibility spans to a Medical Assistance provider for billing purposes. Eligibility site staff may inform a Medical Assistance provider that an application has been denied but may not inform them of the reason why. 4. Access to information concerning applicants or recipients must be restricted to persons or agency representatives who are subject to standards of confidentiality that are comparable to those of the State and the eligibility site. 5. The eligibility site must obtain permission from a family, individual, or authorized representative, whenever possible, before responding to a request for information from an outside source, unless the information is to be used to verify income, eligibility and the amount of Medical Assistance payment. This

(10-ccr-2505-10-8-100)(page-78)Page 78#

CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

78 a. Provide aid, care, services, or other benefits to an individual which is different, or provided in a different manner, from that of others; b. Subject an individual to segregation barriers or separate treatment in any manner related to access to or receipt of assistance, care services, or other benefits; c. Restrict an individual in any way in the enjoyment or any advantage or privilege enjoyed by others receiving aid, care, services, or other benefits provided under the Medical Assistance Program; d. Treat an individual differently from others in determining whether he/she satisfies any eligibility or other requirements or conditions which individuals shall meet in order to receive aid, care, services, or other benefits provided under the Medical Assistance Programs; e. Deny an individual an opportunity to participate in programs of assistance through the provision of services or otherwise, or afford him/her an opportunity to do so which is different from that afforded others under the Medical Assistance Program. 3. No distinction on the grounds of race, color, sex, age, religion, political belief, national origin, or handicap is permitted in relation to the use of physical facilities, intake and application procedures, caseload assignments, determination of eligibility, and the amount and type of benefits extended by the eligibility site to Medical Assistance recipients. 4. An individual who believes he/she is being discriminated against may file a complaint with the eligibility site, the Department, or directly with the Federal government. When a complaint is filed with the eligibility site, the county director is responsible for an immediate investigation of the matter and taking necessary corrective action to eliminate any discriminatory activities found. If such activities are not found, the individual is given an explanation. If the person is not satisfied, he/she is requested to direct his/her complaint, in writing, to the State Department, Complaint Section, which will be responsible for further investigation

(10-ccr-2505-10-8-100)(page-80)Page 80#

CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

80 3. Redetermination forms shall direct members to verify that the information provided on the form is accurate or to report any changes to the information. The following procedures pertain to the redetermination forms: a. A redetermination form shall be sent to the member along with any required verifications to be completed. b. The member must complete and return the redetermination with the necessary verifications and the signature form. c. If the member is unable to complete the redetermination forms due to a disability (a physical or mental impairment that substantially limits one or more major life activity) or other good cause, in response to a request from the member, the eligibility site shall assist the member in accordance with its Civil Rights Plan as described in Section 10 CCR 2505-5 1.020.7.1.d. The assistance of the eligibility site shall be recorded in the case record and CBMS case comments. d. The redetermination form shall require that a recipient and community spouse of a recipient of HCBS, PACE, or institutional services disclose a description of any interest the member or community spouse has in an annuity or similar financial instrument regardless of whether the annuity is irrevocable or treated as an asset. The redetermination form shall include a statement that the Department shall be a remainder beneficiary for any annuity or similar financial instrument purchased on or after February 8, 2006, for the total amount of Medical Assistance provided to the member. e. The eligibility site shall notify in writing the issuer of any annuity or financial instrument that the Department is a preferred remainder beneficiary in the annuity or similar financial instrument for the total amount of Medical Assistance provided to the member. This notice shall require the issuer to notify the eligibility site when there is a change in the amount of income or principal that is being withdrawn from the annuity.

(10-ccr-2505-10-8-100)(page-89)Page 89#

CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

89 c. Earned Income: Income -may be self-attested by an applicant or member and verified through an electronic data source. Individuals who provide self-attestation of income - may provide a SSN for electronic wage verification purposes. If the self-attested earned income cannot be verified electronically, due to a missing SSN, the applicant must provide documentation of income. Earned income must be verified by wage stubs, tax documents, written documentation from the employer stating the employee’s gross income or a telephone call to an employer. Applicants may request that communication with their employers be made in writing. Estimated earned income shall be used to determine eligibility if the applicant/client provides less than a full calendar month of wage stubs for the application month. A single recent wage stub shall be sufficient if the applicant's income is expected to be the same amount for the month of application. Verification of earned income received during the month prior to the month of application shall be acceptable if the application month verification is not yet available. Actual earned income shall be used to determine eligibility if the client provides verification for the full calendar month. Due to the Coronavirus COVID -19 Public Health Emergency, the Department will not take action on any electronic interfaces that notify that the individual’s income has changed for all Medical Assistance programs in which the individual is currently enrolled. The Department will take action and require documentation from the individual once the federal emergency declaration has concluded. Effective May 11, 2023 the Coronavirus COVID-19 Public Health Emergency has been declared to end. d. Unearned income: Unearned income can be self-attested by an applicant. Certain types of unearned income, such as unemployment and survivor benefits may be verified through electronic data sources. Due to the

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

90 Coronavirus COVID -19 Public Health Emergency, the Department will not take action on any electronic interfaces that notify that the individual’s income has changed for all Medical Assistance programs in which the individual is currently enrolled. The Department will take action and require documentation from the individual once the federal emergency declaration has concluded, for all people whose eligibility was maintained during the emergency declaration, for these individuals to maintain eligibility. Effective May 11, 2023 the Coronavirus COVID-19 Public Health Emergency has been declared to end. e. Verification of Legal Immigrant Status: Immigration status may be self- declared by an applicant applying for Medical Assistance, to determine eligibility for full Medical Assistance benefits. This declaration of legal immigration status will be verified through the Verify Lawful Presence (VLP) interface. The VLP interface connects to the Systematic Alien Verification for Entitlements (SAVE) program to verify legal immigration status. See section 8.100.3.G for a description of the VLP interface. If status cannot be verified, or if the applicant does not provide the necessary documents within the reasonable opportunity period, then the applicant’s Medical Assistance application shall be terminated. 2. Additional Verification: No other verification shall be required of the client unless information is found to be questionable on the basis of fact. 3. The determination that information is questionable shall be documented in the applicant's case file and CBMS case comments. 4. Information that exists in another case record or in CBMS shall be used by the eligibility site to verify those factors that are not subject to change, if the information is reasonably accessible. 5. The criteria of age and relationship may be declared by the client unless questionable. If questionable, these criteria may be established with information provided from:

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

102 4. Married couples living together will each be included in the other’s MAGI household regardless of whether or not they expect to file taxes jointly, separately or if one expects to be claimed as a tax dependent of the other. 5. If a child is claimed as a tax dependent by both parents who are married and who will file taxes jointly but one parent lives outside of the household due to separation or pending divorce, the child’s household composition is determined by non-filer rules. The parent living outside of the household will not be counted as part of the household. 6. An individual who is both a tax dependent and a tax filer will be considered a tax dependent for the purpose of determining eligibility for Medical Assistance. 8.100.4.F. MAGI Category Presumptive Eligibility 1. A pregnant woman may apply for presumptive eligibility for ambulatory services through Medical Assistance presumptive eligibility sites. A child under the age of 19 may apply or have an adult apply on their behalf for presumptive eligibility for State Plan approved medical services through presumptive eligibility sites. Presumptive eligibility is available to applicants for limited family planning who are not pregnant. There are no restrictions of age or gender under the limited family planning presumptive eligibility category. 2. To be eligible for presumptive eligibility: a. a pregnant woman must have an attested pregnancy, declare that her household's income shall not exceed 195% of the federal poverty level and declare that she is a United States citizen or a lawfully residing immigrant. Unless they meet the exceptions outlined under 8.100.3.G.1.g.viii. b. a child or youth under the age of 19 shall have a declared household income that does not exceed 142% of federal poverty level and declare that the child is a United States citizen or a documented immigrant unless they meet the exceptions outlined under 8.100.3.G.1.g.viii.

(10-ccr-2505-10-8-100)(page-105)Page 105#

CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

105 change within the three months and the placement become court ordered, the child is no longer considered to be living in the home as of the time the foster care plan is changed. 4. Adults applying for Medical Assistance whose total household income does not exceed 133% of the federal poverty level shall be determined financially eligible for Medical Assistance. This category includes adults who are parents or caretaker relatives of dependent children whose income exceeds the income threshold to qualify for the Parents and Caretaker Relatives MAGI category and who meet all other eligibility criteria. a. A dependent child living in the household of a parent or caretaker relative shall have minimum essential coverage, in order for the parent or caretaker relative to be eligible for Medical Assistance under this category. Refer to section 8.100.4.G.3.a on who is considered a dependent child. b. Due to the COVID-19 Public Health Emergency an applicant who is not eligible for Medical Assistance but has been impacted through exposure to or potential infection with COVID-19 may be eligible to receive services for COVID-19 testing only. To qualify for this limited benefit, the applicant must satisfy residency and immigration or citizenship status and not be enrolled in other health insurance. 5. Pregnant Women whose household income does not exceed 195% of the federal poverty level (MAGI-equivalent) are eligible for the Pregnant Women MAGI Medical Assistance program. Medical Assistance shall be provided to a pregnant woman for a period beginning with the date of application for Medical Assistance through the last day of the 12th month following the date the pregnancy ends. Once eligibility has been approved, Medical Assistance coverage will be provided regardless of changes in the woman's financial circumstances once the income verification requirements are met. a. A pregnant women’s eligibility period will end effective the earliest possible month, if the following occurs:

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

106 i) Fails to provide a reasonable explanation or paper documentation when self- attested income is not reasonably compatible with income information from an electronic data source, by the end of the 30day reasonable opportunity period. This exception only applies the first-time income is verified following an initial eligibility determination or an annual redetermination. 6. A lawfully admitted non-citizen who is pregnant and who has been in the United States for less than five years is eligible for Medical Assistance if she meets all of the other eligibility requirements specified at 8.100.4.G.5 and fits into one of the immigration categories listed in 8.100.3.G.1.g.iii.1-5 and 8.100.3.G.1.g.vi.1-15. This population is referenced as Legal Immigrant Prenatal. 7. A child whose mother is receiving Medical Assistance at the time of the child's birth is continuously eligible for one year. This population is referred to as “Eligible Needy Newborn”. This coverage also applies in instances where the mother received Medical Assistance to cover the child’s birth through retroactive Medical Assistance. The child is not required to live with the mother receiving Medical Assistance to qualify as an Eligible Needy Newborn. a. To receive Medical Assistance under this category, the birth must be reported verbally or in writing to the County Department of Human Services or eligibility site. Information provided shall include the baby’s name, date of birth, and mother’s name or Medical Assistance number. A newborn can be reported at any time by any person. Once reported, a newborn meeting the above criteria shall be added to the mother’s Medical Assistance case, or his or her own case if the newborn does not reside with the mother, according to timelines defined by the Department. If adopted, the newborn’s agent does not need to file an application or provide a Social Security Number or proof of application for a Social Security Number for the newborn 8. Applicants applying for Medical Assistance whose total household income is greater than 133% but does not exceed 260% of the federal poverty level shall

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

107 be determined financially eligible for limited Family Planning Medical Assistance services. The applicant must satisfy residency and immigration or citizenship status to qualify for this limited benefit. The limited family planning services eligibility category has no age or gender restriction and is available for those not eligible for a Medicaid eligibility category that provides full coverage. 8.100.4.H. Needy Persons 1. Medical Assistance shall be provided to certain needy persons under 21 years of age, including the following: a. Those receiving care in a Long Term Care Institution eligible for Medical Assistance reimbursement or receiving active treatment as inpatients in a psychiatric facility eligible for Medical Assistance reimbursement and whose household income is less than the MAGI needs standard for his/her family size when the client applies for assistance. Clients that are receiving benefits under this category and are still receiving active inpatient treatment in the facility at age 21 shall be eligible to age 22. This population is referenced as Psych <21. b. Those for whom the Department of Human Services is assuming full or partial financial responsibility and who are in foster care, in homes or private institutions or in subsidized adoptive homes. A child shall be the responsibility of the county, even if the child may be in a medical institution at that time. See Colorado Department of Human Services “Social Services Staff Manual” section 7 for specific eligibility requirements (12 CCR § 2509-1). 12 CCR § 2509-1 (2013) is hereby incorporated by reference. The incorporation of 12 CCR § 2509-1 excludes later amendments to, or editions of, the referenced material. 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.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

108 c. Those for whom the Department of Human Services is assuming full or partial financial responsibility and who are in independent living situations subsequent to being in foster care. d. Those for whom the Department of Human Services is assuming full or partial responsibility and who are receiving services under the state’s Alternatives to Foster Care Program and would be in foster care except for this program and whose household income is less than the MAGI needs standard for his/her family size. e. Those for whom the Department of Human Services is assuming full or partial responsibility and who are removed from their home either with or without (court ordered) parental consent, placed in the custody of the county and residing in a county approved foster home. f. Those for whom the Department of Human Services is assuming full or partial responsibility and who are receiving services under the state’s subsidized adoption program, including a clause in the subsidized adoption agreement to provide Medical Assistance for the child. g. Those for whom the Department of Human Services is assuming full or partial financial responsibility on their 18th birthday or at the time of emancipation. These individuals also must have received foster care maintenance payments or subsidized adoption payments from the State of Colorado pursuant to article 7 of title 26, C.R.S. immediately prior to the date the individual attained 18 years of age or was emancipated. Eligibility shall be extended until the individual’s 21st birthday for these individuals with the exception of those receiving subsidized adoption payments. 2. Medical Assistance shall be extended to certain needy persons until the end of the month of the individual’s 26th birthday, including the following: a. Those individuals that were formerly in foster care under the responsibility of Colorado or Tribe on their 18th, 19th, 20th or up to their 21st birthday and were receiving Medical Assistance.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

110 Transitional Medical Assistance is eligible for the remaining months of Transitional Medical Assistance. a. A dependent child in the household who received Medical Assistance through continuous eligibility, but is no longer eligible for Medical Assistance based on a redetermination, is eligible for the family’s remaining months of Transitional Medical Assistance. b. An individual in the household who received Medical Assistance, but is no longer eligible for Medical Assistance based on a redetermination, is eligible for the family’s remaining months of Transitional Medical Assistance 3. To become or remain eligible for Transitional Medical Assistance the household must include a dependent child. If it is determined that the household no longer has a child living in the home, Transitional Medicaid Assistance shall discontinue at the end of the month in which the household does not include a dependent child. 4. When Transitional Medical Assistance ends the case will be reassessed for all other categories of Medical Assistance for which the family members may be eligible. A new application shall not be required for this process. 5. Eligibility for Medical Assistance shall be extended for four months (beginning with the first month of ineligibility) for certain families who become ineligible for Medical Assistance due solely or partially to the receipt of support income, such as alimony. The extension shall be applied for a family which receives assistance under Medical Assistance in at least three of the six months immediately preceding the month in which the family becomes ineligible for assistance. To be eligible for the four month Medical Assistance extension, the family shall meet all other eligibility criteria for Medical Assistance before the alimony income is applied. a. Alimony received will be countable income only if the divorce or legal separation is executed on or before December 31, 2018. Alimony will not

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

113 8.100.5. Aged, Blind, and Disabled, Long Term Care, and Medicare Savings Plan Medical Assistance General Eligibility 8.100.5.A. Application Requirements 1. When an individual applies for Medical Assistance on the basis of disability or blindness, the eligibility sites shall take the application and determine whether the individual is eligible for Long Term Care or any of the Aged, Blind, and Disabled categories of assistance described in section 8.100.6. If the applicant does not qualify for Medical Assistance on one of those bases, he/she shall be referred to the local Social Security office to apply for SSI. a. Applicants who apply for Long-Term Care Medical Assistance on the basis of disability or blindness, or who apply for the Medicaid Buy-In Program for Working Adults with Disabilities or the Medicaid Buy-In Program for Children with Disabilities without a current disability determination, shall complete a Medical Assistance disability determination application in addition to the required Single Streamlined Application. The disability determination application is not required for individuals that have already been determined disabled by the Social Security Administration. b. The Medical Assistance disability determination application shall be collected by a designated eligibility site representative and shall be forwarded to the state disability determination contractor upon completion. The state disability determination contractor shall conduct a client disability determination and shall forward the determination to the designated eligibility site representative. c. For the Medicaid Buy-In Program for Working Adults with Disabilities, if an individual does not meet the Social Security Administration definition of disability, the state disability determination contractor can review the individual’s circumstances to determine if the individual meets limited disability. d. Due to the Coronavirus COVID-19 Public Health Emergency, if a person’s existing disability determination has expired, the person shall remain

(10-ccr-2505-10-8-100)(page-117)Page 117#

CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

117 documentation they will remain eligible during the public health emergency period. Effective May 11, 2023 the Coronavirus COVID-19 Public Health Emergency has been declared to end and the effective policy after May 11, 2023 is the Department may request paper documentation only if the Department does not find income to be reasonably compatible and if the applicant does not provide a reasonable explanation or if electronic data are not available. If the applicant is self-employed, ledgers are sufficient for verification of earnings, if a ledger is not available, receipts are acceptable. The ledger included in the Medical Assistance application is sufficient verification of earnings, unless questionable. If an individual cannot provide verification through self-declaration, income shall be verified by wage stubs, written documentation from the employer stating the employees' gross income or a telephone call to an employer. Applicants may request that communication with their employers be made in writing. As of CBMS implementation, estimated earned income shall be used to determine eligibility if the applicant/client provides less than a full calendar month of wage stubs for the application month. A single recent wage stub shall be sufficient if the applicant's income is expected to be the same amount for the month of application. Written documentation from the employer stating the employees' gross income or a telephone call to an employer, if the applicant authorizes the telephone call shall also be acceptable verification of earned income. Verification of earned income received during the month prior to the month of application shall be acceptable if the application month verification is not yet available. Actual earned income shall be used to determine eligibility if the client provides verification for the full calendar month. v) During the federal COVID-19 Public Health Emergency, all earned income and self-employment may be reported by self-attestation.

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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

121 c. is not legally restricted from using the resource or income for his or her support and maintenance. 4. Resources and income shall not be considered unavailable merely because the individual or individual’s spouse may need to initiate legal proceedings to access the resources or income. 5. If the applicant or client demonstrates with clear and convincing evidence that appropriate steps are being taken to secure the resources, Medical Assistance shall not be delayed or terminated. Verification of efforts to secure the resources must be provided at regular intervals as requested by the Eligibility Site. 6. Resources will be considered available and Medical Assistance shall be denied or terminated if the applicant or client refuses or fails to make a reasonable effort to secure potential resources or income. 7. Timely and adequate notice must be given regarding a proposed action to deny, reduce, or terminate assistance due to failure to make reasonable efforts to secure resources or income. If upon receipt of the prior notice, the individual acts to secure the potential resource, the proposed action to deny, reduce, or terminate assistance must be withdrawn, and assistance must be approved or continued until the resource or income is, in fact, available. 8. If the resources or income has been transferred to a trust, the trust shall be submitted for review to the Department to determine the effect of the trust on eligibility in accordance with section 8.100.7.E. 9. A resource may not necessarily be unavailable by virtue that an individual may be unaware of his or her ownership of an asset. The Department will not treat the unknown asset as a resource during the period in which the individual was unaware of his/her ownership. However, the value of the previously unknown asset, including any monies such as interest that have accumulated on the asset through the month of discovery, is evaluated under regular income-counting rules in the month of discovery, and the asset is a resource subject to the resource- counting rules following the month of discovery.

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122 a. The burden is on the individual to prove by clear and convincing evidence that the asset was unavailable by virtue of being unknown by the recipient. b. Unknown assets shall not be deemed an overpayment pursuant to Section 8.065 of the Department’s regulations where the asset was unknown through no fault of the individual. c. If the previously unknown asset causes the individual to be ineligible, the individual may repay the Department from the excess resources to retain Medicaid eligibility. 8.100.5.F. Income Requirements 1. This section reviews how income is looked at for the ABD and Long Term Care Medical Programs and determining premiums for the Medicaid Buy-In Program for Working Adults with Disabilities. For more general income information and income types refer to the Medical Assistance General Eligibility Requirements Section 8.100.3. 2. Income for the ABD Medical Programs eligibility is income which is received by an individual or family in the month in which they are applying for or receiving Medical Assistance, or the previous month if income for the current month is not yet available to determine eligibility. 3. A self-declared common law spouse retains the same financial responsibility as a legally married spouse. Once self-declared as married under the common law, financial responsibility remains unless legal separation or divorce occurs. If two persons live together, but are not married to each other, neither one has the legal responsibility to support the other. This is not changed by the fact that the unmarried individuals may share a common child. 4. Earned income is countable as income in the month received and a countable resource the following month. Earned Income includes the following: a. Wages, which include salaries, commissions, bonuses, severance pay, and any other special payments received because of employment. b. Net earnings from self-employment.

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126 vi) Section 202(h) of the Housing Act of 1959. h. Payments made from Indian judgment funds and tribal funds held in trust by the Secretary of the Interior and/or distributed per capita; and initial purchases made with such funds. (Public Law No 98-64 and Public Law No. 97-458). i. Distributions from a native corporation formed pursuant to the Alaska Native Claims Settlement Act (ANCSA) which are in the form of: cash payments up to an amount not to exceed $ 2000 per individual per calendar year; stock; a partnership interest; or an interest in a settlement trust. Cash payments, up to $2000, received by an applicant/member in one calendar year which is retained into subsequent years is excluded as income and resources; however, cash payments up to $2000 received in the subsequent year would be excluded from income in the month(s) received but counted as a resource if retained beyond that month(s). j. Assistance from other agencies and organizations. k. Major disaster and emergency assistance provided to individuals and families, and comparable disaster assistance provided to states, local governments and disaster assistance organizations shall be exempt as income and resources in determining eligibility for Medical Assistance. l. Payments received for providing foster care. m. Payments to volunteers serving as foster grandparents, senior health aids, or senior companions, and to persons serving in the Service Corps of Retired Executives (SCORE) and Active Corps of Executives (ACE) and any other program under Title I (VISTA) when the value of all such payments adjusted to reflect the number of hours such volunteers are serving is not equivalent to or greater than the minimum wage, and Title II and Title III of the Domestic Volunteer Services Act. n. The benefits provided to eligible persons or households through the Low Income Energy Assistance (LEAP) Program.

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149 e. subtract the Pickle Disregard amount from the current OASDI income to get the countable OASDI income. 2. If the countable OASDI income and all other countable income is less than the current SSI or OAP standard, and the individual meets all other eligibility criteria then medical eligibility must continue or be reinstated. 3. This disregard must also be applied to any OASDI cost of living increases paid to any financially responsible individual such as a parent or spouse whose income is considered in determining the person's continued eligibility for Medical Assistance. 4. The cost of living increase disregard specified in the preceding action must continue to be applied at each eligibility redetermination. 5. An SSI medical only individual who loses SSI due to an OASDI cost-of-living increase shall be contacted by the eligibility site to determine if the individual would continue to remain eligible for Medical Assistance under the provisions for SSI related cases. The individual must complete an application for assistance to continue receiving benefits. 8.100.6.F. 1972 Disregard Individuals 1. Medical Assistance must be provided to a person who was receiving financial assistance under AND or Aid to the Blind (AB) for August 1972 and who – except for the October 1972 Social Security (includes RRB) 20% increase amount would currently be eligible for financial assistance. This disregard must also be applied to a person receiving Medical Assistance in August 1972 who was eligible for financial assistance but was not receiving the money payment and to a person receiving Medical Assistance as a resident in a medical institution in August 1972. 2. To redetermine the eligibility of Medical Assistance recipients to whom the 1972 disregard applies, the eligibility site must: a. review the case against the current applicable program definitions and requirements;

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170 4. Revocable Trusts are considered as follows: a. The corpus of the trust shall be considered resources available to the individual, b. Payments from the trust to or for the benefit of the individual shall be considered income to the individual, and c. Any other payments from the trust shall be considered assets transferred by the individual for less than fair market value and are subject to a 60 month look back period and a penalty period of ineligibility as set forth in the regulations on transfers without fair consideration in this volume. 5. Irrevocable Trusts If there are any circumstances under which payments from the trust could be made to or for the benefit of the individual, the following shall apply: a) The portion of the corpus of the trust, or the income on the corpus, from which payment to the individual could be made, shall be considered as resources available to the individual. b) Payments from that portion of the corpus, or income to or for the benefit of the individual, shall be considered income to the individual. c) Payments from that portion of the corpus or income for any other purpose shall be considered as a transfer of assets by the individual for less than fair market value and are subject to a 60 month look back period and a penalty period of ineligibility as set forth in the regulations on transfers without fair consideration in this volume. d) Any portion of the trust or income on the corpus from which no payment could be made to the individual under any circumstances shall be considered as a transfer of assets for less than fair market value and shall be subject to a 60 month look back period and penalty period of ineligibility as set forth in the regulations on transfers without fair consideration in this volume. The transfer will be effective as of the date of the establishment of the trust, or the date on which payment to the individual from the trust was

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196 i) deprive the individual of medical care such that the individual’s health or life would be endangered; or ii) deprive the individual of food, clothing, shelter or other necessities of life. b. Undue hardship shall not exist when the application of the trust or transfer rules merely causes the individual inconvenience or when such application might restrict his or her lifestyle but would not put him or her at risk of serious deprivation. c. Notice of an undue hardship exception shall be given to the applicant or client. The Eligibility Site shall make a determination on the request within 15 working days from when the request is received. The Eligibility Site shall issue a notice of action on the determination of hardship. An adverse determination may be appealed in accordance with the appeal process as described at Section 8.057 of this volume. d. The facility in which an institutionalized individual is residing may file an undue hardship waiver application on behalf of the individual with the individual's or his or her personal representative's consent. Where the individual is unable to give consent and where the personal representative of the individual has a conflict of interest concerning the particular circumstance giving rise to the period of ineligibility, the facility may request an undue hardship on behalf of the individual. An example of such a conflict of interest would be a situation where the personal representative who is also an agent under a power of attorney transfers property to himself or herself. The facility shall submit the undue hardship request to the Eligibility Site and give sufficient detail of the circumstance surrounding the conflict of interest and the information required below to the Eligibility Site. These provisions are not intended to change the Department’s requirements under Section 8.057 of the Department’s regulations as to who has standing to file an appeal.

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197 e. An individual or representative may request that the Eligibility Site waive a transfer penalty on the basis of undue hardship. The request shall be made in writing to the applicant’s or client’s Eligibility Site case worker. The individual making the request has the burden of proof and must provide clear and convincing evidence to substantiate the circumstances surrounding the transfer, attempts to recover the assets, and the impact of the denial of Medicaid payments for Long-Term Care services. The request and documentation shall include all of the following: i) the reason(s) for the transfer including the individual’s participation in the transfer or grant of legal authority to another that gave rise to the transfer, and the relationship between the transferor and transferee; ii) evidence to prove that the assets have been irretrievably lost and that all reasonable attempts made to recover the asset(s), including any legal actions and the results of the attempts, including but not limited to a request for an adult protection investigation (such as in a case of financial exploitation), filing a police report, or filing a civil action have been exhausted or have been or are being pursued; and, iii) documentation such as a notice of discharge or pending discharge from the facility and a physician’s statement detailing how the inability to receive nursing facility or community based services would result in the individual’s inability to obtain life-sustaining medical care or that the individual would not be able to obtain food, clothing or shelter. f. To the extent that the transferred assets are recovered pursuant to the attempts in (e)(ii) above, the individual shall reimburse Medicaid for the funds expended as a result of an approved undue hardship request. g. If the transferee and the transferor of the assets for which the transfer penalty is being imposed are related parties there shall be a rebuttable

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215 c. The amount a court has ordered the institutionalized spouse to transfer to the community spouse for monthly support of the community spouse or a dependent family member. 2. The resources allotted to the community spouse as the CSRA shall be transferred into the name of the community spouse and shall not be considered available to the institutionalized spouse. After the transfer of the CSRA to the community spouse, the income from these resources shall be attributed to the community spouse. 3. The transfer of the CSRA shall be completed as soon as possible, but no later than the next redetermination when the community spouse becomes institutionalizes; whichever is earlier. If the transfer is not completed within this time period, the resources shall be attributed to the institutionalized spouse and shall affect his/her Medical Assistance eligibility. Verification of the transfer of assets to the community spouse shall be provided to the eligibility site. The institutionalized spouse may transfer the resources allotted to the community spouse as the CSRA to another person for the sole benefit of the community spouse. 4. If the community spouse is in control of resources attributed to the institutionalized spouse, but fails to make such resources available for his/her cost of care, this fact shall not make the institutionalized spouse ineligible for Medical Assistance, where: a. The institutionalized spouse has assigned The Department any rights to support from the community spouse; or b. The institutionalized spouse lacks the ability to execute an assignment due to physical or mental impairment but The Department has the right to bring a support proceeding against the community spouse without such assignment; or c. The eligibility site determines that the denial of eligibility would work an undue hardship upon the institutionalized spouse. For the purposes of this

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219 4. The total that results from adding the current MMMNA and the excess shelter allowance shall not exceed the current maximum MMMNA which is $2,175.00 for the year 2001 and is adjusted by the Health Care Financing Administration in January of each year. 8.100.7.R. Calculating the Amount of Income to be Contributed by the Institutionalized Spouse for the Community Spouse's Monthly Needs 1. The Monthly Income Allowance (MIA) is the amount of money necessary to raise the community spouse's income to the level of his/her monthly needs, and shall be obtained from the monthly income of the institutionalized spouse. For individuals who become institutionalized on or after February 8, 2006, all income of the institutionalized spouse that could be made available to the community spouse must be considered to have been made available to the community spouse before an MIA is allocated to the community spouse. 2. The MIA shall be the amount by which the community spouse's minimum monthly needs, which is the MMMNA, exceed his/her income from sources other than the institutionalized spouse. The community spouse’s income shall be calculated by using the gross income less mandatory deduct ions for FICA and Medicare tax. 3. If a court has entered an order against the institutionalized spouse for monthly support of the community spouse, the MIA shall not be less than the monthly amount ordered by the court. 4. The eligibility site shall make adjustments to the MMMNA and/or the MIA on a monthly basis for any continuing change in circumstances that exceeds $50 a month. Continuing changes of less than $50 in a month, and any infrequent or irregular changes, shall be considered at redetermination. 8.100.7.S. Increasing the Community Spouse Resource Allowance 1. The CSRA shall be increased above the maximum amount if additional resources are needed to raise the community spouse's monthly income to the level of the Minimum Monthly Maintenance Needs Allowance (MMMNA). In making this determination the items listed below are calculated in the following order:

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237 equals at least 5 percent of the value of the property or assets of the disclosing entity; (e) Is an officer or director of a disclosing entity that is organized as a corporation; or (f) Is a partner in a disclosing entity that is organized as a partnership. Enrollment is defined as the process by which an individual or entity not currently enrolled as a Colorado Medicaid provider submits a provider application, undergoes any applicable screening, pays an application fee, as appropriate for the provider type, and is approved by the Department for participation in the Medicaid program. Entities that have never previously enrolled as Medicaid providers or whose enrollment was previously terminated and are not currently enrolled are required to enroll. The date of enrollment shall be considered the date that is communicated to the provider in communication from the Department or its fiscal agent verifying the provider’s enrollment in Medicaid. Revalidation is defined as the process by which an individual or entity actively enrolled as a Colorado Medicaid provider resubmits a provider application, undergoes a state- defined screening process, pays an application fee, as appropriate for the provider type, and is approved by the Department to continue participation in the Medicaid program. Disclosing Entity, defined at 42 CFR § 455.101, means a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent. Other Disclosing Entity,defined at 42 CFR § 455.101, means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or XX of the Act. This includes: (a) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII); (b) Any medicare intermediary or carrier; and

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245 8.125.10 REVALIDATION 8.125.10.A. Actively enrolled providers must complete all requirements for revalidation at least every 5 years as established by the Department, or upon request from the Department for an off-cycle review. 8.125.10.B. The date of revalidation shall be considered the date that the provider’s application was initially approved plus 5 years, or by an off-cycle request from the Department. 8.125.10.C. If a provider fails to comply with any requirement for revalidation by the deadlines established by Sections 8.125.10.A. or 8.125.10.B., the provider agreement may be terminated. In the event that the provider agreement is terminated pursuant to this section, any claims for dates of service submitted after deadlines established by Sections 8.125.10.A. or 8.125.10.B., are not reimbursable beginning on the day after the date indicated by Section 8.125.10.B. 8.125.11 SITE VISITS 8.125.11.A. All providers designated as “moderate” or “high” categorical risks to the Medicaid program must consent to and pass a site visit before they may be enrolled or re-validated as Colorado Medicaid providers. The purpose of the site visit is to verify that the information submitted to the state department is accurate and to determine compliance with federal and state enrollment requirements. 8.125.11.B. All enrolled providers who are designated as “moderate” or “high” categorical risks must consent to and pass an additional site visit after enrollment or revalidation. The purpose of the site visit is to verify that the information submitted to the state department is accurate and to determine compliance with federal and state enrollment requirements. Post-enrollment or post-revalidation site visits may occur anytime during the five-year period after enrollment or revalidation. 8.125.11.C. All providers enrolled in the Colorado Medicaid program must permit the Centers for Medicare and Medicaid Services (CMS), its agents, its designated

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248 a. for a revalidating provider, the Department shall immediately suspend the provider until a subsequent site visit demonstrates provider is in compliance. b. for an enrolling provider, deny the application and require the provider to restart the enrollment process. 8.125.11.I. The Department shall deny or terminate enrollment or revalidation of any provider who refuses to allow a site visit, unless the Department determines the provider or the provider’s staff refused the on-site inspection in error. The provider must provide credible evidence to the Department that it refused the on- site inspection in error within in 7 days of the date of the issuance of the report in Section 8.125.11.E. Any provider who does not provide credible evidence to the Department that it refused the on-site inspection in error shall be denied or terminated from enrollment or revalidation. 8.125.11.J. The Department shall deny an application or terminate a provider’s enrollment when an on-site inspection provides credible evidence that the provider has committed Medicaid fraud. 8.125.11.K. The Department shall refer providers in Section 8.125.11.J to the State Attorney General. 8.125.12 CRIMINAL BACKGROUND CHECKS AND FINGERPRINTING 8.125.12.A. As a condition of provider enrollment, any person with an ownership or control interest in a provider designated as “high” categorical risk to the Medicaid program, must consent to criminal background checks and submit a set of fingerprints, in a form and manner to be determined by the Department. 8.125.12.B. Any provider, and any person with an ownership or control interest in the provider, must consent to criminal background checks and submit a set of fingerprints, in a form and manner designated by the Department, within 30 days upon request from the Centers for Medicare and Medicaid Services (CMS), the Department, the Department’s agents, or the Department’s designated contractors.

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251 8.125.14 TEMPORARY MORATORIA 8.125.14.A. In consultation with the Centers for Medicare and Medicaid Services (CMS) and the United States Department of Health and Human Services (HHS), the Department may impose temporary moratoria on the enrollment of new providers or provider types, or impose numerical caps or other limits on providers that the Department and the Secretary of HHS identify as being a significant potential risk for fraud, waste, or abuse, unless the Department determines that such an action would adversely impact Medicaid members’ access to medical assistance. 8.125.14.B. Before imposing any moratoria, caps, or other limits on provider enrollment, the Department shall notify the Secretary of the United States Department of Health and Human Services (HHS) in writing and include all details of the moratoria. 8.125.14.C. The Department shall obtain the Secretary of the United States Department of Health and Human Services (HHS) concurrence with imposition of the moratoria, caps, or other limits on provider enrollment, before such limits shall take effect. 8.125.15 DISCLOSURES BY MEDICAID PROVIDERS, MANAGED CARE ENTITIES, MEDICARE PROVIDERS AND FISCAL AGENTS 8.125.15.A. All providers, disclosing entities, fiscal agents, and managed care entities must provide the following federally required disclosures to the Department: 1. The name and address of any entity (individual or corporation) with an ownership or control interest in the disclosing entity, fiscal agent, or managed care entity having direct or indirect ownership of 5 percent or more. The address for corporate entities must include, as applicable, primary business address, every business location, and P.O. Box address. 2. For individuals: Date of birth and Social Security number 3. For business entities: Other tax identification number for any entity with an ownership or control interest in the disclosing entity (or fiscal agent or

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252 managed care entity) or in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a 5 percent or more interest. 4. Whether the entity (individual or corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or managed care entity) is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling; or whether the entity (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a 5 percent or more interest is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling. 5. The name of any other disclosing entity (or fiscal agent or managed care entity) in which an owner of the disclosing entity (or fiscal agent or managed care entity) has an ownership or control interest. 6. The name, address, date of birth, and Social Security Number of any managing employee of the disclosing entity (or fiscal agent or managed care entity). 7. The identity of any person who has an ownership or control interest in the provider, or is an agent or managing employee of the provider who has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, Children’s Health Insurance Program or the Title XX services since the inception of these programs. 8. Full and complete information about the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12 month period ending on the date of the request; and any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request.

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255 reimburse any claim from any provider or entity or make any payment to an entity that fails to disclose information related to business transactions as required by 42 CFR § 455.105 beginning on the day following the date the information was due and ending on the day before the date on which the information was supplied. 42 CFR § 455.105 (2024) is hereby incorporated by reference. The incorporation of 42 CFR § 455.105 (2024) excludes later amendments to, or editions of the referenced material. 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 303 E. 17th Avenue, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart- B/section-455.105. Any payment made to a provider or entity that is not reimbursable in accordance with this section shall be considered an overpayment. 8.125.15.F. The Department may terminate the agreement of any provider or entity or deny enrollment of any provider that fails to disclose information when requested or required by 42 CFR § 455.100-106. 42 CFR § 455.100-106 (2024) is hereby incorporated by reference. The incorporation of 42 CFR § 455.100-106 (2024) excludes later amendments to, or editions of the referenced material. 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 303 E. 17th Avenue, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at https://www.ecfr.gov/current/title-42/chapter- IV/subchapter-C/part-455/subpart-B/section-455.106. 8.126 COLORADO NPI RULE 8.126.1 Definitions A. Billing Provider Field means the data field on a Claim that reflects the Health Care Provider to which the payer issues payment.

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256 B. Campus means the physical area immediately adjacent to the Hospital’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis by the Centers of Medicare and Medicaid Services to be part of the provider's campus. C. Claim means a request for payment for the delivery of medical care, services, or goods authorized under the Medical Assistance Program, submitted to the Department through its fiscal agent by a Health Care Provider. Claim includes the transmission of encounter information for the purpose of reporting the delivery of medical care, services, or goods. D. Health Care Provider means any person or organization that furnishes, bills for, or is paid for medical care, services, or goods to one or more Medical Assistance Program members. 1. A Health Care Provider includes an Organization Health Care Provider, Subpart of an Organization Health Care Provider, Off Campus Location, and a Site of an Organization Health Care Provider. 2. Unless specified otherwise in Subsection 8.126.1, a Health Care Provider may include a Health Care Provider located outside the state of Colorado (out-of-state provider) that is licensed and/or certified pursuant to their state laws. E. Hospital means an Organization Health Care Provider that is enrolled in the Medical Assistance Program under the Provider Type of “Hospital - General” as defined in this Subsection 8.126.1. F. Medical Assistance Program means the programs authorized under Articles 4, 5, 6, 8, and 10 of Title 25.5. G. National Provider Identifier (NPI) means the standard, unique health identifier for Health Care Providers or Organization Health Care Providers that is used by the National Plan and Provider Enumeration System (NPPES) in accordance with 45 C.F.R. sec. 162.406. 45 CFR sec. 162.406 (2024) is hereby incorporated by

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278 8.126.6 New Providers as of January 1, 2020 A. A Health Care Provider that is not enrolled as of January 1, 2020, shall not apply to be enrolled to deliver medical care, services, or goods authorized under the Medical Assistance Program unless the Health Care Provider complies with Section 8.126. 8.126.7 Existing Providers as of January 1, 2021 A. A Health Care Provider that is enrolled as of January 1, 2021, shall not apply to have their enrollment revalidated to deliver medical care, services, or goods authorized under the Medical Assistance Program, as required under 42 C.F.R. § 455.414, unless the Health Care Provider complies with Section 8.126. 8.130 PROVIDER PARTICIPATION Providers will not discriminate on the basis of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, or disability. 8.130.1 DEFINITIONS A. “Advanced Directive” means a written instruction, such as a Living Will or Durable Power of Attorney for health care, recognized under state law, whether statutory or as recognized by the courts of the state, that relates to the provision of medical care when the individual is incapacitated. B. "Agent" means any person who has been delegated the authority to obligate or act on behalf of a Provider. C. “Change of Information” means any change in information contained in the Provider’s current enrollment record with the Department, including, but not limited to, any change to a person or entity who holds a direct or indirect ownership interest in the Provider exceeding five percent and any change to the Provider’s licensure, certification registration status, accreditation, bankruptcy status, address (including any change to location(s) where good and services are rendered), contact person, telephone number, email address, or criminal conviction disclosures within the scope of 42 CFR § 455.106.

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283 2. Each Provider shall screen its employees and contractors against the List of Excluded Individuals/Entities at least monthly to capture any exclusions or reinstatements that have occurred since the last search of the database. 3. If a Provider determines that an employee or contractor of the Provider has been excluded, then the Provider shall report this to the Department within five (5) business days of the date of discovery. 4. Each screening must be documented in a manner that can be provided to the Department upon request. B. Except as otherwise provided in federal law, if the Medical Assistance Program pays for any goods or services furnished, ordered, or prescribed by an excluded individual or entity that is employed by or has contracted with a Provider, such payment shall constitute an overpayment and shall be subject to overpayment recovery, pursuant to Section 8.076. Such Provider may also be subject to sanctions by the Department, including the termination of the Provider agreement, as described at 8.076.5., if the Provider knew or should have known of the exclusion. The Provider may also be subject to civil and monetary penalties imposed by the US Department of Health and Human Services. 1. To the extent that such amount can be traced, the amount of the overpayment shall include any funds expended by the Medical Assistance Program to pay the excluded individual’s or contractor’s salary, expenses, or fringe benefits. C. Subject to federal law and the Department’s discretion, failure of a Provider to comply with the screening requirements listed at Section 8.130.35.A. may constitute good cause sufficient to justify termination of the Provider agreement, as described at 8.076.5. 8.130.40 PROVIDER EMPLOYEE OR CONTRACTOR LICENSE VERIFICATION A. As a condition of participation in the Medical Assistance program, any Provider who provides or who has employees or contractors who provide services or

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