210 The following are covered benefits including any applicable limitations:

A. Emergency Care and Urgent/After Hours Care; B. Emergency Transport/Ambulance Services; C. Hospital/Other Facility Services Including: 1. Inpatient; 2. Physician; 3. Outpatient/Ambulatory; D. Medical Office Visits Including: 1. Physician; 2. Mid-Level Practitioner; 3. Specialist; E. Diagnostic Services; F. Preventative, Routine and Family Planning Services Including: 1. Immunizations; 2. Well-child visits; 3. Health maintenance visits; 4. Abortion (Effective January 1, 2026) G. Maternity Care Including: 1. Prenatal; 2. Delivery and inpatient well-baby care; 3. Postpartum care 4. Lactation Services & Support H. Mental Illness Treatments such as: 1. Neurobiologically-based mental illness 2. Mental disorders 3. All other mental illness; I. Physical Therapy, Speech Therapy and Occupational Therapy shall be limited to 30 visits per diagnosis per year. Effective November 1, 2007, Physical, Speech and Occupational Therapy services shall be unlimited for children from birth up to the child’s third birthday. J. Durable Medical Equipment shall be limited to the lesser of the purchase price or rental price for medically necessary durable medical equipment that shall not exceed two thousand dollars per year. K. Transplants must be medically necessary and are limited to: 1. Liver; 2. Heart; 3. Heart/lung; 4. Cornea; 5. Kidney; 6. Bone marrow which shall be limited to the following conditions: a. Aplastic anemia; b. Leukemia; c. Immunodeficiency disease; d. Neuroblastoma; e. Lymphoma; f. High risk stage II and III breast cancer; g. Wiskott aldrich syndrome; 7. Peripheral stem cell support which shall be limited to the following conditions: a. Aplastic anemia; b. Leukemia; c. Immunodeficiency disease; d. Neuroblastoma; e. Lymphoma; f. High risk stage II and III breast cancer; g. Wiskott aldrich syndrome; L. Home health care; M. Hospice care; N. Prescription medication; O. Kidney dialysis shall be excluded only if the member is also eligible for Medicare; P. Skilled nursing facility care must be provided only when there is a reasonable expectation of measurable improvement in the members' health status. Q. Vision services shall be limited to: 1. Vision screenings for age appropriate preventative care; 2. Referral required for refraction services; 3. Minimum fifty dollar benefit for eyeglasses; R. Audiology services shall be limited to: 1. Hearing screenings for age appropriate preventative care; 2. Hearing aids without financial limitation for enrollees age 18 and under no more than once every five years unless medically necessary including: a. A new hearing aid when alterations to the existing hearing aid cannot adequately meet the needs of the child b. Services and supplies including, but not limited to, the initial assessment, fitting, adjustments, and auditory training that is provided according to accepted professional standards. S. Intractable pain; T. Gender-affirming care (see 10 CCR 2505-10, 8.735) U. Case management is covered only when medically necessary; except that Targeted Case Management authorized by the 1115 Demonstration Waiver titled Colorado Expanding the Substance Use Disorder (SUD) Continuum of Care and described in Attachment G to the Center for Medicare & Medicaid Services’ (“CMS”) Demonstration Approval dated October 14, 2025 is available to inmates of public institutions 90 days prior to their release. Targeted Case Management is only available while approved by CMS. CMS’s Demonstration Approval dated October 14, 2025 is hereby incorporated by reference. This incorporation 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. 17 Ave., 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 www.medicaid.gov. V. Dietary counseling/nutritional services shall be limited to: 1. Formula for metabolic disorders; 2. Total parenteral nutrition; 3. Enterals and nutrition products; 4. Formulas for gastrostomy tubes; W. Dental services are limited to: 1. Those dental services described in the Children’s Basic Health Plan dental Evidence of Coverage booklet provided to enrollees, who are less than nineteen years of age. Beginning October 1, 2019, the dental services listed below are covered benefits for enrolled pregnant women of any age, excepting Limited Orthodontic services under Section 210.W.1.h for pregnant women age nineteen and above. Children’s Basic Health Plan dental services are provided by the dental MCO (or its designee) with which the Department has contracted for the applicable plan year to provide the following dental services; a. Diagnostic b. Preventive c. Restorative d. Endodontic e. Periodontic f. Prosthodontic g. Oral and Maxillofacial Surgery h. Limited Orthodontic, excepting pregnant women age nineteen and above. i. Adjunctive General Services 2. Orthodontic and prosthodontic treatment for cleft lip or cleft palate in newborns (covered as a medical service in accordance with section 10-16-104, C.R.S.); and 3. Treatment of teeth or periodontium required due to accidental injury to naturally sound teeth (covered as a medical service in accordance with section 10-16-104, C.R.S.). A physician or legally licensed dentist must perform treatment within 72 hours of the accident. X. Therapies covered shall include: 1. Chemotherapy; 2. Radiation; Y. The following are not covered benefits: 1. Acupuncture; 2. Artificial conception; 3. Biofeedback; 4. Storage Costs for umbilical blood; 5. Chiropractic care; 6. Convalescent care or rest cures; 7. Cosmetic surgery; 8. Custodial care; 9. Domiciliary care; 10. Duplicate coverage; 11. Government institution or facility services; 12. Hair loss treatments; 13. Hypnosis; 14. Infertility services; 15. Maintenance therapy; 16. Nutritional therapy unless specified otherwise; 17. Personal comfort items; 18. Physical exams for employment or insurance; 19. Private duty nursing services; 20. Routine foot care; 21. Taxes; 22. Temporomandibular joint (TMJ) treatment, unless it has a medical basis; 23. Other therapies and treatments which are not medically necessary; 24. Vision services unless specified otherwise; 25. Vision therapy; 26. War-related conditions; 27. Weight-loss programs; 28. Work-related conditions;