Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

Other Services

Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Colorado (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes			Limited to procedures safely performed in ambulatory setting, as approved by CMS	Fee for service using lower of a percentage of Medicare allowable payment and inpatient hospital payment rates as ceiling	CN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes	$2/visit		Clinics must be state approved	Fee for service or prospective cost based rate	CN
Federally Qualified Health Center Services
Yes	$2/visit			Prospective cost based rate/visit with ancillaries paid fee for service, or alternative reimbursement methodology	CN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	$10/day up to 50% of payment for first day of care	Admissions for specified procedures, elective surgery admissions	Second opinions required for specified procedures, 45 day LOS for psych admissions unless court-ordered	Prospective payment/discharge using DRG or prospective per diem	CN
Outpatient Hospital Services
Yes	$3/visit			Cost based payment	CN
Rehabilitation Services: Mental Health and Substance Abuse
Yes			Rehab centers must be state-approved	Fee for service or prospective cost based rate	CN
Rural Health Clinic Services
Yes	$2/visit			Prospective cost based rate/visit with ancillaries paid fee for service or alternative reimbursement methodology	CN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes				Fee for service	CN
Chiropractor Services
No
Dental Services
No
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes				Fee for service	CN
Nurse Midwife Services
Yes				Fee for service	CN
Nurse Practitioner Services
Yes				Fee for service	CN
Optometrist Services
Yes	$2/visit	Yes		Fee for service	CN
Physician Services
Yes	$2/office or home visit, $.50/15 minute psych service			Fee for service	CN
Podiatrist Services
Yes	$2/visit			Fee for service	CN
Psychologist Services
Yes	$2/office visit, $.50/15 minute psych service			Fee for service	CN
Prescription Drugs
Prescription Drugs
Yes	$1/generic or multi-source Rx, $3/brand or single source Rx	Over the counter drugs other than insulin and aspirin, compounded Rxs	8 Rxs/month	AWP-13.5% for brand Rx, AWP-35% for generic Rx, plus $4.00 dispensing fee for each, non-traditional pharmacies receive a $1.89 dispensing fee	CN
Physical Therapy and Other Services
Occupational Therapy Services
Yes		Additional therapy	24 15-minute units/year	Fee for service	CN
Physical Therapy Services
Yes		Additional therapy	24 15-minute units/year	Fee for service	CN
Services for Speech, Hearing and Language Disorders
Yes			Diagnostic audiology procedures limited to specified conditions	Fee for service	CN
Products and Devices
Dentures
No
Eyeglasses
Yes			Limited to post-surgery lenses and eyeglasses	Fee for service	CN
Hearing Aids
No
Medical Equipment and Supplies
Yes	$1/date of service	Specified med equipment and med supply items		Fee for service	CN
Prosthetic and Orthotic Devices
Yes		Specified services or items		Fee for service, some items paid acquisition cost plus 20%	CN
Transportation Services
Ambulance Services
Yes				Fee for service	CN
Non-Emergency Medical Transportation Services
Yes				See service-specific FN	CN
Other Services
Diagnostic, Screening and Preventive Services
Yes				Dependent upon service and billing provider	CN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes	$1/date of service			Fee for service	CN
Targeted Case Management
Yes				Fee for service or negotiated rate	CN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Services for the following populations: 1, 2, 3, 4, 5, 7 & 8 - See service-specific FN	Dependent upon the services provided	CN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes		Plan of care required	Fee for service, using maximum daily rate	CN
Hospice Care
Yes			Prospective rates based on Medicare methodology	CN
Personal Care Services
No
Private Duty Nursing Services
Yes	Yes	Limited to technology-dependent beneficiaries,16 hours/day	Fee for service	CN
Program of All-Inclusive Care for the Elderly
Yes		See service-specific FN	Capitated payment	CN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes			Prospective cost based per diem	CN
Inpatient Psychiatric Services, under age 21
Yes			Prospective cost based per diem or cost based payment	CN
Intermediate Care Facility Services for the Mentally Retarded
Yes		Hosp leave days not covered, 42 therapeutic leave days/year	Cost based payment	CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes		Hosp leave days not covered, 42 therapeutic leave days/year	Prospective per diem based on cost, acuity adjusted, with limits	CN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has an approved Section 1115 HIFA Waiver from CMS, relying on federal SCHIP authority, under which it extended Medicaid eligibility to pregnant women with family income at or below 200 percent of the Federal Poverty Level. Any identified copayment requirements are applicable to beneficiaries age 19 and older. Providers may collect multiple copayments, if applicable, on the same date of service, e.g., a hospital could collect a copayment for both an outpatient visit and a laboratory service. Substance abuse treatment for pregnant women can extend up to 12 months post partum if services were initiated prior to delivery.