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Although every effort is made to ensure the accuracy of this information, discrepancies may occur. The fee schedule may not reflect any changes to rates that occurred after the effective date of the fee schedule. Such changes will be reflected in the next release of the fee schedule.
The Average Acquisition Cost (AAC) rates are used to reimburse pharmacies for covered outpatient drugs. Effective July 1, 2016, Myers and Stauffer is the vendor responsible for determining AAC rates.
If a pharmacy believes that an AAC rate does not accurately reflect the cost of a drug, the pharmacy may request a rate review by submitting a completed AAC inquiry form to Myers and Stauffer.
Pharmacy providers may contact Myers and Stauffer’s toll-free help desk line at 800-591-1183 for questions concerning the AAC rates or inquiries.
Current AAC rates are posted on Myers and Stauffer’s website at www.mslc.com/Colorado/.
In order to comply with the Protecting Access to Medicare Act (PAMA), Health First Colorado will adjust Clinical Diagnostic Laboratory Test (CDLT) rates on a per test basis to align with Medicare's quarterly release of Clinical Laboratory Fee Schedule (CLFS) rates. PAMA enacted changes to the Medicare CLFS and required that Medicaid payments for CDLTs not exceed the Medicare allowed amount for the same CDLTs. These requirements can be found in section 1903(i)(7) and section 1833(h) of the Social Security Act. Below is the rate tracking sheet for CDLT UPL codes:Clinical Diagnostic Laboratory Test (CDLT) Rate Tracking Sheet (2018.7-2020.1)
Health First Colorado is required to comply with the Consolidated Appropriations Act of 2016 (Section 503) which means Health First Colorado cannot pay more than what Medicare would have paid in the aggregate for certain DME services. The Department is referring to this requirement as the DME Upper Payment Limit (UPL). Below is the fee schedule for the codes that fall within the scope of the DME UPL.
Durable Medical Equipment Fee Schedule (2018)
Durable Medical Equipment Fee Schedule (2019)
Durable Medical Equipment Fee Schedule (2020)
Additional information regarding the UPL can be found in this letter to providers.
The remainder of the DMEPOS codes can be found under the Health First Colorado Fee Schedule drop-down.
HCBS Waiver Rate Increase Update Memo - October 2017
ACF/SLP/TLP PETI Form (8/18)
ACF/ALP/TLP PETI Form (10/18)
ACF/ALP/TLP PETI Form (1/19)
ACF and TLP PETI Form Effective 7/1/2019 (6/19)
ACF TLP PETI Effective January 2020 (12/19)
SLP PETI Effective January 2020 (12/19)
ACF TLP PETI Form (7/2020)
SLP PETI Form (7/20)
ACF TLP PETI No BI SLP (4/20)
SLP PETI (4/20)
Home Health (07/20)
Home Health (06/19)
Home Health (04/18)
Home Health (04/18)
Home Health (08/16)
Immunization Rates (01/20)
Immunization Rates (03/17)
Immunization Rates (10/16)
PETI Audiology Fee Schedule - (See Health First Colorado Fee Schedules section above)
PETI Dental Fee Schedule
PETI Vision Fee Schedule
Skilled Nursing Facility Statewide Average Fee Schedule FY 2021 (7/20)
EMT Rates (7/20)
NEMT Rates (7/20)
EMT Rates (06/19)
NEMT Rates (06/19)
EMT Rates (06/18)
NEMT Rates (06/18)
EMT Rates (04/18)
NEMT Rates (04/18)
NEMT Mass Transit Rates (04/18)
EMT Rates (09/16)
NEMT Rates (09/16)
EMT Rates (02/16)
NEMT Rates (02/16)
In May 2019 the legislature approved across the board (ATB) and targeted rate increases (TRI) and decreases (TRD) for several state plan and waiver services packages. The approved ATB effective July 1, 2019 is 1.0% for most services. The approved TRIs and TRDs are listed below. Please note HCBS TRIs will not be effective July 1, 2019; all other TRIs will be effective for July 1, 2019.
All updates require approval from CMS prior to their implementation. Once approved the Department will load rates in the interChange (iC) with a July 1, 2019 effective date. The Department will provide updates on this page and through provider bulletins when CMS approval is received, rates have been loaded and mass adjustments have occurred. Links to current information regarding rates increases are provided below. Rates are currently being updated and will posted on this page with ATB and TRI on June 1, 2019.
In May 2019, the legislature approved across the board (ATB) increases and targeted rate increases (TRI) all waiver services packages, except the HCBS Children with Autism (CWA) waiver. The approved ATB effective July 1, 2019 is 1.0% for most HCBS waiver services. The approved TRIs for HCBS waiver services are listed below. Please note HCBS TRIs will not be effective July 1, 2018. HCBS services receiving targeted rate increases include:
HCBS waiver services not listed in the table above will receive the ATB increase. All TRI updates require approval from CMS prior to their implementation. The Department is loading HCBS rates receiving the 1.0% ATB in the interChange (iC) and rates will be in place and reimburse for dates of services on or after July 1, 2019. Once approved the Department will load rates for TRIs in the iC with the CMS approved effective date. The expected effective dates for TRI implementation is shown in the table above. The Department will provide updates on this page and through provider bulletins when CMS approval is received for TRIs, rates have been loaded and mass adjustments have occurred. Fee schedules have been updated and will on this page with ATB increases. Fee schedules are currently being updated and will posted on this page with TRIs on June 1, 2019.
Procedure codes for health care services are updated annually in January to add new codes, remove obsolete codes, update existing codes and replace codes that have changed. Coding Procedure Terminology (CPT) is determined and published by the American Medical Association (AMA), and HCPCS (Healthcare Common Procedure Coding System) is determined and published by Centers for Medicare and Medicaid Services (CMS). The list of code changes is released in the 4th quarter of each year. See the documents below detailing the Rate Methodology for setting rates for new codes, the fee schedule, crosswalk, code list file, and rate methodology inputs by code for each fiscal year below:
January 1, 2019 HCPCS Updates
January 1, 2018 HCPCS Updates
Laboratory Rebalancing Effective July 1, 2019
Laboratory and Pathology procedure codes were reviewed through the Medicaid Provider Rate Review Advisory Committee (MPRRAC) in 2016. During this year the Centers for Medicare and Medicaid Services (CMS) reviewed clinical laboratory codes in relation to the addition of clinical laboratory diagnostic tests to the Social Security Act through the Protecting to Access to Medicare Act (PAMA). CMS released the clinical laboratory fee schedule with the new rate methodology effective January 1, 2018.
Department has been working internally on laboratory rebalancing in alignment with the recommendations from the MPRRAC to review rates following the release of revised CMS laboratory fee schedule. The Department identified hundreds of codes that were outside of 80%-100% of Medicare benchmark. As a result the Department focused on rebalancing codes that were less than 20% of Medicare and greater than 200% of Medicare. Laboratory procedure codes impacted by rebalancing are displayed below:
The Department will issue a provider bulletin on June 1, 2019, and has posted a clinical laboratory fee schedule for rebalanced codes and additional information is provided below. All clinical laboratory code rates can be found on the Health First Fee Schedule and will be updated and posted to the website with rates effective July 1, 2019 in June.