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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/.
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.
ACF/SLP/TLP PETI Form (8/18)
ACF/ALP/TLP PETI Form (10/18)
ACF/ALP/TLP PETI Form (1/19)
Home Health (04/18)
Home Health (04/18)
Home Health (08/16)
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
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 2018 the legislature approved across the board (ATB) and targeted rate increases (TRI) for several state plan and waiver services packages. The approved ATB effective July 1, 2018 is 1.0% for most services. The approved TRIs are listed below. Please note HCBS TRIs will not be effective July 1, 2018; all other TRIs will be effective retroactively for July 1, 2018.
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, 2018 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, 2018.
FY2018-19 Annual Across-the-Board (ATB) and Targeted Rate Increases for HCBS Waivers
The Department is currently working to implement HB 18-1407 rates effective March 1, 2019 (link and additional information provided below). The Department was not required to seek CMS approval for these increases. HCBS fee schedules will be updated to reflect the 6.5% increase and posted under HCBS fee schedules on March 1, 2019. To ensure providers have access to the rates being implemented with HB 18-1407 the Department has created HB 18-1407 specific fee schedules provided below. The HB 18-1407 fee schedule lists only those services receiving the 6.5% increase. The Support Plan Authorization Limits (SPALs) have been updated to include the 6.5% increase and are included on the HB 18-1407 fee schedules. Additional information regarding the implementation of HB 18-1407 is provided in the Information Memo, IMPLEMENTATION OF HOUSE BILL 18-1407, STABILIZATION OF DIRECT SUPPORT PROFESSIONAL WORKFORCE STAKEHOLDER ENGAGEMENT and can be found below:
The Department received approval from legislature for targeted rate increase for Personal Care and Homemaker Services for the HCBS EBD, CMHS, BI, and SCI waivers. The Personal Care and Homemaker rate will increase by 5.25% effective January 1, 2019 and HCBS fee schedules have been updated to include these increases. The updated rates are being loaded into the interChange at this time. Providers will not have to submit adjustments to claims to receive the increased payment unless the usual and customary charges are less than the new rate effective January 1, 2019.
The Department received approval from Centers for Medicare & Medicaid Services (CMS) for the Alternative Care Facility targeted rate increase. The ACF rate will increase by 25% to $64.90 effective October 1, 2018. The updated rates have been loaded into the interChange and HCBS fee schedules have been updated to include these increases.. Providers will not have to submit adjustments to claims to receive the increased payment unless the usual and customary charges are less than the new rate effective October 1, 2018.
In May 2018, 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, 2018 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:
*Services will receive 1% ATB increase in addition to TRI listed above
HCBS waiver services not listed in the table above will receive the ATB increase. Please note that the HCBS DD, SLS, and CES services receiving a TRI will also receive the 1.0% ATB increases, with the exception of Non-Medical Transportation. All other HCBS services receiving a TRI will not receive the ATB rate increases. All TRI updates require approval from CMS prior to their implementation. The Department is loading rates in the interChange (iC) with a July 1, 2018, effective for ATB increases and rates will be in place and reimburse for dates of services on or after July 1, 2018. 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. Links to current information regarding rates increases are provided below. 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 15, 2018. Links to current information regarding rates increases are provided below.
The Department received approval from Centers for Medicare & Medicaid Services (CMS) for the CCT services transition to the waiver and TXIX programs: Transition Coordination, Transition Set Up-Coordination, Transition Set Up-Expense, Home Delivered Meals, Transition Independent Living Skills Training, Peer Mentorship. The service rates are effective January 1, 2019 and HCBS fee schedules have been updated to include these services. The updated rates have been loaded into the interChange. Providers will not have to submit adjustments to claims to receive the increased payment unless the usual and customary charges are less than the new rate effective January 1, 2019.
The Department implemented Colorado Choice Transitions demonstration program in April 2013 to help transition Medicaid members out of nursing homes, intermediate care facilities or regional centers into home and community-based settings. Federal funding for the CCT demonstration will end in December 2018. The Colorado legislature passed House Bill 18-1326, directing the Department to implement the CCT services that were successful in helping client’s transition services in the Home and Community Based Waiver (HCBS) and in the Medicaid state plan. The transition of these services requires amendments to the Medicaid State Plan and to adult HCBS waivers. To avoid a gap in new enrollments the services will transition to the HCBS waivers and state plan effective January 1, 2019, pending CMS approval.
The following services will be transitioning to the Adult Long Term Support Services (LTSS) waivers (Elderly, Blind and Disabled, Community Mental Health Supports, Brain Injury, Spinal Cord Injury, Developmental Disabilities, and Supportive Living Services) pending approval from CMS. The table below includes the rates, units and limits to for the transitioning services effective January 1, 2019 with CMS approval.
In 2017 the Department calculated all LTSS HCBS fee-for-service waiver rates utilizing the HCBS rate methodology. The rate methodology and rate setting were required to receive approval of the across the board and targeted rate increases approved by the legislature for FY2017-18. The Department introduced the methodology to stakeholders in May 2017 and solicited feedback on the rate methodology. After the calculation of the rates, stakeholders were provided with the salary and capital inputs used to develop each service rate. The Department solicited feedback on these inputs prior to finalizing the rates. Resources related to the HCBS rate methodology, inputs by service, and the final rates can be found below:
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.