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In accordance with Section 21 of Article X (Tobacco Taxes for Health-Related Purposes) of the State Constitution, an increase in Colorado’s tax on cigarettes and tobacco products became effective January 1, 2005 and created a cash fund that was designated for health-related purposes. House Bill 05-1262 divided the tobacco tax cash fund into separate funds, assigned 19% of the moneys to establish the Primary Care Fund, set forth how the funds will be allocated and designated the Department of Health Care Policy and Financing (the Department) as the administrator of the Primary Care Fund.
The Primary Care Fund provides an allocation of moneys to health care providers that make basic health care services available in an outpatient setting to residents of Colorado who are considered medically indigent. Moneys shall be allocated based on the number of medically indigent patients served by one health care provider in an amount proportionate to the total number of medically indigent patients served by all health care providers who qualify for moneys from this fund.
To qualify for PCF the agency must provide or arrange for the provision of services on a year-round basis (consecutive 52-week period) for the following comprehensive primary care services:
Patients that you may count on the PCF application are those who have had a face-to-face visit/encounter and received at least one of the services under the definition of comprehensive primary care during the applicable calendar year but you may not count the same patient more than once. The following patients are not allowable in the unduplicated patient count:
Patients who received services from any of the following are not allowable:
The freeze date will act as a point of time in which data is fixed and definite so that a count can be made. The patient’s visit closest to your freeze date is the source designation used in the application. The unduplicated patient count should be calculated on a specific point-in-time occurring between the end of the applicable calendar year and prior to the submission of the application. For example, the FY 2020-21 PCF application due May 22, 2020 and includes data from the calendar year 2019. In this example, your freeze date could be anywhere from December 31, 2019 – May 21, 2020.
The PCF awards are based on the uninsured population of patients whose Federal Poverty Level (FPL) is below 200%. Those patients that are with Colorado Indigent Care Program (CICP) may be included in this population. PCF funding does not include patients who were enrolled in:
Under 10 CCR 2505-10, Section 8.950.2.Q., a Third-Party Payer is defined as:
"Any individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient. Examples include the Medical Assistance Program; the Children's Basic Health Plan; Medicare; commercial, individual or employment-related health insurance; court-ordered health insurance (such as that required by non-custodial parents); workers' compensation; automobile insurance; and long-term care insurance. The Colorado Indigent Care Program is not considered a Third-Party Payer and payments received from the Colorado Indigent Care Program are not considered Third Party Payments."
Note that the definition of Medically Indigent Patient is not limited to those who do not have public or private health insurance, but also those without "any other governmental reimbursement for health care costs" and where "there is no Third-Party Payer." Also note that the definition of Third-Party Payer is "any individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient" and that some of the examples are not health insurance plans. Third Party Payer is not limited to health insurance plans or to those plans or programs that provide coverage for the full array of comprehensive primary care services.
To meet the qualifications of a Primary Care Fund provider the provider must accept all patients regardless of their ability to pay and use a Sliding Fee Schedule for payments or do not charge Medically Indigent Patients for services (10 CCR 2505-10 8.950.2.N.1.). The Sliding Fee Schedule is a tiered co-payment system that determines the level of patient’s financial participation and guarantees that the patient financial participation is below usual and customary charges. Factors considered in establishing the tiered co-payment system shall only be financial status and the number of members in the patient’s family unit (10 CCR 2505-10 8.950.2.P.).
As a result, if a provider is charging patients on a Self-Pay rate that is outside of the provider’s Sliding Fee Schedule or is not at a zero dollar rate those patients are not to be included in the final Medically Indigent Patient count and should be eliminated during the methodology process on the Primary Care Fund application.
The following documentation is required for the PCF application:
Sliding Fee Scales and Co-Payments
Certification by Outside Entity
An agency must complete the entire application if you are a new applicant. In addition, returning applicants must complete the entire application every three years.
Recipients of PCF funding can expect to go through the audit process approximately every three years by the Department and their vendor.
Access to files and documentation supporting the data in your application shall be made available for a period of 5 – 7 years following the submission of the application.
If the data validation review uncovers overreported numbers in your application, you can expect a financial adjustment reflecting those findings in your fourth quarter payment.
The awarded amount is allocated based on the number of medically indigent patients served and the initial budget appropriation of tobacco tax revenue. PCF payments are dispersed in quarterly installments beginning the fall of the grant fiscal year. Recipients of PCF funding can expect their fourth quarter payment to be adjusted to the final tobacco tax revenue received in the grant fiscal year and final data validation findings.