SECRETARY OF STATE
RULES ACTION SUMMARY AND FILING INSTRUCTIONS

SUMMARY OF ACTION ON RULE(S)

1.  Department / Agency Name:	Health Care Policy and Financing / Medical Services Board	
2.  Title of Rule:	MSB 06-08-21-C, Children's Basic Health Plan, benefits and cost-sharing premium assistance rule	
3.  This action is an adoption of:	new rules	
4.  Rule sections affected in this action (if existing rule, also give Code of Regulations number and page numbers affected): 	
Sections(s) affected include CBHP Benefits Package 220 and Enrollment Fees and Copayments 360, Colorado Department of Health Care Policy and Financing, Medical Assistance (10 CCR 2505-3).	
5.  Does this action involve any temporary or emergency rule(s)?	Yes	
If yes, state effective date:		
Is rule to be made permanent? (If yes, please attach notice of hearing).	Yes	

FILING INSTRUCTIONS

Date rule is to be effective							10/17/06

Please insert Section 220 (new section to rule) PREMIUM ASSISTANCE immediately following Section 210.26.FF

Please insert Section 360 (new section to rule) PREMIUM ASSISTANCE immediately following Section 350.4.D

A copy of the Attorney General’s opinion attached

A copy of the Statement of Basis and Purpose is attached
If a rule has been amended:

Title of Rule:	Children's Basic Health Plan, benefits and cost-sharing premium assistance rule	
Rule Number:	MSB 06-08-21-C	
Division / Contact / Phone:	Children's Basic Health Plan / Sarah L. Sills / 303-866-3385	
STATEMENT OF BASIS AND PURPOSE
1.	Summary of the basis and purpose for the rule or rule change.  (State what the rule says or does and explain why the rule or rule change is necessary).	
The purpose of this rule is to implement a premium assistance program as required by the Standard Terms and Conditions for the Adult Prenatal Coverage in CHP+ 1115 HIFA Waiver.	
2.	An emergency rule-making is imperatively necessary	
	to comply with state or federal regulation and/or	
	for the preservation of public health, safety and welfare.	
Explain:	
Since 2002, the requirements for 1115 HIFA waiver have been changed to require the implementation of a premium assistance program.  At this time the implementation of a premium assistance program is a required component of the new Adult Prenatal Coverage in CHP+ 1115 HIFA waiver.  The Department received federal approval for the waiver in on September 29, 2006.

If the Department does not implement the premium assistance program the Department will lose its federal financial participation funds to operate the Adult Prenatal Coverage in CHP+ program. The loss of federal financial participation will result in a state only funded program and possibly the termination of benefits provided to the program's enrollees. 	
3.	Federal authority for the Rule, if any:	
42 C.F.R. Section 457.402 (y) 	
4.	State Authority for the Rule:	
25.5-1-301 through 25.5-1-303, C.R.S. (2006);
Section 25.5-8-102(5)(d), C.R.S., 25.5-8-107(1)(f), and 25.5-8-112, C.R.S., (2006).     	

Initial Review		Final Adoption	11/09/06	
Proposed Effective Date	10/13/06	Emergency Adoption	10/13/06	
DOCUMENT # 01

Title of Rule:	Children's Basic Health Plan, benefits and cost-sharing premium assistance rule	
Rule Number:	MSB 06-08-21-C	
Division / Contact / Phone:	Children's Basic Health Plan / Sarah L. Sills / 303-866-3385	

REGULATORY ANALYSIS

1.	Describe the classes of persons who will be affected by the proposed rule, including classes that will bear the costs of the proposed rule and classes that will benefit from the proposed rule.
This rule will affect CBHP eligible persons up to age 19 by allowing them to enroll in either CBHP or the CBHP premium assistance program. Persons enrolled in the premium assistance program will have access to health benefits via their guardian's employer. The employer sponsored insurance will be required to meet basic benefit coverage standards, including the coverage of emergency care, well baby/child examinations, inpatient hospital services, and age appropriate immunizations. 

The cost of implementing the premium assistance program and the rules will be absorbed by the existing CBHP budget. Since the program is a required component of the Department's Adult Prenatal Coverage in CHP+ 1115 HIFA waiver the budget must be neutral; therefore as long as state and federal funds are adequate to cover Title XXI and HIFA waiver enrollees, premium assistance will not be limited.

Beneficiaries of this rule include children and their families. Through the implementation of the premium assistance program the Department will be able to provide increased coverage to CBHP eligible children and their families if it is determined to be cost effective for the state.  

2.	To the extent practicable, describe the probable quantitative and qualitative impact of the proposed rule, economic or otherwise, upon affected classes of persons.
Eligible CBHP enrollees will be able to select the current CBHP program or the premium assistance program for their health care needs. The family will be able to purchase that coverage with a subsidy from the Department based on the number of CBHP eligible children.

A premium assistance enrollee will receive the benefits provided by the employer sponsored insurance, ESI plan. The ESI plan must at a minimum cover emergency care, well baby/child examinations, inpatient hospital services, and age appropriate immunizations. The family will not receive wrap-around benefits that are not covered by the employer sponsored insurance plan.

Families will be responsible for all cost sharing requirements associated with the selected employer sponsored insurance plan including but not limited to co-payments, coinsurance, and deductibles. 

3.	Discuss the probable costs to the Department and to any other agency of the implementation and enforcement of the proposed rule and any anticipated effect on state revenues.
The costs of implementation and enforcement of these rules will be absorbed by the existing Children's Basic Health Plan (CBHP) appropriation. Tasks related to the implementation of the premium assistance program will be absorbed by existing Department CBHP staff. 

4.	Compare the probable costs and benefits of the proposed rule to the probable costs and benefits of inaction.
The cost of inaction is the noncompliance with the standard terms and conditions of the Adult Prenatal Coverage in CHP+ 1115 HIFA waiver. This noncompliance would result in the loss of federal financial participation (FFP) for the waiver's expansion population, pregnant women over age 19 and result in a state only funded program.

5.	Determine whether there are less costly methods or less intrusive methods for achieving the purpose of the proposed rule.
At this time there is not a less costly or intrusive method for implementing a premium assistance program, unless the Department proposes to terminate the Adult Prenatal Coverage in CHP+ waiver. 

6.	Describe any alternative methods for achieving the purpose for the proposed rule that were seriously considered by the Department and the reasons why they were rejected in favor of the proposed rule.
At this time no other alternative methods for achieving the implementation of premium assistance exist. A feasibility study, completed in 2001, determined the implementation of a premium assistance program was not feasible at the time due to low projected enrollment numbers and high administrative costs. As a result the Department did not propose a premium assistance program as part of its 2002 Adult Prenatal Coverage in CHP+ 1115 HIFA waiver. 

Since 2002 the requirements for 1115 HIFA waiver have changed to require the implementation of a premium assistance program. At this time the implementation of a premium assistance program will be a required component of the new Adult Prenatal Coverage in CHP+ 1115 HIFA waiver. 

BENEFITS PACKAGE                                                                                           200-210
210	The following are covered benefits including any applicable limitations:
1.	Emergency Care and Urgent/After Hours Care;
2.	Emergency Transport/Ambulance Services;
3.	Hospital/Other Facility Services Including:
A.	Inpatient;
B.	Physician;
C.	Outpatient/Ambulatory;
4.	Medical Office Visits Including:
A.	Physician;
B.	Mid-Level Practitioner;
C.	Specialist;
5.	Diagnostic Services;
6.	Preventative, Routine and Family Planning Services Including:
A.	Immunizations;
B.	Well-child visits;
C.	Health maintenance visits;
7.	Maternity Care Including:
A.	Prenatal;
B.	Delivery and inpatient well-baby care;
C.	Postpartum care
8.	Mental Illness Treatments such as:
A.	Neurobiologically-based mental illness including:
a.	Schizophrenia;
b.	Schizoaffective disorder;
c.	Bipolar affective disorder;
d.	Major depressive disorder;
e.	Specific obsessive compulsive disorder;
f.	Panic disorder;
B.	All other mental illness;
a.	Inpatient coverage shall be limited to 45 inpatient days with the option of converting those 45 inpatient days to 90 outpatient days of day treatment services;
b.	Outpatient coverage shall be limited to 20 visits;
9.	Chemical Dependency Treatments shall be limited to 20 visits with no inpatient coverage;
10.	Physical Therapy, Speech Therapy and Occupational Therapy shall be limited to 30 visits per diagnosis per year;
11.	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.
12.	Transplants must be medically necessary and are limited to:
A.	Liver;
B.	Heart;
C.	Heart/lung;
D.	Cornea;
E.	Kidney;
F.	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;
G.	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;
13.	Home health care;
14.	Hospice care;
15.	Prescription medication;
16.	Kidney dialysis shall be excluded only if the member is also eligible for Medicare;
17.	Skilled nursing facility care must be provided only when there is a reasonable expectation of measurable improvement in the members' health status.
18.	Vision services shall be limited to:
A.	Vision screenings for age appropriate preventative care;
B.	Referral required for refraction services;
C.	Maximum fifty dollar benefit for eyeglasses;
19.	Audiology services shall be limited to:
A.	Hearing screenings for age appropriate preventative care;
B.	A maximum of eight hundred dollars per year for hearing aides for the following conditions:
a.	congenital
b.	traumatic injury
20.	Intractable pain;
21.	Autism;
22.	Case management is covered only when medically necessary;
23.	Dietary counseling/nutritional services shall be limited to:
A.	Formula for metabolic disorders;
B.	Total parenteral nutrition;
C.	Enterals and nutrition products;
D.	Formulas for gastrostemy tubes;
24.	Dental services are limited to:
A.	Those dental services described in the Evidence of Coverage provided to enrollees aged 18 and under by the MCO (or its designee) with which the Department has contracted for the applicable plan year to provide such dental services;
B.	Orthodontic and prosthodontic treatment for cleft lip or cleft palate in newborns (covered as a medical service in accordance with 10-16-104, C.R.S.); and
C.	Treatment of teeth or periodontium required due to accidental injury to naturally sound teeth (covered as a medical service in accordance with 10-16-104, C.R.S.). A physician or legally licensed dentist must perform treatment within 72 hours of the accident.
25.	Therapies covered shall include:
A.	Chemotherapy;
B.	Radiation;
26.	The following are not covered benefits:
A.	Acupuncture;
B.	Artificial conception;
C.	Biofeedback;
D.	Blood, plasma or derivatives;
E.	Inpatient chemical dependency treatment;
F.	Chiropractic care;
G.	Convalescent care or rest cures;
H.	Cosmetic surgery;
I.	Custodial care;
J.	Domiciliary care;
K.	Duplicate coverage;
L.	Government institution or facility services;
M.	Hair loss treatments;
N.	Hypnosis;
O.	Infertility services;
P.	Maintenance therapy;
Q.	Nutritional therapy unless specified otherwise;
R.	Post-termination services;
S.	Personal comfort items;
T.	Physical exams for employment or insurance;
U.	Private duty nursing services;
V.	Routine foot care;
W.	Sex change operations;
X.	Sexual disorder treatments;
Y.	Taxes;
Z.	TMJ treatment;
AA.	Other therapies and treatments which are not medically necessary;
BB.	Vision services unless specified otherwise;
CC.	Vision therapy;
DD.	War-related conditions;
EE.	Weight-loss programs;
FF.	Work-related conditions;
220	PREMIUM ASSISTANCE

220.1	The benefit package as described in section 210 shall not apply to Children’s Basic Health Plan premium assistance enrollees.
220.2	An employers’ health benefits plan shall meet minimum health coverage standards that includes, but is not limited to:
A.	Preventive health services (including well-baby/well-child examinations);
B.	Immunizations;
C.	Inpatient hospital services; and
D.	Emergency care.
220.3	A Children’s Basic Health Plan premium assistance program enrollee shall receive benefits limited to those covered by the employer sponsored insurance plan. The enrollee shall not receive wrap around benefits.

220.4	If a Children’s Basic Health Plan premium assistance program enrollee does not agree with the employer sponsored insurance benefit coverage decisions, the enrollee shall use the employer sponsored insurance, ESI, grievance and appeals process.

ENROLLMENT FEES AND COPAYMENTS					     300-320.1
300	ENROLLMENT FEES AND COPAYMENTS
310	ANNUAL ENROLLMENT FEES AND DUE DATE
310.1	For eligible children, the following annual enrollment fees shall be due prior to enrollment in the Children's Basic Health Plan:
A.	For families with income, at the time of eligibility determination, less than 151% of the federal poverty level, the annual enrollment fee shall be waived.
B.	For families with income, at the time of eligibility determination, between 151% and 200% of the federal poverty, the annual enrollment fee shall be:
1.	Twenty-five dollars for a single eligible child; and
2.	Thirty-five dollars for two or more eligible children.
3.	Waived for families who include an eligible pregnant woman.
310.2	If the required enrollment fee is not received with the application for the Children's Basic Health Plan, the Department or its designee shall notify the applicant:
A.	That applicable enrollment fees are a requirement for enrollment;
B.	That fees shall be due within thirty (30) days of the date of notification;
C.	Of effective date of enrollment if payment is received; and
D.	That the application shall be denied if payment is not received by the due date indicated.
310.3	The application shall be denied if payment is not received by the due date indicated on the notification.
310.4	The enrollment fees stated in this section shall apply to applications received on or after January 1, 2001.
310.5	Once enrollment has occurred, the annual enrollment fee is non-refundable.
320	COPAYMENTS
320.1	The following copayments shall be due for enrollees at the time of service:
A.	For families with income, at the time of eligibility determination, less than 101% of the federal poverty level, all copayments shall be waived, except for emergency and urgent/after hours care, which shall be three dollars per use.
B.	For families with income, at the time of eligibility determination, between 101% and 150% of the federal poverty level, the copayment shall be:
1.	Two dollars per office visit;
2.	Two dollars per outpatient mental health or substance abuse visit;
3.	One dollar per prescription; 
4.	Two dollars per physical therapy, occupational therapy or speech therapy visit;
5.	Two dollars per vision visit;
6.	Three dollars per use of emergency care and urgent/after hours care.
C.	For families with income, at the time of eligibility determination, between 151% and 200% of federal poverty level, the copayment shall be:
1.	Five dollars per office visit;
2.	Five dollars per outpatient mental health or substance abuse visit;
3.	Three dollars per generic prescription;
4.	Five dollars per brand name prescription;
5.	Five dollars per physical therapy, occupational therapy or speech therapy visit;
6.	Five dollars per vision visit;
7.	Fifteen dollars per use of emergency care and urgent/after hours care.
330	COST SHARING LIMITATIONS
330.01	Cost sharing shall mean payments, such as copayments or enrollment fees that are due on behalf of the enrollee.
330.1	American Indians and Alaskan Natives shall be exempt from cost sharing requirements.  American Indian shall mean a member of a federally recognized Indian tribe, band, or group, or a descendant in the first or second degree of any such member.  Alaskan Native shall mean an Eskimo or Aleut or other Alaska Native enrolled by the Secretary of the Interior.
330.2	The maximum yearly cost sharing requirements for families of enrollees shall be 5% of income.
330.3	No copayments shall apply to preventive services. For the purpose of this section, preventive services shall mean:
A.	All healthy newborn and newborn inpatient visits, including routine screening whether provided on an inpatient or outpatient basis.
B.	Routine examinations.
C.	Laboratory tests.
D.	Immunizations and related office visits.
E.	Routine preventive and diagnostic dental services.
350	APPEALS PROCESS
350.1	Applicants shall be notified of any action regarding the cost sharing requirements for the enrollee’s participation in the Children’s Basic Health Plan and appeal rights regarding those requirements by the Department or its designee.
350.2	If an applicant is to be denied for nonpayment of the enrollment fee, the Department or its designee shall notify the applicant within ten (10) calendar days of the decision to deny the application.  The notice shall:
A.	Be in writing; and
B.	Be in his/her primary language, to the extent practicable; and
C.	Describe to the applicant the reasons for the decision; and
D.	Document authority for the decision (e.g. rule citation); and
E.	Inform the applicant of his/her rights and responsibilities regarding the decision.
350.3	If an applicant does not agree with the cost sharing requirements for the enrollee’s participation, the applicant may appeal the requirements by requesting, in writing, reassessment of income.
350.4	An applicant who disagrees with a denial of enrollment for nonpayment of the enrollment fee may appeal by means of a dispute resolution conference, which shall be requested by the applicant in writing within thirty (30) calendar days of the date of the notification of denial.  The results of the dispute resolution conference shall be communicated to the applicant within ten (10) calendar days of the dispute resolution conference and shall be final.  The following guidelines shall apply to the dispute resolution conference:
A.	The dispute resolution conference shall be conducted by an independent panel appointed by the Executive Director of the Department.  The panel shall include at least three people not previously involved with the grievance.  A person previously involved with the grievance may be present at the conference and appear before the panel to present information and answer questions, but shall not have a vote.  The Department shall ensure that those appointed to the panel have sufficient experience to make an informed decision regarding the grievance under review.
B.	The applicant may be present at the dispute resolution conference in person or by telephone.
C.	The applicant may be represented by the person of the applicant's choice (i.e. legal counsel, friend, family member, etc.) during the dispute resolution conference.
D.	The applicant may have access to documents that were used by the Department or its designee in making the decision under appeal.
360	PREMIUM ASSISTANCE
360.1	Sections 310 Annual enrollment fees and due date, 320 Copayments, 330 Cost sharing limitations, 350 Appeals process shall not apply to the Children’s Basic Health Plan premium assistance enrollees.
360.2	A Children’s Basic Health Plan premium assistance program enrollee shall be responsible for paying all copayments, coinsurance, premiums, and deductibles required by the employer sponsored insurance plan regardless of any maximum cost-sharing limits established by the Children’s Basic Health Plan.
360.3	If a Children’s Basic Health Plan premium assistance program enrollee does not agree with the employer sponsored insurance cost sharing requirements, the enrollee shall use the employer sponsored insurance appeals process.