10 Colo. Code Regs. § 2505-10-8.3001

Current through Register Vol. 47, No. 18, September 25, 2024

Section 10 CCR 2505-10-8.3001 - [Effective 10/12/2024] DEFINITIONS

1. "Act" means the Colorado Healthcare Affordability and Sustainability Enterprise Act of 2017, § 25.5-4-402.4, C.R.S.

2. "CHASE" or "Enterprise" means the Colorado Healthcare Affordability and Sustainability Enterprise described in C.R.S. § 25.5-4-402.4(3).

3. "CICP" means the Colorado Indigent Care Program, as described in 10 CCR 2505-10, Section 8.900.

4. "CICP Day" means an inpatient hospital day for a recipient enrolled in the CICP.

5. "CMS" means the federal Centers for Medicare and Medicaid Services.

6. "Critical Access Hospital" means a hospital qualified as a critical access hospital under 42 U.S.C. § 1395i-4(c)(2) and licensed or certified as a critical access hospital by the Colorado Department of Public Health and Environment.

7. "Disproportionate Share Hospital Payment" or "DSH Payment" means the payments made to qualified hospitals that serve a disproportionate share of Medicaid and uninsured individuals as required under 42 U.S.C. § 1396r-4. Federal law establishes an annual DSH allotment for each state that limits federal financial participation for total statewide DSH payments made to hospitals.

8. "Enterprise Board" means the Colorado Healthcare Affordability and Sustainability Enterprise Board described in C.R.S. § 25.5-4-402.4(7).

9. "Essential Access Hospital" means a Critical Access Hospital or General Hospital not located within a Metropolitan Statistical Area (MSA) designated by the United States Office of Management and Budget and having 25 or fewer licensed beds.

10. "Exclusive Provider Organization" or "EPO" means a type of managed care health plan where members are not required to select a primary care provider or receive a referral to receive services from a specialist. EPOs will not cover care provided out-of-network except in an emergency.

11. "Fund" means the healthcare affordability and sustainability fee cash fund described in C.R.S. § 25.5-4-402.4(5).

12. "General Hospital" means a hospital licensed as a general hospital by the Colorado Department of Public Health and Environment.

13. "High Volume Medicaid and CICP Hospital" means a hospital with at least 30,000 Medicaid Days per year that provides over 35% of its total days to Medicaid and CICP clients.

14. "Health Maintenance Organization" or "HMO" means a type of managed care health plan that limits coverage to providers who work for or contract with the HMO and requires selection of a primary care provider and referrals to receive services from a specialist. HMOs will not cover care provided out-of-network except in an emergency.

15. "High Medicaid Utilization Hospital" means a hospital with a Medicaid payer mix greater than or equal to twenty-five percent (25%) and a Medicaid non-managed care patient days utilization rate greater than or equal to forty percent (40%).

16. "Heart Institute Hospital" means a hospital recognized as a HeartCARE Center by the American College of Cardiology (ACC) with at least 25,000 Medicaid Non-Managed Care Days per year.

17. "Hospital-Specific Disproportionate Share Hospital Limit" or "Hospital-Specific DSH Limit" means a hospital's maximum allowable Disproportionate Share Hospital payment eligible for Medicaid federal financial participation allowed under 42 U.S.C. § 1396r-4.

18. "Hospital Transformation Program Supplemental Medicaid Payments" or "HTP Supplemental Medicaid Payments" means the:

1. Outpatient Hospital Supplemental Medicaid Payment described in Section 8.3004.B.,

2. Inpatient Hospital Supplemental Medicaid Payment described in Section 8.3004.C., and

3. Essential Access Hospital Supplemental Medicaid Payment described in Section 8.3004.E.

19. The HTP Supplemental Medicaid Payments do not include the Hospital Quality Incentive Payment described in Section 8.3004.F. or Rural Support Program Hospital Supplemental Medicaid Payment described in Section 8.3004.G.

20. "Independent Metropolitan Hospital" means an independently owned and operated hospital located within a Metropolitan Statistical Area (MSA) designated by the United States Office of Management and Budget with at least 1,500 Medicaid Days per year.

21. "Inpatient Services Fee" means an assessment on hospitals based on inpatient Managed Care Days and Non-Managed Care Days.

22. "Inpatient Upper Payment Limit" means the maximum amount that Medicaid can reimburse a provider for inpatient hospital services and still receive federal financial participation.

23. "Long Term Care Hospital" means a General Hospital that is certified as a long-term care hospital by the Colorado Department of Public Health and Environment.

24. "Managed Care Day" means an inpatient hospital day for which the primary payer is a managed care health plan, including HMO, PPO, POS, and EPO days.

25. "Medicaid Day" means a Managed Care Day or Non-Managed Care Day for which the primary or secondary payer is Medicaid.

26. "Medicaid Managed Care Day" means a Managed Care Day for which the primary payer is Medicaid.

27. "Medicare Cost Report" means the Medicare hospital cost report, form CMS 2552-96 or CMS 2552-10, or any successor form created by CMS.

28. "MMIS" means the Medicaid Management Information System, the Department's Medicaid claims payment system.

29. "MIUR" means Medicaid inpatient utilization rate which is calculated as Medicaid Days divided by total hospital days.

30. "Neonatal Intensive Care Unit Hospital" or "NICU Hospital" means a hospital with a NICU classification of Level III or IV according to guidelines published by the American Academy of Pediatrics (AAP).

31. "Non-Managed Care Day" means an inpatient hospital day for which the primary payer is an indemnity insurance plan or other insurance plan not serving as an HMO, PPO, POS, or EPO.

32. "Non-State-Owned Government Hospital" means a hospital that is either owned or operated by a local government.

33. "Outpatient Services Fee" means an assessment on hospitals based on outpatient hospital charges.

34. "Outpatient Upper Payment Limit" means the maximum amount that Medicaid can reimburse a provider for outpatient hospital services and still receive federal financial participation.

35. "Pediatric Specialty Hospital" means a hospital that provides care exclusively to pediatric populations.

36. "POS" or "Point of Service" means a type of managed care health plan that charges patients less to receive services from providers in the plan's network and requires a referral from a primary care provider to receive services from a specialist.

37. "PPO" or "Preferred Provider Organization" means a type of managed care health plan that contracts with providers to create a network of participating providers. Patients are charged less to receive services from providers that belong to the network and may receive services from providers outside the network at an additional cost.

38. "Privately-Owned Hospital" means a hospital that is privately owned and operated.

39. "Psychiatric Hospital" means a hospital licensed as a psychiatric hospital by the Colorado Department of Public Health and Environment.

40. "Rehabilitation Hospital" means an inpatient rehabilitation facility.

41. "Respiratory Hospital" means a hospital that primarily specializes in respiratory related diseases.

42. "Rural Hospital" means a hospital not located within a Metropolitan Statistical Area (MSA) designated by the United States Office of Management and Budget.

43. "Safety Net Metropolitan Hospital" means a hospital that provides services within the Pueblo, Colorado Metropolitan Statistical Area designated by the United States Office of Management and Budget (Pueblo MSA) with no less than 15,000 Days per year reported on its Medicare Cost Report, Worksheet S-3, Part 1, Column 7 (Title XIX), lines 1-18, and 28 (adult, pediatrics, intensive care, and subunits).

44. "State-Owned Government Hospital" means a hospital that is either owned or operated by the State.

45. "Teaching Hospital" means a High-Volume Medicaid and CICP Hospital which provides supervised teaching experiences to graduate medical school interns and residents enrolled in a state institution of higher education, and in which more than fifty percent (50%) of its credentialed physicians are members of the faculty at a state institution of higher education.

46. "Supplemental Medicaid Payments" means the:

1. Outpatient Hospital Supplemental Medicaid Payment described in 8.3004.B.,

2. Inpatient Hospital Supplemental Medicaid Payment described in 8.3004.C.,

3. Essential Access Hospital Supplemental Medicaid Payment described in 8.3004.E.,

4. Hospital Quality Incentive Payment described in 8.3004.F., and

5. Rural Support Program Hospital Supplemental Medicaid Payment described in 8.3004.G.

47. "Uninsured Cost" means uninsured days and charges allocated to routine and ancillary cost centers and multiplied by the most recent provider-specific per diem cost and cost-to-charge ratio from the Medicare Cost Report.

10 CCR 2505-10-8.3001

46 CR 15, August 10, 2023, effective 7/14/2023 (EMERGENCY)

46 CR 19, October 10, 2023, effective 10/30/2023

47 CR 14, July 25, 2024, effective 7/1/2024, exp. 10/12/2024 (Emergency)

47 CR 17, September 10, 2024, effective 9/30/2024