Current through Register Vol. 47, No. 5, March 10, 2024
8.715.1
DEFINITIONS
Breast and Cervical Cancer Program
(BCCP) means the Medicaid program established, operated and
monitored by the Department.
Colorado Women's Cancer Control Initiative
(CWCCI) means the program administered by the Colorado Department
of Public Health and Environment and funded by the Centers for Disease Control
and the National Breast and Cervical Cancer Early Detection Program.
In Need of Treatment means services
necessary to determine the extent and proper course of cancer or precancerous
treatment as well as definitive cancer treatment itself. Treatment can include
surgery, radiation, chemotherapy and approved medications following treatment
as determined by the client's physician and the Department.
National Breast and Cervical Cancer Early
Detection Program (NBCCEDP) means the program where the Centers
for Disease Control (CDC) provides breast and cervical screening services to
underserved women. In Colorado, the CDC provider is the Department of Public
Health and Environment's Colorado Women's Cancer Control Initiative.
Presumptive Eligibility for BCCP
means the temporary eligibility for benefits that begin on the date a Qualified
Entity determines the client meets eligibility requirements for the BCCP and
the client signs the presumptive eligibility form. Women identified by the
CWCCI as being In Need of Treatment for breast or cervical cancer or a
precancerous condition shall apply for presumptive eligibility on a simplified
Medicaid application.
Qualified Entity means a provider
contracted with the Department of Public Health and Environment under a
cooperative agreement with the CDC to support activities related to the
NBCCEDP. A qualified entity shall provide breast and cervical cancer assessment
services for the CWCCI.
State Designated Entity means an
agency acting on behalf of and at the direction of the Department and whose
function may include, but is not limited to, processing eligibility
determinations and assisting clients with the application process.
8.715.2
ELIGIBILITY
REQUIREMENTS
8.715.2.A. Clients shall
meet all requirements of the CWCCI program.
8.715.2.B. Clients shall enroll for screening
at participating Breast and Cervical Cancer assessment sites through the
CWCCI.
8.715.2.C. Clients shall:
1. Be a woman who has not yet attained the
age of 65.
2. Be a resident of
Colorado.
3. Be a citizen of the
United States or a qualified alien as described in 8.100.53(A)(2) through
8.100.53(A)(4).
4. Have been
screened by a Qualified Entity and found to be In Need of Treatment for breast
or cervical cancer, including precancerous conditions as determined through
pathological tests.
5. Not have
creditable coverage as described in 8.715.3.
6. Not be eligible under another Medicaid
program.
7. Be a client who has
previously qualified and enrolled in a NBCCED program in another state and
chooses to transfer her enrollment to CWCCI.
8.715.2.D. Clients shall not have been
previously screened or received treatment for breast or cervical cancer prior
to July 1, 2002.
8.715.2.E. Clients
shall not be considered to be In Need of Treatment if it is determined she only
requires routine follow-up monitoring services.
8.715.2.F. Clients shall be willing to seek
Medicaid approved breast or cervical cancer or precancerous treatment within
three months of the date of eligibility. If a client does not seek such
treatment within three months of the date of presumptive eligibility, the
client shall be removed from the program on the last day of the third month.
The client will be re-entered in the BCCP program at such time as treatment is
scheduled to begin. If treatment has not been started within one month of the
scheduled date, the client will be disenrolled.
8.715.3
CREDITABLE COVERAGE
8.715.3.A. Creditable coverage shall include
coverage of any individual as defined at
10-16-102, C.R.S.
(2002).
8.715.3.B. The following
are not considered creditable coverage:
1.
Limited scope coverage such as that which covers only dental, vision or long
term care;
2. Coverage only for a
specific disease or illness (unless the specific disease or illness includes
breast or cervical cancer); or
3. A
medical care program run by the Indian Health Services or a tribal
organization.
8.715.3.C.
An individual who otherwise has creditable coverage may qualify for the program
if:
1. The individual is in a period of
exclusion for treatment of breast or cervical cancer; or
2. The individual has exhausted her lifetime
limits on benefits under the plan for breast or cervical cancer.
8.715.3.D. Individuals who have
coverage that contains yearly limited drug benefits, yearly limits on
outpatient visits or high deductibles shall be considered to have creditable
coverage.
8.715.4
PRESUMPTIVE ELIGIBILITY
8.715.4.A. Presumptive eligibility shall be
determined by Qualified Entities.
8.715.4.B. The Department shall make
available to Qualified Entities:
1.
Information on the BCCP presumptive eligibility form and card;
2. Information on how to obtain the Medicaid
application; and
3. Information on
how to assist CWCCI personnel and individuals on application completion and
filing.
8.715.4.C.
Qualified Entities shall determine presumptive eligibility based on verbal
confirmation by the potential client that she meets CWCCI criteria and shall
enroll the clients who appear to be eligible.
8.715.4.D. Presumptive eligibility shall
begin on the date the client completes the BCCP presumptive eligibility form
and the Qualified Entity determines the client meets all eligibility
criteria.
8.715.4.E. All potential
clients shall be required to complete the BCCP presumptive eligibility form and
the Medicaid application at the same time.
8.715.4.F. The Qualified Entity shall submit
the presumptive eligibility form, a copy of the presumptive eligibility card,
the CWCCI history and physical, the diagnosis pathology report and the signed
consent form to the Department.
8.715.4.G. The Designated Entity shall
process the Medicaid application within thirty calendar days of
receipt.
8.715.4.H. The presumptive
eligibility period shall end on the following:
1. The date on which a formal determination
is made on the client's Medicaid application; or
2. If a full determination cannot be made on
the basis of the BCCP presumptive eligibility form and the client fails to
complete the Medicaid application, then eligibility will end on last day of the
month following the month in which the client was determined to be
presumptively eligible.
8.715.5
ELIBILITY PERIOD
8.715.5.A. Eligibility shall begin on the
date the client is determined to be presumptively eligible.
8.715.5.B. The client shall be eligible to
receive services for up to one year from the date of initial eligibility unless
she is no longer In Need of Treatment or no longer meets program eligibility
requirements.
8.715.5.C. If the
client remains in treatment beyond one year, renewed eligibility shall be
determined consistent with BCCP and Medicaid requirements.
8.715.5.D. A period of renewed eligibility
begins each time the client is screened under the CWCCI program and is found to
be In Need of Treatment for breast or cervical cancer and meets all other
eligibility criteria.
8.715.5.E. A
client may be determined no longer eligible for the program if:
1. She does not complete the Medicaid
application; or
2. She is no longer
In Need of Treatment for breast or cervical cancer or qualified precancerous
conditions when the client's provider notifies the Department; or
3. She reaches the age of 65; or
4. She obtains other creditable coverage
describe in 8.715.3.
8.715.5.F. Clients who are determined no
longer eligible shall be notified in writing as described in 8.715.6(B).
8.715.6
NOTIFICATION
8.715.6.A. The BCCP
presumptive eligibility form shall include a statement of the applicant's
rights and responsibilities.
8.715.6.B. The Department shall notify
clients who are no longer In Need of Treatment for the BCCP
in writing thirty days prior to their disenrollment date.
This notice will be provided only to those clients who have completed their
course of treatment per their provider.
1. Copies of the notice shall be sent to the
client, her designated representative if applicable, the CWCCI site, the State
Designated Entity and the client's provider.
2. The notification shall include information
regarding appeal rights described in 10 C.C.R. 2505-10, Section
8.057.
8.715.6.C. The
Department shall notify clients who no longer meet the BCCP eligibility
criteria at least ten days prior to program termination.
8.715.7
BENEFITS
8.715.7.A. Eligible clients shall receive all
Medicaid benefits included in the State Plan.
8.715.7.B. Breast reconstructive surgery
shall be a covered benefit when completed up to seven months following a
mastectomy.
8.715.7.C. Breast or
cervical cancer or precancerous treatment provided prior to the NBCCED program
implementation or client enrollment into the BCCP is not a covered
benefit.
8.715.7.D. Clients
eligible for this program shall receive all mental health services through the
Mental Health Assessment Service Agency of the county in which the client
resides.
8.715.8
ROLES/RESPONSIBILITIES
8.715.8.A. County Departments of Human/Social
Services shall:
1. Assist in providing
information to the client about services and benefits available through the
program;
2. Assist the client in
accessing health care services or contact the appropriate agencies for
services, such as the enrollment broker, mental health provider and
transportation provider;
3. Assist
the client in applying for and accessing other benefits for which she may
qualify, such as home care allowance, food stamps and financial assistance;
and
4. Assist the Department by
notifying the Department when a client's eligibility status changes.
8.715.8.B. Clients shall notify
the Department and healthcare providers if the client receives creditable
coverage or if a third party is responsible for illness or injury to the
client.
8.715.8.C. Providers shall
respond to inquiries from the Department and provide information required to
verify the client's In Need of Treatment status within ten calendar days of the
Department's request.
8.715.8.D.
Provider's shall follow Medicaid billing instructions and obtain prior
authorizations when necessary.
8.715.8.E. The State Designated Entities
shall have the following responsibilities:
1.
To determine whether a client is eligible for Medicaid in any other eligibility
group;
2. To complete review of the
Medicaid application form within fifteen days of receipt;
3. To notify the client she has thirty days
to submit addition information if needed and if the information is not received
the client will be found ineligible;
4. To inform the client of her appeal rights
if eligibility is denied; and
5. To
disenroll the client from the BCCP when notified the client is no longer in
Need of Treatment.
