Current through Register Vol. 47, No. 5, March 10, 2024
8.941.1
GENERAL DESCRIPTION - OLD AGE
PENSION HEALTH CARE PROGRAM
In accordance with the Constitution of Colorado, Article
XXIV, Section 7, and the Colorado Public Assistance Act, an Old Age Pension
Health Care Program is established to provide necessary medical care for the
Old Age Pension (OAP) recipients who do not qualify for Medicaid under Title
XIX of the Social Security Act and Colorado statutes. The State Department is
designated as the single State agency to administer the program.
A. The Old Age Pension Health Care Program
provides optional benefits to clients who qualify for (State only) OAP pensions
who do not qualify for Federal Financial Participation (FFP) in the Colorado
Medicaid Program. These cases are coded with Supplemental Income Status Code
(SISC) C.
B. Under the Old Age
Pension Health Care Program, only the following State funded benefits are
provided:
1. Physician and practitioner
services
2. Inpatient
hospital
3. Outpatient
services
4. Lab and x-ray
5. Emergency transportation
6. Emergency services
7. Dental
8. Pharmacy
i. Medicare Part D prescription drugs
provided pursuant to the Medicare Prescription Drug, Improvement and
Modernization Act of 2003 (defined at
42 U.S.C. sections
1395w-102 and
141 and 42 C.F.R. Part 423 , et
seq.) are not a benefit for those individuals who are eligible for both
Medicare and the Old Age Pension Health Care Program. The pharmacy drug benefit
under the Old Age Pension Health Care Program is subject to the requirements
set forth at s Section 8.800.
9. Home health services and
supplies
10. Medicare cost sharing
i. If Medicare pays for a medical service
that is a non-benefit under the Old Age Pension Health Care Program, the
co-insurance and deductible will not be paid by the Old Age Pension Health Care
Program.
C.
For the benefits listed above, the Old Age Pension Health Care Program shall
only be used to provide clients with health care services determined to be
medically necessary by a qualified health care provider.
D. All other medical benefits not listed in
paragraph B are excluded under the Old Age Pension Health Care Program.
Inpatient care in an institution for tuberculosis or mental diseases, skilled
and intermediate nursing facility services, and home and community-based
services are also excluded.
E.
Eligibility shall not be retroactive and shall begin on the date of application
or date eligibility is established, whichever is later.
F. Counties shall provide information to Old
Age Pension Health Care Program clients regarding the disposal of excess
resources in order to qualify for the Medicaid program. Such information shall
include advisements concerning the prohibition of transfer of assets without
fair consideration.
8.941.2
DEFINITIONS
A. Aid to the Needy Disabled-Colorado
Supplement (AND-CS)- Program that provides a supplemental payment for
individuals age zero (0) to fifty-nine (59) who are receiving Social Security
Income (SSI) due to a disability or blindness, but are not receiving the full
SSI benefit standard, as defined in
9 CCR
2503-53.510.
B. Aid to the Needy Disabled-State Only
(AND-SO)- Program that provides interim assistance to individuals age eighteen
(18) through fifty-nine (59) years of age (unless diagnosed with blindness,
then age zero [0] through fifty-nine [59] years of age) who are disabled or
blind but have not been approved for SSI or Social Security Disability
Insurance (SSDI). Individuals are required to meet the total disability
requirements of the program in addition to the non-financial and financial
eligibility requirements. Individuals who are partially disabled or have a
short-term disability are not eligible.
C. Federal Financial Participation (FFP) -
The portion paid by the federal government to states for their share of
expenditures for providing Medicaid services and for administering the Medicaid
program and certain other human services programs.
D. Medical ID Card - The card issued to
members and used by providers to verify member eligibility.
E. Old Age Pension (OAP) - Program that
provides financial assistance for low-income Colorado residents who are sixty
(60) years of age or older who meet all financial and non-financial eligibility
requirements.
F. Old Age Pension-C
(OAP-C) - Program for individuals who are sixty (60) years of age or older who
have been committed to the Colorado Mental Health Institute or to a Regional
Center by order of the district or probate court.
G. State Department or Department- The
Colorado Department of Health Care Policy and Financing.
H. Supplemental Income Status Code (SISC)-
System codes used to distinguish the different types of state supplementary
benefits (such as OAP) a recipient may receive. Supplemental Income Status
Codes determine the FFP for benefits paid on behalf of groups covered under the
Medical Assistance program.
I.
Supplemental Security Income (SSI)- A Federal income supplement program funded
by general tax revenues (not Social Security taxes) that provides income to
aged, blind, or disabled individuals with little or no income and
resources.
8.941.3
GROUPS ASSISTED UNDER THE OLD AGE PENSION HEALTH CARE PROGRAM
Old Age Pension Health Care Program benefits are provided to
persons receiving OAP who do not meet SSI eligibility criteria but do meet the
State eligibility criteria for the Old Age Pension Health Care Program. These
persons qualify for a SISC C..
A. SISC
C - this code is for persons eligible to receive financial assistance under OAP
who do not receive an SSI payment, and do not otherwise qualify for the
Colorado Medicaid Program. SISC C signifies that no FFP is available in medical
assistance program expenditures.
B.
Recipients of financial assistance under AND-CS, AND-SO, or OAP-C are not
eligible for assistance under the Old Age Pension Health Care
Program.
8.941.4
FINANCIAL ASSISTANCE
All rules applicable to Old Age Pension financial assistance
program payments (as set forth in the Department of Human Services rules at
9 CCR
2503-5) shall apply to the Old Age Pension Health Care
Program.
8.941.5
CERTIFICATION OF PAYMENT FOR PROVIDERS
When submitting a claim for medical services to the Old Age
Pension Health Care Program providers must submit a certification that states
the following: "I will accept as payment in full, payment made under the Old
Age Pension Health Care Program, and certify that no supplemental charges have
been, or will be, billed to the patient, except for those non-covered items, or
services, if any, which are not reimbursable under the Old Age Pension Health
Care Program."
8.941.6
OUT-OF-STATE MEDICAL CARE
All requirements for out-of-state medical care as defined by
Section 8.013 apply to the Old Age Pension Health Care Program for covered
services with the exception that any reduction, suspension or elimination of
benefits must be applied.
8.941.7
SUBMISSION OF CLAIMS
Rules governing the submission or payment of claims, provider
or recipient appeals, third party liability, overpayment, fraud and abuse, and
State identification numbers as defined in Section 8.100 , apply to the Old Age
Pension Health Care Program for covered services with the exception that any
reduction, suspension or elimination of benefits provided must also be
applied.
8.941.8
REIMBURSEMENT TO PROVIDERS
When reimbursement rates are modified, notifications shall be
published on the Department's website and will be published in the Provider
Bulletin.
8.941.9
CLIENT CO-PAYMENT
Clients are responsible for paying directly to providers a
co-payment according to the regulations and fee schedule as set forth under
Section 8.754.1.
Clients whose co-payments reach a limit of $300 within a
January 1 through December 31 calendar year will be exempted from further
co-payments during that year. The exemption will begin on the date of payment
that the $300 limit cumulative maximum has been reached.
A client must present the Medical ID Card to the provider at
the time a service is rendered in order to claim exemption from copayment for
that service.
