As used in this article 4 and articles 5 and 6 of this
title 25.5, unless the context otherwise requires:
(1) Repealed.
(1.5) Accountable care collaborative means a medicaid care delivery
system established pursuant to section 25.5-5-419.
(2) Applicant means an individual who is seeking an eligibility
determination for himself or herself under this article and articles 5 and 6 of this
title through an application submission or a transfer from another agency or
insurance affordability program.
(2.5) Case management agency has the same meaning as set forth in
section 25.5-6-1702 (2).
(3) Case management services means services provided by case
management agencies and comprehensive community behavioral health providers,
as defined in section 27-50-101, to assist persons in gaining access to needed
medical, social, educational, and other services.
(4) Categorically needy means those persons who are eligible for medical
assistance under this article and articles 5 and 6 of this title due to their eligibility
for one or more of the federal categories of public assistance. A person may be
categorically needy and eligible for medical assistance under mandatory provisions
as provided under section 25.5-5-101 or may be categorically needy under optional
provisions as provided under section 25.5-5-201.
(5) Clinic services means those services as defined in section 25.5-5-301.
(5.5) Dementia diseases and related disabilities has the same meaning set
forth in section 25-1-502 (2.5).
(6) Essential person means a person who meets the requirements of
section 26-2-103 (5), C.R.S.
(7) Home health services is synonymous with home health care and
includes the following services provided to an eligible person through a certified
home health agency, pursuant to a home health plan of care:
(a) Nursing services;
(b) Home health aide services;
(c) Provision of medical supplies, equipment, and appliances suitable for use
in the home;
(d) Physical therapy, occupational therapy, or speech and hearing therapy.
(8) Hospice care means services provided by a public agency or private
organization, or any subdivision thereof, which entity shall be known as a hospice
and shall be primarily engaged in providing care to an individual for whom a
certified medical prognosis has been made indicating a life expectancy of six
months or less and who has elected to receive such care in lieu of other medical
benefits available under this article and articles 5 and 6 of this title.
(9) Intermediate nursing facility for persons with intellectual and
developmental disabilities means a tax-supported, state-administered
intermediate nursing facility, or a distinct part of such facility, which meets the
state nursing home licensing standards set forth in section 25-1.5-103 (1)(a)(I),
C.R.S., and the requirements in 42 U.S.C. sec. 1396d and which:
(a) Is maintained primarily to provide health-related care on a regular basis
for persons with intellectual and developmental disabilities, as defined in section
27-10.5-102 (11), C.R.S., and section 25.5-10-202, C.R.S., who do not require the
degree of services and supports that a hospital or skilled nursing facility can
provide but who, because of their mental or physical condition, require care and
services above the level of room and board, which can be made available only
through institutional facilities; and
(b) May provide care which includes but is not limited to moderate assistance
or therapy functions; occasional direction, supervision, or therapy; moderate
assistance or therapy for loss of mobility; routine, nonskilled nursing services; and
monitoring of the drug regimen.
(10) Lawfully residing means an individual who is not a citizen or national of
the United States and who was lawfully admitted to the United States by the
immigration and naturalization service, or any successor agency, as an actual or
prospective permanent resident or whose extended physical presence in the United
States is known to and allowed by the immigration and naturalization service, or any
successor agency.
(11) Liable or liability means the legal liability of a third party, either by
reason of judgment, settlement, compromise, or contract, as the result of negligent
acts or other wrongful acts or otherwise for all or any part of the medical cost of an
injury, a disease, or the disability of an applicant for or member of medical
assistance.
(12) Managed care system means a health-care system organized to
manage costs, utilization, and quality. The statewide managed care system provides
for the delivery of health benefits and additional services through contracted
arrangements between state medicaid agencies and MCEs.
(13) Medical assistance means payment on behalf of members eligible for
and enrolled in the state medical assistance program established pursuant to this
article 4 and articles 5 and 6 of this title 25.5, which is funded through Title XIX of
the federal Social Security Act, 42 U.S.C. sec. 1396u-1, to providers enrolled in the
state medical assistance program who render or provide medical care, services,
goods, and devices to members pursuant to this article 4 and articles 5 and 6 of this
title 25.5, and other related payments, pursuant to this article 4 and articles 5 and
6 of this title 25.5 and the rules of the state department.
(13.2) Member means a person who has been determined eligible to receive
benefits under this article 4 and articles 5 and 6 of this title 25.5.
(13.5) Modified adjusted gross income or MAGI means an amount of
income, as determined pursuant to section 1902 (e)(14) of the federal Social
Security Act, that is used to establish eligibility for medical assistance.
(14) Nursing facility means a facility, or a distinct part of a facility, that
meets the state nursing home licensing standards in section 25-1.5-103 (1)(a)(I), is
maintained primarily for the care and treatment of inpatients under the direction of
a physician, and meets the requirements in 42 U.S.C. sec. 1396r for certification as a
qualified provider of nursing facility services. The patients in such a facility require
supportive, therapeutic, or compensating services and the availability of a licensed
nurse for observation or treatment on a twenty-four-hour basis. Nursing care may
include terminal care; extensive assistance or therapy in the activities of daily
living; continual direction, supervision, or therapy; extensive assistance or therapy
for loss of mobility; nursing assessment and services that involve assessment of the
total needs of the patient, planning of patient care, and observing, monitoring, and
recording the patient's response to treatment; and monitoring, observing, and
evaluating the drug regimen. Nursing facility includes private, nonprofit, or
proprietary intermediate nursing facilities for persons with intellectual and
developmental disabilities.
(15) Overpayment means the amount paid by an agency administering the
medical assistance program to an enrolled provider under the state medical
assistance program participating in the program, which amount is in excess of the
amount that is allowable for services furnished and which is required by Title XIX of
the social security act to be refunded to the appropriate medicaid agencies.
(16) Patient personal needs trust fund means any fund or account
established by the nursing care facility or intermediate care facility or its agents,
employees, or designees to manage the personal needs funds of the facility's
patients.
(17) Personal needs funds means moneys received by any person admitted
to a nursing care facility or intermediate care facility, which moneys are received by
said person to purchase necessary clothing, incidentals, or other personal needs
items which are not reimbursed by any federal or state program, or items of value,
which moneys or items of value are in any way surrendered to the management or
control of said facility, its agents, employees, or designees.
(18) Pilot program, as used in section 25.5-5-319, means the family
planning pilot program established in section 25.5-5-319, which is carried out by all
medicaid providers who provide family planning services and which shall be
repealed, effective July 1 five years after the issuance of the federal waiver or July 1
in the year in which the waiver is terminated, whichever occurs first.
(19) (a) Provider means any person, public or private institution, agency, or
business concern providing medical care, services, or goods authorized under this
article and articles 5 and 6 of this title and holding, where applicable, a current
valid license or certificate to provide such services or to dispense such goods and
enrolled under the state medical assistance program. These services must be
provided and goods must be dispensed only if performed, referred, or ordered by a
doctor of medicine or a doctor of osteopathy. Services of dentists, podiatrists, and
optometrists or services provided by a school district under section 25.5-5-318
need not be referred or ordered by a doctor of medicine or a doctor of osteopathy.
(b) Provider includes a laboratory certified under the federal Clinical
Laboratories Improvement Act of 1967, as amended, 42 U.S.C. sec. 263a, to
perform high complexity testing.
(19.5) Psychiatric residential treatment facility means a facility that is
licensed as a residential child care facility, as defined in section 26-6-903, that is
not a hospital, and that provides inpatient psychiatric services for individuals who
are less than twenty-one years of age under the direction of a physician licensed
pursuant to article 240 of title 12, and that meets any other requirement
established in rule by the state board. Psychiatric residential treatment facility
includes a state-owned psychiatric residential treatment facility as defined in
section 26-6-903.
(20) Qualified alien shall have the meaning ascribed to that term in section
431 (b) of the federal Personal Responsibility and Work Opportunity Reconciliation
Act of 1996, Public Law 104-193, as amended.
(21) Repealed.
(22) Recovery or amount recovered means the amount payable to the
applicant or member or the applicant's or member's heirs, assigns, or legal
representatives as the result of any liability of a third party.
(23) Rehabilitative services means any medical or remedial services
recommended by a physician which may reduce physical or mental disability and
which may improve functional level.
(24) Resident means any individual who is living, other than temporarily,
within the state. Resident includes any unemancipated child whose parent, or
other person entitled to custody, lives within the state. The state board shall adopt
rules for making this determination. Temporary absences from the state shall not
cause an individual to lose his status as a resident of this state.
(24.5) Serious mental illness means the following psychiatric illnesses, as
defined by the American Psychiatric Association in the most recent version of the
Diagnostic and Statistical Manual of Mental Disorders:
(a) Bipolar disorders (hypomanic, manic, depressive, and mixed);
(b) Depression in childhood and adolescence;
(c) Major depressive disorders (single episode or recurrent);
(d) Obsessive-compulsive disorders;
(e) Paranoid and other psychotic disorders;
(f) Schizoaffective disorders (bipolar or depressive); and
(g) Schizophrenia.
(25) Social security act means the federal Social Security Act and
amendments thereto.
(25.5) State university teaching hospital means a hospital licensed or
certified pursuant to section 25-1.5-103 (1)(a), C.R.S.:
(a) That provides supervised teaching experiences to graduate medical
school interns and residents enrolled in a state institution of higher education as
defined in section 23-18-102 (10), C.R.S.; and
(b) In which more than fifty percent of its credentialed physicians are
members of the faculty at a state institution of higher education as defined in
section 23-18-102 (10), C.R.S.
(25.7) Telemedicine means the delivery of medical and health-care
services and any diagnosis, consultation, or treatment using interactive audio,
interactive video, or interactive data communication.
(26) Third party means an individual, institution, corporation, or public or
private agency that is or may be liable to pay all or any part of the medical cost of
an injury, a disease, or the disability of an applicant for or member of medical
assistance.
(27) Title XIX means Title XIX of the social security act, as amended,
administered by the federal department of health and human services, or any
successor agency, and includes amendments thereto and other federal social
security laws replacing said title, in whole or in part.
(28) Transitional medicaid means the medical assistance provided to
members eligible pursuant to section 25.5-5-101 (1)(b).