Purpose
Hospital Discounted Care limits the cost of hospital care for low income, uninsured Coloradans receiving services through general acute care and critical access hospitals and free-standing emergency departments. This new law requires financial assistance programs to be transparent and easy to understand. The law calls for the Department of Health Care Policy and Financing (the Department) to set rates that approximate 100% of Medicare or 100% of Medicaid, whichever is greater. As such, the Department is not setting rates that would result in pricing individual claims but is calculating rates based on the greater of the Medicare or Medicaid Base Rate. These rates are the maximum that can be charged for hospital services under Hospital Discounted Care.
Hospital Discounted Care Rates
Hospital Discounted Care directs the Department to set outpatient/inpatient/professional base rates for all CPT codes or facilities based on the greater of either Medicaid rates or Medicare rates. Any CPT code that is assigned a $0 rate has neither a Medicaid or Medicare set rate.
The Hospital Discounted Care rates are the greater of Medicare or Medicaid rates. These rates are the maximum that can be charged for hospital services under Hospital Discounted Care.
- Inpatient Service Rates
Inpatient Service Rates are used when a patient has health care provided in a hospital and is discharged after 24 hours. Inpatient Service Rates are determined by comparing the Medicare and Medicaid rates for each hospital and selecting the greater of the two.
Inpatient Service Rates are subject to eligibility and billing maximums. Hospitals can bill no more than four (4) % of the patient’s gross monthly household income. Once 36 months’ worth of payments are made, the payment plan is considered paid in full. Please refer to the Hospital Discounted Care Maximum Payment Calculator at the bottom of the page for more information.
To look up Inpatient Service Rates you will need the name of the hospital and/or their Medicare Provider number also known as the Centers for Medicare & Medicaid Services Certification Number (CCN).
Inpatient Service Rates files include the following:
- Medicare Provider CCN - The “CCN” is a unique hospital facility identifier assigned by the Centers for Medicare & Medicaid Services.
- Hospital Name - The "Hospital Name" is the name of the hospital.
- Rate - The "Rate" is the maximum amount a patient can be charged for inpatient services. This rate is separate from the maximum total amount a patient is responsible for under the Hospital Discounted Care.
FY 2024-25 Rates
FY 2023-24 Rates
FY 2022-23 Rates
- Outpatient Service Rates
Outpatient Service Rates are used when a patient has health care provided in a general acute care, critical access hospital or a free-standing emergency department and is discharged within a 24 hour period. Outpatient Service Rates are determined by comparing the Medicare rate and Medicaid base rate and selecting the greater of the two.
Outpatient Service Rates are subject to eligibility and billing maximums. Hospitals can bill no more than four (4) % of the patient’s gross monthly household income. Once 36 months’ worth of payments are made, the payment plan is considered paid in full. Please refer to the Hospital Discounted Care Maximum Payment Calculator at the bottom of the page for more information.
To look up Outpatient Services Rates you will need the hospital name and procedure code(s) used during your hospital visit. Your hospital visit may involve one or more outpatient procedures. Add each procedure rate together to get the total amount. If you had Clinical Diagnostic Laboratory Services completed at the hospital, add those into your calculation. Clinical Diagnostic Laboratory Service Rates are statewide and do not vary by hospital.
- When using the Excel Workbook, from the “Table of Contents” the “Link” column can be used to view the rates for a specific hospital. When viewing a hospital’s rates procedure codes, you will need to look up the rate for each procedure. Multiple procedures may occur during a visit and all procedures during a visit should be included when calculating a total amount for a visit.
Outpatient Service Rates files include the following:
- Procedure Code - A collection of codes that represent procedures and services which may be provided to Medicaid and Medicaid beneficiaries.
- Code Description - The "Code Description" is a shortened explanation of the procedures or services the procedure code is associated with.
- Rate - The "Rate" is the maximum amount a patient can be charged for the associated procedure or service.
In the section below, links will go to excel spreadsheets where you will find your hospital's name and corresponding outpatient rates. The procedure codes are listed alpha-numerically. You can filter by procedure code and code description.
FY 2024-25 Outpatient Rates (Excel)
FY 2023-24 Outpatient Rates (Excel)
FY 2022-23 Outpatient Rates (Excel)
Clinical Diagnostic Laboratory Rates for Fiscal Year 2023-24 have received updates correcting procedures that had their rates misrepresented. Links to this updated file can be found below.
FY 2024-25 Outpatient Clinical Diagnostic Laboratory Rates
FY 2023-24 Outpatient Clinical Diagnostic Laboratory Rates
FY 2022-23 Outpatient Clinical Diagnostic Laboratory Rates
- Professional Service Rates
Professional Service Rates are used when a patient receives services from a certified health care professional during a hospital visit. Professional Service Rates do not vary by hospital and are the same statewide. Professional Service Rates are determined by comparing the Medicare rate and the Medicaid base rate and selecting the greater of the two.
Professional Service Rates are subject to eligibility and billing maximums. Health care professionals can bill no more than two (2) % of a patient's gross monthly household income. Once 36 months’ worth of payments are made, the payment plan is considered paid in full. Please refer to the Hospital Discounted Care Maximum Payment Calculator at the bottom of the page for more information.
To look up the professional service rates for a procedure, you will need all procedure codes used during a hospital visit. Health care professionals that bill separately from the hospital may have performed more than one procedure. Add each procedure rate together to get the total amount.
Professional Rates for Fiscal Year 2023-24 have received updates correcting procedures that had their rates misrepresented. Links to these updated files can be found below.
Professional Service Rates files now include the following:
- Procedure Code
- A collection of codes that represent procedures and services which may be provided to Medicare and Medicaid members.
- Code Description
- The "Code Description" is a shortened explanation of the procedures of services the HCPCS is associated with.
- Rate
- The "Rate" is the maximum amount a patient can be charged for the procedure or service.
- Asterisk
- (For FY 2023-24) An Asterisk indicating if the specified rate has had corrections made to it.
FY 2024-25 Professional Rates
FY 2023-24 Professional Rates
FY 2022-23 Professional Rates
- Procedure Code
- Hospital Discounted Care Maximum Payment Calculator
The Hospital Discounted Care Maximum Payment Calculator can be used to see if a patient is eligible for Hospital Discounted Care rates and the maximum payment amount the patient is responsible to pay. To use the calculator, you’ll need to know the number of people in the household and the monthly or annual gross household income.
To be eligible for Hospital Discounted Care rates, a patient must have a gross household income equal to or below 250% of the Federal Poverty Guidelines (FPG). The FPG is a measure of income issued every year by the Department of Health and Human Services (HHS).
Maximum Payment
Hospital Discounted Care puts a limit on how much a patient is responsible to pay for hospital services. These limits are based on income. The hospital and health care professionals may bill separately. If billing separately, you may receive a bill from the hospital for Inpatient or Outpatient Services, and another bill from each health care professional. For Inpatient and Outpatient Services, hospitals may bill up to four (4) % of the patient’s gross monthly household income. When Professional Services are being billed separately, each licensed health care professional can bill up to two (2) % of the patient’s gross monthly household income.
If everything is on one hospital bill, the total amount a hospital may bill is up to four (4)% of the patient’s gross monthly household income. Once 36 months’ worth of payments are made, the payment plan is considered fulfilled.
Hospital Discounted Care Maximum Payment Calculator (Excel) - Coming Soon
More Information about Hospital Discounted Care
- Hospital Discounted Care Frequently Asked Questions
- Hospital Discounted Care (Patient Page)
- Hospital Discounted Care (Provider Page)