Provider Rates and Fee Schedule

Health First Colorado Fee Schedule

Although every effort is made to ensure the accuracy of this information, discrepancies may occur. The fee schedule may not reflect any changes to rates that occurred after the effective date of the fee schedule. Such changes will be reflected in the next release of the fee schedule.

2022 2021 2020 2019 2018
January 2022 Fee Schedule (XLSX) (02/22) January 2021 Fee Schedule (XLSX) (02/21) January 2020 Fee Schedule (01/20) January 2019 Fee Schedule (03/19) January 2018 Fee Schedule Instructions (03/18)
January 2022 Fee Schedule (PDF) (02/22) January 2021 Fee Schedule (PDF) (02/21) July 2020 Fee Schedule (PDF) (07/20) July 2019 Fee Schedule (07/19) January 2018 Fee Schedule Data File (06/18)
July 2022 Fee Schedule (XLSX) (07/22) July 2021 Fee Schedule (XLSX) (07/21) July 2020 Fee Schedule (XLSX) (07/20) November 2019 Fee Schedule (02/20) July 2018 Fee Schedule Data File (12/18)
July 2022 Fee Schedule (PDF) (07/22) July 2021 Fee Schedule (PDF) (07/21)      

Ambulatory Surgical Centers (ASC) Rate Schedule

List of All ASC Codes and Respective Groupers

Fiscal Year (2022-2023) Fiscal Year (2021-2022) Fiscal Year (2020-2021) Fiscal Year (2019-2020) Fiscal Year (2018-2019) Fiscal Year (2017-2018)
ASC FY 2022-23 Rate Schedule (07/22) ASC FY 2021-22 Rate Schedule (07/21) ASC FY 2020-21 Rate Schedule (07/20) ASC FY 2019-20 Rate Schedule (04/20) ASC FY 2018-19 Rate Schedule (06/18) ASC FY 2017-18 Rate Schedule (04/18)

Child Health Plan Plus Fee-for-Service (FFS) Rates

2021 CHP+ FFS Rate Schedule

Child Health Plan Plus Specialty Drug Guidance

Clinical Diagnostic Laboratory Test, Upper Payment Limit

In order to comply with the Protecting Access to Medicare Act (PAMA), Health First Colorado will adjust Clinical Diagnostic Laboratory Test (CDLT) rates on a per-test basis to align with Medicare's quarterly release of Clinical Laboratory Fee Schedule (CLFS) rates. PAMA enacted changes to the Medicare CLFS and required that Medicaid payments for CDLTs not exceed the Medicare allowed amount for the same CDLTs. These requirements can be found in section 1903(i)(7) and section 1833(h) of the Social Security Act. Below is the rate tracking sheet for CDLT UPL codes:

Dental Fee Schedule

Dialysis Rate Schedule

Fiscal Year (2022-2023) Fiscal Year (2021-2022) Fiscal Year (2020-2021) Fiscal Year (2019-2020) Fiscal Year (2018-2019) Fiscal Year (2017-2018)
Dialysis (07/22) Dialysis (07/21) Dialysis (07/20) Dialysis (06/19) Dialysis (06/18) Dialysis (04/18)

 

Durable Medical Equipment, Upper Payment Limit

Health First Colorado is required to comply with the Consolidated Appropriations Act of 2016 (Section 503) which means Health First Colorado cannot pay more than what Medicare would have paid in the aggregate for certain DME services. The Department is referring to this requirement as the DME Upper Payment Limit (UPL). Below is the fee schedule for the codes that fall within the scope of the DME UPL.

Additional information regarding the UPL can be found in this letter to providers.

The remainder of the DMEPOS codes can be found under the Health First Colorado Fee Schedule.

Fee For Service Rates

This section opens on a new page and contains information on annual rate increases, HCBS rate increases, HCPCS rates and State Plan XIX.

HCBS Rate Schedule

Rates Effective
8/1/2022
Rates Effective
7/1/2020
Rates Effective 1/1/2020 Rates Effective 7/1/2019
EBD, CMHS, BI, CIH (8/22) EBD, CMHS, BI, SCI(7/20) EBD, CMHS, BI, SCI (12/19)v EBD, CMHS, BI, SCI (10/19)
DD, SLS, CES (8/22) DD, SLS, CES (7/20) CHCBS, CLLI (12/19) CHCBS, CLLI (6/19)
CLLI, CHCBS, CHRP (8/22) CLLI, CHCBS (7/20) CHRP (12/19) CHRP (7/19)
  CHRP (7/20) DD, SLS, CES (01/20) DD, SLS, CES (10/19)
  CCT (7/20) CCT (2/20) CCT (6/19)

HCBS American Rescue Plan Act (ARPA) Rate Schedule

Rates Effective
7/1/2022
Rates Effective
4/1/2022
Rates Effective
1/1/2022
Rates Effective
7/1/2021
Rates Effective
4/1/2021-6/30/2021
EBD, CMHS, BI, CIH (7/22) EBD, CMHS, BI, SCI (4/22) EBD, CMHS, BI, SCI (1/22) EBD, CMHS, BI, SCI (7/21) EBD, CMHS, BI, SCI (4/21)
DD, SLS, CES (7/22) DD, SLS, CES (4/22) DD, SLS, CES (1/22) DD, SLS, CES (7/21) DD, SLS, CES (4/21)
CHCBS, CLLI, CHRP (7/22) CHCBS, CLLI, CHRP (4/22) CHCBS, CLLI, CHRP (1/22) CHCBS, CLLI, CHRP (7/21) CLLI, CHCBS, CHRP (4/21)
    CHCBS (4/1/22)    

 

 Prior HCBS COVID-19 Enhanced Rates

Enhanced COVID-19 Rates Effective
04/01/2021-06/30/2021
Enhanced COVID-19 Rates Effective
01/01/2021-03/31/2021
Enhanced COVID-19 Rates Effective
07/18/2020-12/31/2020
Children's Waivers (4/20-21) Children's Waivers (1/21) Children's Waivers (7/20-21)
DD, SLS, CES (4/20-21) DD, SLS, CES (1/21) DD, SLS, CES (7/20-21)
EBD, CHMS, BI, SCI (4/20-21) EBD, CHMS, BI, SCI (1/21) EBD, CHMS, BI, SCI (7/20-21)

Prior HCBS Fee Schedules

Rates Effective 3/1/2019 Rates Effective 1/1/2019 Rates Effective 10/01/2018-06/30/2019 Fiscal Year (2018-2019) Rates Effective 10/01/2017-06/30/2018 Fiscal Year (2017-2018)
EBD, CMHS, BI, SCI (3/19) EBD, CMHS, BI, SCI (1/19) BI, CMHS, EBD, SCI (12/18) BI, CMHS, EBD, SCI (6/18) BI, CMHS, EBD, SCI (1/18) BI, CMHS, EBD, SCI(6/17)
CHCBS, CLLI (3/19) CHCBS, CLLI (1/19) CHCBS, CLLI (9/18) CHCBS, CLLI (6/18) CHCBS, CLLI,  CWA (9/17) CHCBS, CLLI, CWA (8/17)
CHRP (3/19) CHRP (1/19) CHRP (9/18) CHRP (6/18) CHRP (9/17) CHRP (6/17)
DD, SLS, CES (3/19) CCT (1/19) SLS, TCM, DD,  CES (10/18) CCT (6/18) CCT (10/18) CCT (2/18)
CCT(6/19) DD, SLS, CES (1/19)   SLS, TCM, DD, CES (6/18) SLS, TCM, DD, CES (12/17) SLS, TCM, DD, CES (2/18)
        CCT (12/17)  

 

ACF/SLP/TLP PETI Form
Enhanced COVID-19 PETI Forms

 

DIDD Support Level Determination
Supports Intensity Scale (SIS) and Support Level Flow Chart-Support Levels are numeric values determined using an algorithm that includes factors based on assessments of the client's needs as measured by the adaptive, medical and behavioral components of the SIS Assessment plus factors for defined safety risk.
HRSI/DDD Support Level Algorithm-The factors applied in the Support Level Algorithm are: Adaptive Skills, Behavioral and Medical support needs scores from the SIS Assessment and extreme safety risk to self or public safety risk.

Home Health and PDN Rate Schedule

Fiscal Year (2022-2023) Fiscal Year (2021-2022) Fiscal Year (2020-2021) Fiscal Year (2019-2020) Fiscal Year (2018-2019) Fiscal Year (2017-2018)

Home Health (07/22)

PDN (07/22)

Home Health (07/21)

PDN (07/21)

Home Health (07/20)

PDN (07/20)

Home Health (06/19)

PDN (06/19)

Home Health (04/18)

PDN (07/18)

Home Health (04/18)

PDN (07/17)

 

Hospice Fee Schedule

Fiscal Year (2021- 2022) Fiscal Year (2020- 2021) Fiscal Year (2019- 2020) Fiscal Year (2018 - 2019) Fiscal Year (2017 - 2018)
Hospice (2/22) Hospice (09/20) Hospice (09/19) Hospice (09/18) Hospice (04/18)

Hospital Discounted Care

Hospital Discounted Care limits the cost of hospital care for low income, uninsured Coloradans receiving services through hospitals’ financial assistance. Rates approximate 100% of Medicare or 100% of Medicaid, whichever is greater. These rates are the maximum that can be charged for hospital services under Hospital Discounted Care.

Rates are effective September1, 2022 and will be updated annually by July 1.

Inpatient Service Rates - effective 9/1/2022
Inpatient Rates eff. 9/1/22
Professional Service Rates - effective 9/1/2022
Professional Rates eff. 9/1/22
Outpatient Service Rates - effective 9/8/2022
Outpatient Rates A-B Outpatient Rates C Outpatient Rates D-F Outpatient Rates G-J Outpatient Rates K-L
Outpatient Rates M-N Outpatient Rates O-R Outpatient Rates S Outpatient Rates T-U Outpatient Rates V-Z
Clinical Diagnostic Laboratory Rates – effective 9/1/2022

Immunization Rate Schedule

Fiscal Year (2022-2023) Fiscal Year (2021-2022) Fiscal Year (2020-2021) Fiscal Year (2019-2020) Fiscal Year (2018-2019) Fiscal Year (2017-2018)
Immunization Rates (07/22) Immunization Rates (07/21) Immunization Rates (07/20) Immunization Rates (01/20) Immunization Rates (06/18) Immunization Rates (04/18)
 

Nursing Facility PETI Fee Schedules

PETI Audiology Fee Schedule-(See Health First Colorado Fee Schedules section above)

  • Effective January 1, 2016 - Audiology Fee Schedule has been replaced by the most current Health First Colorado Fee Schedules

PETI Dental Fee Schedule

  • Effective January 1, 2016 - Dental Fee Schedule has been replaced by the most current Health First Colorado Fee Schedules

PETI Vision Fee Schedule

 

Outpatient Substance Abuse Fee Schedule

2022 2021 2020 2019 2018 2017
July 2022 Outpatient Substance Abuse Fee Schedule July 2021 Outpatient Substance Abuse Fee Schedule July 2020 Outpatient Substance Abuse Fee Schedule July 2019 Outpatient Substance Abuse Fee Schedule July 2018 Outpatient Substance Abuse Fee Schedule July 2017 Outpatient Substance Abuse Fee Schedule

Pharmacy Rate List 

The below rates are used in the outpatient pharmacy reimbursement methodology. Please note that these are published rates only and do not reflect the coverage status for any prescription drugs. For outpatient pharmacy coverage information go to the Pharmacy Resources webpage.

Average Acquisition Cost (AAC)

AAC rates are used to reimburse pharmacies for covered outpatient drugs, including clotting factor drugs effective April 1, 2022, and Myers and Stauffer is the contractor responsible for maintaining the AAC rates.

  • The AAC rate list is monitored and maintained weekly to account for changing market prices.
  • A rate list is effective until another list is posted by Myers and Stauffer the following week.

If a pharmacy believes that an AAC rate does not accurately reflect the ingredient cost of a drug, the pharmacy may request a rate review by submitting a completed AAC inquiry form to Myers and Stauffer.

Pharmacy providers may contact Myers and Stauffer's toll-free help desk line at 800-591-1183 for questions concerning the AAC rates or inquiries.

Current AAC rates are posted on Myers and Stauffer's website.

National Average Drug Acquisition Cost (NADAC)

NADAC rates are used to reimburse pharmacies for covered outpatient drugs, excluding clotting factor drugs, and Myers and Stauffer is the contractor responsible for maintaining the NADAC rates.

  • The NADAC rate list is updated weekly to account for changing market prices as well as additions and deletions of NDCs.
  • A rate list is effective until another list is posted by CMS the following week.
  • Please contact the NADAC Help Desk for support with the NADAC survey, or to provide notification of recent drug price changes that are not reflected in posted NADAC files. Please reference the NADAC Methodology for further information on the calculation of the NADAC.
    • Telephone: (855) 457-5264
      Email: info@mslcrps.com
      Facsimile: (844) 860-0236
    • Help Desk Form (PDF, 740.26 KB)
      Please note that the NADAC Help Desk will not address pharmacy inquiries into specific state claim reimbursement related questions or concerns.

Current NADAC rates are posted on CMS's website at www.medicaid.gov.

Maximum Allowable Cost (MAC)

MAC rates are used to reimburse pharmacies for covered outpatient drugs, excluding clotting factor drugs, when a drug possesses neither Average Acquisition Cost nor National Average Drug Acquisition Cost rates. The rate is calculated using an adjustment of the national pricing benchmark Wholesale Acquisition Cost (WAC) as follows:

  • The generic drug MAC rate shall be WAC minus 10 percent.
  • The brand name drug MAC rate shall be WAC minus 3 percent.

Please note that unlike AAC and NADAC rates, providers cannot appeal MAC rates or submit rate inquiries. If providers have general questions regarding pharmacy rates direct them to hcpf_Colorado.SMAC@state.co.us.

Clotting Factor Maximum Allowable Cost (CFMAC)

Effective April 1, 2022, CFMAC rates will be used to reimburse pharmacies for clotting factor drugs when a clotting factor drug does not possess an Average Acquisition Cost rate. This rate is determined based on available acquisition cost data and publicly available data unique to each clotting factor drug.

Please note that unlike AAC and NADAC rates, providers cannot appeal CFMAC rates or submit rate inquiries. If providers have general questions regarding pharmacy rates direct them to hcpf_Colorado.SMAC@state.co.us.

Below are the drugs subject to the clotting factor reimbursement methodology:

Advate

Adynovate

Afstyla

Alphanate

Alphanine SD

Alprolix

Benefex

Coagedex

Corifact Kit

Eloctate

Esperoct

Feiba NF

Hemlibra

Hemofil M

Humate-P

Idelvion

Ixinity

Jivi

Kcentra

Koate

Koate-DVI

Kogenate FS

Kovaltry

Novoeight

Novoseven

Nuwiq

Obizur

Profiline

Rebinyn

Recombinate

Rixibus

Sevenfact

Tretten

Vovendi

Wilate

Xyntha

Xyntha Solofuse

     

 

Physician Administered Drug Fee Schedule

2022

2021

2020

2019

2018

2017

Q1/Q2/Q3 2022 PAD Fee Schedule Q1/Q2/Q3/Q4 2021 PAD Fee Schedule Q1/Q2/Q3/Q4 2020 PAD Fee Schedule Q1/Q2/Q3/Q4 2019 PAD Fee Schedule Q4 2018 PAD Fee Schedule Q3/Q4 2017 PAD Fee Schedule
 

Prenatal Plus and Special Connections Fee Schedule

2022 2021 2020 2019 2018 2017
July 2022 Prenatal Plus and Special Connections Fee Schedule July 2021 Prenatal Plus and Special Connections Fee Schedule July 2020 Prenatal Plus and Special Connections Fee Schedule July 2019 Prenatal Plus and Special Connections Fee Schedule July 2018 Prenatal Plus and Special Connections Fee Schedule July 2017 Prenatal Plus and Special Connections Fee Schedule

Primary Care Alternative Payment Model Fee Schedule

Fiscal Year (2021-2022) Fiscal Year 2020-2021 Fiscal Year 2019-2020 Fiscal Year 2018-2019
Alternative Payment Model Fee Schedule (7/21) Alternative Payment Model Fee Schedule (7/20) Alternative Payment Model Fee Schedule (9/19) Alternative Payment Model Fee Schedule (6/18)

Psychiatric Residential Child Care Facility Rate Schedule

Fiscal Year 2022-2023 Fiscal Year 2021-2022 Fiscal Year (2020-2021) Fiscal Year (2019-2020) Fiscal Year (2018-2019) Fiscal Year (2017-2018)
Psychiatric Residential Child Care Facility Rates (07/22) Psychiatric Residential Child Care Facility Rates (07/21) Psychiatric Residential Child Care Facility Rates (07/20) Psychiatric Residential Child Care Facility Rates (06/19) Psychiatric Residential Child Care Facility Rates (06/18) Psychiatric Residential Child Care Facility Rates (04/18)

Qualified Residential Treatment Program (QRTP)

October 2021 QRTP Rate Schedule

Skilled Nursing Facility

State General Fund Programs Direct Service Rates Fee Schedule (formerly CCB)

8/1/2022 7/1/2022 4/1/2022 7/1/2021 Enhanced COVID-19 Rates Effective
03/01/2021
7/1/2020
SGF Direct Service (8/22) SGF Direct Service (7/22) SGF Direct Service (4/22) SGF Direct Service (7/21) SGF Direct Service (3/21) SGF Direct Service (7/20)

Targeted Case Management

FY 2022-2023 FY 2021-2022 FY 2020-2021 FY 2019-2020
Targeted Case Management (07/22) Targeted Case Management (07/21)
Targeted Case Management 04/1/22
Targeted Case Management (07/20) Targeted Case Management (06/19)

Transportation Rate Schedule

Fiscal Year (2022-2023) Fiscal Year (2021-2022) Fiscal Year
(2020-2021)
Fiscal Year
(2019-2020)
Fiscal Year
(2018-2019)
Fiscal Year
(2017-2018)

EMT Rates (07/22)

NEMT Rates (07/22)

EMT Rates (07/21)

NEMT Rates (07/21)

EMT Rates (07/20)

NEMT Rates (07/20)

EMT Rates (06/19)

NEMT Rates (06/19)

EMT Rates (06/18)

NEMT Rates (06/18)

EMT Rates (04/18)

NEMT Rates (04/18)

NEMT Mass Transit Rates (04/18)