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.
 

Ambulatory Surgery Centers (ASC) Rate Schedule

List of All ASC Codes and Respective Groupers

Behavioral Health Fee-for-Service (FFS) Rates

• Behavioral Health Fee-for-Service Rates FY 24/25
• Behavioral Health Fee-for-Service Rates FY 25/26

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

Request CHP+ Fee Schedule Corrections

CHP+ Behavioral Health Fee Schedules

• Child Health Plan Plus Behavioral Health Rate Schedule 2024-2025
• Child Health Plan Plus Behavioral Health Rate Schedule 2025-2026

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:

Community First Choice Fee Schedule

Dental Fee Schedule

• DentaQuest

Dialysis Rate Schedule

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.

Home Health and Private Duty Nursing (PDN) Rate Schedule

Hospice Fee Schedule

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 September 1, 2022. New rates will be posted annually by July 1 and updated with new codes January 1.  Rates for Hospital Discounted Care can be viewed on the Hospital Discounted Care Rates web page.

Immunization Rate Schedule

Integrated Care

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

• Effective January 1, 2025 - Vision Fee Schedule has been replaced by the most current Health First Colorado Fee Schedule.

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.

• The AAC inquiry form may also be emailed to copharmacy@mslc.com or faxed to 317-571-8481.
• AAC Inquiry Form

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 20 percent.
• The brand name drug MAC rate shall be WAC minus 3.5 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:

Physician-Administered Drug Fee Schedule

Prenatal Plus and Special Connections Fee Schedule

Psychiatric Residential Child Care Facility Rate Schedule

Qualified Residential Treatment Program (QRTP)

Skilled Nursing Facility

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

Targeted Case Management

Transportation Rate Schedule