Colorado Medicaid Managed Care Program

As of August 2019, Colorado has approximately 1,274,139 individuals enrolled in Medicaid and CHIP. Colorado expanded coverage to low income adults under ACA effective January 2014, which increased its Medicaid population by more than 400,000 lives. The Medicaid population in Colorado is approximately 10% managed care and 90% Fee-For-Service (FFS).

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Overview

Colorado currently operates two (2) limited managed care capitation initiatives with passive/voluntary enrollment, operated by the following managed care organizations (MCOs):

Denver Health Medicaid Choice – 85,697 members as of October 2019.

This plan is limited to members residing in Denver county and covers the same services as traditional Medicaid.

Rocky Mountain Health Plan – 36,013 members as of October 2019.

This is a limited benefit prepaid health plan for members residing in Garfield, Gunnison, Mesa, Montrose, Pitkin and Rio Blanco counties. RMHP covers most medical services like doctors, hospitals, and preventive care. Excluded services include hospice, non-emergent medical transportation (NEMT), private duty nursing, skills nursing facility services, orthodontia, hearing aids, and certain home health and case management services.

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In 2011, the state introduced its latest managed care arrangement, the Accountable Care Collaborative (ACC) program, which is a PCCM program that utilizes a network of regional organizations, formerly referred to as Regional Care Collaborative Organizations (RCCOs) to coordinate acute, primary, and specialty care, pharmacy, select behavioral health services to most Medicaid beneficiaries in the state.

In a traditional PCCM program, each enrollee is assigned to a designated primary care medical provider (PCMP) who is paid a monthly case management fee to assume responsibility for care management and coordination. Individual providers are not at financial risk and continue to be paid on an FFS basis for covered services

On July 1, 2018, new Regional Accountable Entities (RAEs) began serving as the single entity responsible for coordinating both physical and behavioral health (defined as mental health and substance use disorder) for Health First Colorado (Colorado’s Medicaid Program) members and administering the capitated behavioral health benefit. These are the duties previously contracted by Regional Care Collaborative Organizations (RCCOs) and Behavioral Health Organizations (BHOs).

All full-benefit Health First Colorado members (excluding members enrolled in Program for All-Inclusive Care for the Elderly [PACE]) are mandatorily enrolled in a RAE. There are five (5) RAE organizations serving seven (7) regions covering all of Colorado:

Rocky Mountain Health Plans (region 1); 177,533 members*.

Colorado Access (regions 3 & 5); 470,886 members combined across regions.*

Health Colorado, Inc. (region 4); 122,494 members*

Colorado Community Health Alliance (region 6 & 7); 313,828 members combined across regions.*

United Healthcare Community Plan of Ohio, Inc. 24,892*

Members are assigned to a PCMP in one of the following ways:

Demonstrated claims history with a PCMP over the past 18 months
Family member’s claims history with a PCMP if the member has no utilization history
Closest appropriate PCMP within the member’s region if member has no utilization history
Member chooses PCMP by calling Health First Colorado Enrollment

Physical health services in Colorado are reimbursed on a fee-for-service basis. However, in an effort to maintain the full continuum of community-based, alternative services that are only available under capitation and a waiver with the federal Centers for Medicare & Medicaid Services (CMS), a capitation payment methodology will be retained for core behavioral health services that will be paid directly to the RAEs.

*RAE enrollment figures above are as of October 2019.

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Data Considerations

HMS receives both FFS paid claims data and MCO encounter data on behalf of Colorado Medicaid. The data set for FFS claims and encounter data for Colorado is complete. That being, it is important to note that the Colorado Department of Health Care Policy and Financing, implemented a new Medicaid Management Information Systems (MMIS) on March 1, 2017. As a result, there are a couple of data considerations to keep in mind:

Colorado supplied HMS with a 3-year refresh file of converted data as part of its MMIS conversion. As a result, the data set summary information for Colorado contains duplicated claims from the state’s former MMIS.
HMS does not currently receive rendering/treating dentist information for dental claims processed after the state’s MMIS conversion go-live date of 3/1/2017