(1) The state board shall adopt rules to implement a statewide managed care
system for Colorado medical assistance members pursuant to the provisions of this
article 5 and articles 4 and 6 of this title 25.5. The statewide managed care system
shall be implemented to the extent possible.
(2) The statewide managed care system implemented pursuant to this article
5 does not include:
(a) The services delivered pursuant to the residential child health-care
program described in section 25.5-6-903;
(b) Long-term care services and the program of all-inclusive care for the
elderly, as described in section 25.5-5-412. For purposes of this subsection (2),
long-term care services means nursing facilities and home- and community-based
services provided to eligible members who have been determined to be in need of
such services pursuant to the Colorado Medical Assistance Act and the state
board's rules.
(c) (I) The services delivered in a qualified residential treatment program, as
defined in section 26-5.4-102, or in a psychiatric residential treatment facility, as
defined in section 25.5-4-103, to members who are in the care and custody of a
county department of human or social services.
(II) This subsection (2)(c) is repealed, effective July 1, 2026.
(3) The statewide managed care system must include a statewide system of
community behavioral health care that must:
(a) Address the economic, social, and personal costs to the state of Colorado
and its citizens of untreated behavioral health disorders, including mental health
and substance use disorders;
(b) Approach behavioral health disorders as treatable conditions not unlike
other chronic health issues that require a combination of behavioral change and
medication or other treatment;
(c) Offer timely access through multiple points of entry to a full continuum
of culturally responsive behavioral health services, including prevention, early
intervention, crisis response, treatment, and recovery services, that support
individuals living full, productive lives;
(c.5) Provide coordination of care for the full continuum of substance use
disorder and mental health treatment and recovery, including support for
individuals transitioning between levels of care;
(d) Feature a comprehensive and integrated system of quality behavioral
health care that is individualized and coordinated to meet individuals' changing
needs;
(e) Be paid for by the state department establishing capitated rates
specifically for behavioral health services that account for a comprehensive
continuum of needed services such as those provided by licensed behavioral health
providers, including essential and comprehensive community behavioral health
providers, as defined in section 27-50-101;
(f) Make the behavioral health system's administrative processes, service
delivery, and funding more effective and efficient to improve outcomes for
Colorado citizens;
(g) In addition to network adequacy requirements determined by the state
department, require each MCE to offer an enrollee an initial or subsequent
nonurgent care visit within a reasonable period where medically necessary and at
appropriate therapeutic intervals, as determined by state board rule;
(h) Specify that the diagnosis of an intellectual or developmental disability, a
neurological or neurocognitive disorder, or a traumatic brain injury does not
preclude an individual from receiving a covered behavioral health service; and
(i) Require an MCE to cover all medically necessary covered treatments for
covered behavioral health diagnoses, regardless of any co-occurring conditions.
(3.5) (a) No later than July 1, 2023, the state department, in collaboration
with the behavioral health administration in the department of human services and
other state agencies, shall develop the universal contract as described in section
27-50-203.
(b) Repealed.
(4) The statewide managed care system must promote the utilization of the
medical home model of care for all enrolled members. The medical home model of
care establishes a focal point of care for comprehensive primary care and efficient
coordination with specialty care providers and other health-care systems. The
medical home model has proven effective in promoting early intervention and
prevention, improving individuals' health, and reducing health-care costs.
(5) The statewide managed care system builds upon the lessons learned
from previous managed care and community behavioral health-care programs in
the state in order to reduce barriers that may negatively impact medicaid member
experience, medicaid member health, and efficient use of state resources. The
statewide managed care system is authorized to provide services under a single
MCE type or a combination of MCE types.
(6) (a) The state department is authorized to assign a medicaid member to a
particular MCE, consistent with federal requirements and rules promulgated by the
state board.
(b) For a child or youth who obtains eligibility for services under the state's
medicaid program through a dependency and neglect action resulting in out-of-home placement pursuant to article 3 of title 19 or a juvenile delinquency action
resulting in out-of-home placement pursuant to article 2.5 of title 19, the state
department shall assign the child or youth to the MCE covering the county with
jurisdiction over the action. The state department shall only change the assignment
if the change is requested by the county with jurisdiction over the action or by the
child's or youth's legal guardian.
(7) The state department is authorized to enter into a contract with MCOs,
PCCM Entities, prepaid ambulatory health plans, and prepaid inpatient health plans,
subject to the receipt of any required federal authorizations and pursuant to the
requirements of this section.
(7.3) (a) Beginning January 1, 2026, for a claim that must be reprocessed as a
result of updating the provider rates, an MCO shall issue payment to the contracted
provider within one year after the provider rate is updated.
(b) The state department shall notify the MCOs of any change to the provider
rates within sixty days of changing the provider rates.
(7.5) (a) The state department shall offer to enter into a direct contract for
physical health-care services with the MCO operated by or under the control of
Denver health and hospital authority, created pursuant to article 29 of title 25, from
July 1, 2025, until June 30, 2032, as long as the MCO meets all MCO criteria
required by the state department. If the state department designates an MCE other
than the MCO operated by or under the control of Denver health and hospital
authority to manage behavioral health-care services pursuant to this article 5,
Denver health and hospital authority, or any subsidiary, shall collaborate with the
MCE during the term of contract.
(b) The MCO operated by or under the control of Denver health and hospital
authority shall:
(I) Maintain adequate financials to ensure proper solvency as a risk manager;
(II) Accept rates determined by the state department, through standard
methodologies, to cover the population it is serving. Rates paid by the MCO to
contracted providers must not be higher than the state department's medicaid fee-for-service rates unless the provider enters into a quality incentive agreement with
the MCO.
(III) Maintain service and quality metrics, as determined by the state
department; and
(IV) Meet statewide managed care system standards and operate as part of
the overall managed care system.
(8) Waivers. The implementation of this part 4 is conditioned, to the extent
applicable, on the issuance of necessary waivers by the federal government. The
provisions of this part 4 must be implemented to the extent authorized by federal
waiver, if so required by federal law.
(9) Bidding. (a) The state department is authorized to institute a program for
competitive bidding pursuant to section 24-103-202 or 24-103-203 for MCEs
seeking to provide, arrange for, or otherwise be responsible for the provision of
services to its members. The state department is authorized to award contracts to
more than one offeror. The state department shall use competitive bidding
procedures to encourage competition and improve the quality of care available to
medicaid members over the long term that meets the requirements of this section
and section 25.5-5-406.1.
(b) (I) On or before January 1, 2023, in order to promote transparency and
accountability, the state department shall require each MCE that has twenty-five
percent or more ownership by providers of behavioral health services to comply
with the following conflict of interest policies:
(A) Providers who have ownership or board membership in an MCE shall not
have control, influence, or decision-making authority in the establishment of
provider networks.
(B) Each MCE shall report quarterly the number of providers who applied to
join the network and were denied and a comparison of rate ranges for providers
who have ownership or board membership versus providers who do not.
(C) An employee of a contracted provider of an MCE shall not also be an
employee of the MCE unless the employee is a clinical officer or utilization
management director of the MCE. If the individual is also an employee of a provider
that has board membership or ownership in the MCE, the MCE shall develop
policies, approved by the executive director of the state department, to mitigate
any conflict of interest the employee may have.
(D) An MCE's board shall not have more than fifty percent of contracted
providers as board members, and the MCE is encouraged to have a community
member on the MCE's board.
(II) No later than July 1, 2025, the state department shall appropriately
address perceived or actual provider ownership and control of MCEs participating
in the statewide managed care system in the interest of transparency and
accountability. In designing a competitive bidding process, the state department
shall incorporate community feedback and have a public process related to
governing requirements, including how to address conflicts of interest.
(III) As used in this subsection (9)(b):
(A) Clinical officer means a physician who provides the clinical vision for
the MCE or provides clinical direction to network management, quality
improvement, utilization management, or credentialing divisions.
(B) MCE means a managed care entity responsible for the statewide
system of community behavioral health care, as described in section 25.5-5-402
(3), and is not owned, operated by, or affiliated with an instrumentality, municipality,
or political subdivision of the state.
(C) Ownership means an individual who is a legal proprietor of an
organization, including a provider or individual who owns assets of an organization,
or has a financial stake, interest, or governance role in the MCE.
(D) Utilization management director means a licensed health-care
professional with behavioral health clinical experience who leads and develops the
utilization management program or manages the medical review and authorization
process.
(10) An MCE that is contracting for a defined scope of services under a risk
contract shall certify the financial stability of the MCE pursuant to criteria
established by the division of insurance.
(11) The state department shall conduct a review of each MCE, in accordance
with federal requirements, prior to the implementation of a contract to assess the
ability and capacity of the MCE to satisfactorily perform the operational
requirements of the contract.
(12) Graduate medical education. The state department shall continue the
graduate medical education, referred to in this subsection (12) as GME, funding to
teaching hospitals that have graduate medical education expenses in their
medicare cost report and are participating as providers under one or more MCEs
with a contract with the state department under this part 4. GME funding for
members enrolled in an MCE is excluded from the premiums paid to the MCE and
must be paid directly to the teaching hospital. The state board shall adopt rules to
implement this subsection (12) and establish the rate and method of
reimbursement.
(13) Nothing in this part 4 creates an exemption from the applicable
provisions of title 10.
(14) Nothing in this part 4 creates an entitlement to an MCE to contract with
the state department.
(15) On or before July 1, 2020, the state department shall include utilization
management guidelines for the MCEs in the state board's managed care rules.
(16) The state department shall provide information on its website specifying
how the public may request the network adequacy plan and quarterly network
reports for an MCE. The plan must include actions taken by the MCE to ensure that
all necessary and covered primary care, care coordination, and behavioral health
services are provided to enrollees with reasonable promptness. Such actions
include, without limitation:
(a) Utilizing single case agreements with out-of-network providers when
necessary; and
(b) Using financial incentives to increase network participation.
(17) If the state department receives a complaint from the office of the
ombudsman for behavioral health access to care established pursuant to part 3 of
article 80 of title 27 that relates to possible violations of subsection (3) of this
section or the MHPAEA, the state department shall examine the complaint, as
requested by the office, and shall report to the office in a timely manner any actions
taken related to the complaint.