§ 25.5-5-403 — Definitions

Colorado § 25.5-5-403

• Jurisdiction: Colorado
• Title 25.5: Health
• Art.: Colorado Medical Assistance Act -

Text

As used in this part 4, unless the context otherwise
requires:

(1) Repealed.

(2) Essential community provider, referred to in this part 4 as an ECP,
means a health-care provider that:

(a) Has historically served medically needy or medically indigent patients
and that demonstrates a commitment to serve low-income and medically indigent
populations who comprise a significant portion of its patient population or, in the
case of a sole community provider, serves the medically indigent patients within its
medical capability; and

(b) Waives charges or charges for services on a sliding scale based on
income and does not restrict access or services because of a member's financial
limitations.

(2.5) Global payment means a population-based payment mechanism that
is constructed on a per-member, per-month calculation. Global payments must
account for prospective local community or health system cost trends and value, as
measured by quality and satisfaction metrics, and incorporate community cost
experience and reported encounter data to the greatest extent possible to address
regional variation and improve longitudinal performance. Risk adjustments, risk-sharing, and aligned payment incentives may be utilized to achieve performance
improvement. The rate calculations for global payment are exempt from the
provisions of section 25.5-5-408. An entity that uses global payment pursuant to
section 25.5-5-402 shall meet the applicable financial solvency requirements of
sections 25.5-5-402 (10) and 25.5-5-408 (1)(f) and the essential community provider
requirements of sections 25.5-5-406.1 (1)(f)(II) and 25.5-5-408 (1)(d).

(3) (a) Managed care means a health-care delivery system organized to
manage costs, utilization, and quality. Medicaid managed care provides for the
delivery of medicaid health benefits and additional services through contracted
arrangements between state medicaid agencies and MCEs.

(b) Nothing in this section affects the benefits authorized for members of the
state medical assistance program.

(4) Managed care entity, referred to in this part 4 as an MCE, means an
entity that enters into a contract to provide services in the statewide managed care
system, including MCOs, prepaid inpatient health plans, prepaid ambulatory health
plans, and PCCM Entities.

(5) Managed care organization, referred to in this part 4 as an MCO,
means an entity contracting with the state department that meets the definition of
managed care organization as defined in 42 CFR 438.2.

(5.5) Medical home means an appropriately qualified medical health-care
practice that verifiably ensures continuous access to comprehensive, accessible,
and coordinated community-based primary care. All medical homes may have, but
are not limited to, the following:

(a) Health maintenance and preventive care;

(b) Anticipatory guidance and health education;

(c) Acute and chronic illness care;

(d) Coordination of medications, specialists, and therapies;

(e) Provider participation in hospital care; and

(f) Mental health care, oral health care, and other related services, as
appropriate.

(5.7) MHPAEA means the federal Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008, Pub.L. 110-343, as
amended, and all of its implementing and related regulations.

(6) Prepaid ambulatory health plan, referred to in this part 4 as a PAHP,
means an entity contracting with the state department that meets the definition of
prepaid ambulatory health plan as defined in 42 CFR 438.2.

(7) Prepaid inpatient health plan, referred to in this part 4 as PIHP, means
an entity contracting with the state department that meets the definition of prepaid
inpatient health plan as defined in 42 CFR 438.2.

(7.5) Primary care case management entity, referred to in this part 4 as a
PCCM Entity, means an entity contracting with the state department that meets
the definition of primary care case management entity as defined in 42 CFR 438.2.

(8) Primary care case manager, referred to in this part 4 as a PCCM,
means a physician, a physician group practice, or other practitioner as identified by
the state that meets the definition of primary care case manager as defined in 42
CFR 438.2.

Legislative History

Source: L. 2006: Entire article added with relocations, p. 1884, � 7, effective July 1. L. 2007: (1)(a) amended, p. 1354, � 3, effective May 29. L. 2008: Entire section amended, p. 390, � 2, effective August 5. L. 2012: (2.5) added, (HB 12-1281), ch. 246, p. 1187, � 4, effective June 4. L. 2018: (1) repealed, (2.5), (3)(a), (4), and (8) amended, and (5.5) and (7.5) added (HB 18-1431), ch. 313, p. 1881, � 2, effective August 8. L. 2019: (5.7) added, (HB 19-1269), ch. 195, p. 2134, � 13, effective May 16. L. 2024: (2)(b) and (3) amended, (SB 24-176), ch. 152, p. 653, � 57, effective August 7.