(1) General features. All medicaid managed care programs must contain the following
general features, in addition to others that the federal government, state
department, and state board consider necessary for the effective and cost-efficient
operation of those programs:
(a) The MCE shall accept all enrollees that the state department assigns to
the MCE in the order in which they are assigned, without restriction, regardless of
health status or need for health-care services;
(b) The MCE shall not discriminate against enrolled members on the basis of
race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation,
gender identity, gender expression, disability, religion, creed, or political beliefs,
and shall not use any policy or practice that has the effect of discriminating on the
basis of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual
orientation, gender identity, gender expression, disability, religion, creed, or
political beliefs;
(c) The MCE shall allow each enrolled member to choose his or her network
provider to the extent possible and appropriate;
(d) Notwithstanding any waivers authorized by the federal department of
health and human services, or any successor agency, each contract between the
state department and an MCE selected to participate in the statewide managed
care system under this part 4 shall comply with the requirements of 42 U.S.C. sec.
1396a (a)(23)(B);
(e) The MCE shall ensure access to care for all enrolled members in need of
medically necessary services covered in the contract;
(f) The MCE shall create, administer, and maintain a network of providers,
building on the current network of medicaid providers, to serve the health-care
needs of its members. In doing so, the MCE shall:
(I) Support providers in serving the medicaid population and implement
value-based payment methodologies for network providers that incentivize and
reward providers for the effective and efficient delivery of high-quality services to
enrolled members;
(II) (A) Seek proposals from each ECP in a county in which the MCE is
enrolling members for those services that the MCE provides or intends to provide
and that an ECP provides or is capable of providing. The MCE shall consider such
proposals in good faith and shall, when deemed reasonable by the MCE based on
the needs of its members, contract with ECPs. Each ECP shall be willing to
negotiate on reasonably equitable terms with each MCE. ECPs making proposals
under this subsection (1)(f)(II) must be able to meet the contractual requirements of
the MCE. The requirements of this subsection (1)(f)(II) do not apply to an MCE in
areas in which the MCE operates entirely as a group health maintenance
organization.
(B) In selecting MCEs, the state department shall not penalize an MCE for
paying cost-based reimbursement to federally qualified health centers as defined
in the federal Social Security Act.
(III) Demonstrate that there are sufficient Indian health-care providers
participating in the provider network to ensure timely access to services available
under the contract from such providers for Indian enrollees who are eligible to
receive services.
(IV) Enter into single case agreements with willing providers of behavioral
health services enrolled in the medical assistance program when network
development and access standards established by the state department are not
met and a member needs access to a medically necessary behavioral health service
covered under the scope of the MCE's contract with the state department. The
MCE:
(A) Shall consider any behavioral health provider enrolled in the medical
assistance program for a single case agreement if the MCE cannot provide a
covered service through its contracted provider network;
(B) Shall ensure all care coordination staff and staff who provide member
and provider support are trained in the single case agreement process;
(C) Can refuse to offer single case agreements based on factors of provider
cost and quality concerns;
(D) Shall offer both member and out-of-network providers assistance in
navigating its single case agreement process;
(E) Shall ensure the single case agreement process is executed within the
standards and timeliness requirements established by the state department;
(F) Shall not require providers that enter into a single case agreement to
serve additional members; and
(G) Shall complete single case agreements on a timeline that is informed by
stakeholder input.
(g) The MCE shall ensure that its contracted network providers are capable
of serving all members, including contracting with providers with specialized
training and expertise across all ages, levels of ability, gender identities, and
cultural identities;
(h) The MCE shall meet the network adequacy standards, as established by
the state department, describing the maximum time and distance an enrolled
member is expected to travel in order to access the provider types covered under
the state contract;
(i) The MCE shall meet, and require its network providers to meet, standards
as established by the state department for timely access to care and services,
taking into account the urgency of the need for services;
(j) (I) The MCE shall not interfere with appropriate medical care decisions
rendered by its contracted network providers;
(II) A prepaid inpatient health plan shall not require prior authorization for
outpatient psychotherapy services, as defined in the most recent version of the
Current Procedural Terminology, as developed and copyrighted by the American
Medical Association or its successor entity;
(k) The MCE shall comply with the state department's transition of care
policy to ensure continued access to services during a transition from fee-for-service to an MCE or transition from one MCE to another when an enrollee, in the
absence of continued access to services, would suffer serious detriment to his or
her health or be at risk of hospitalization or institutionalization;
(l) The MCE shall provide and facilitate the delivery of services in a culturally
competent manner to all members, including those with limited English proficiency,
diverse cultural and ethnic backgrounds, and disabilities, and regardless of gender,
sexual orientation, gender identity, or gender expression;
(m) The MCE shall provide communications in a manner and format that may
be easily understood and is readily accessible by members;
(n) Grievances and appeals. (I) (A) Each MCE shall establish a grievance and
appeal system that complies with rules established by the state board and federal
government.
(B) An enrollee is entitled to designate a representative, including but not
limited to an attorney, the ombudsman for medicaid managed care, a lay advocate,
or the enrollee's physician, to file and pursue a grievance or appeal on behalf of the
enrollee. The procedure must allow for the unencumbered participation of
physicians.
(II) The MCE shall have an established grievance system that allows for
member expression of dissatisfaction at any time about any matter related to the
MCE's contracted services, other than an adverse benefit determination. The
grievance system must provide timely resolution of the matters in a manner
consistent with the medical needs of the individual member.
(III) (A) The MCE shall have an appeal system for review of any determination
by the MCE to deny a service authorization request or to authorize a service in an
amount, duration, or scope that is less than requested.
(B) Each MCE shall utilize an appeal process for expedited reviews that
complies with rules established by the state board. The appeal process for
expedited reviews must provide a means by which an enrollee may complain and
seek resolution concerning any action or failure to act in an emergency situation
that immediately impacts the enrollee's access to quality health-care services,
treatments, or providers.
(C) The state department shall establish the position of ombudsman for
medicaid managed care. The ombudsman shall, if the enrollee requests, act as the
enrollee's representative in resolving appeals with the MCE. It is the intent of the
general assembly that the ombudsman for medicaid managed care be independent
from the state department and selected through a competitive bidding process. In
the event the state department is unable to contract with an independent
ombudsman, an employee of the state department may serve as the ombudsman
for medicaid managed care. An enrollee whose appeal is not resolved to his or her
satisfaction by a procedure described in this subsection (1)(n), or whose appeal is
deemed exhausted, is entitled to request a state fair hearing by an independent
hearing officer, further judicial review, or both, as provided for by federal law and
any state statute or rule.
(o) The MCE shall maintain and participate in an ongoing comprehensive
quality assessment and performance improvement program that must include but
not be limited to the following:
(I) Performance improvement projects designed to achieve significant
improvement, sustained over time, in clinical care and nonclinical care areas that
are expected to have a favorable effect on health outcomes and member
satisfaction;
(II) The collection and submission of performance measurement data as
required by the state department;
(III) The implementation and maintenance of mechanisms to detect
overutilization and underutilization of services and to assess the quality and
appropriateness of care furnished to its members, including members with special
health-care needs; and
(IV) Annual participation in an independent quality review and validation of
performance improvement projects, performance measures, and other contract
requirements;
(p) (I) The MCE shall administer a program integrity system to ensure
compliance with all requirements established by the federal government, state of
Colorado, state department, and state board that includes, but is not limited to:
(A) Procedures to detect and prevent fraud, waste, and abuse;
(B) Screening and disclosure processes to prevent relationships with
individuals or entities that are debarred, suspended, or otherwise excluded from
participating in any federal health-care program, procurement activities, or
nonprocurement activities; and
(C) Treatment of recoveries of overpayment to providers;
(II) Prepaid inpatient health plans shall not retroactively recover provider
payments if:
(A) A member was initially determined to be eligible for medical benefits
pursuant to section 25.5-4-205 when the provider has an eligibility guarantee
number for the member; or
(B) The prepaid inpatient health plan makes an error processing the claim
but the claim is otherwise accurately submitted by the provider.
(III) (A) Prepaid inpatient health plans shall not retroactively recover provider
payments after twelve months from the date a claim was paid, except when
medicare, commercial insurance, or third-party liability is the primary payer for a
claim; the claim is the subject of a state or federal audit, including audits
contractually required by the state department; the claim is subject to a law
enforcement investigation; the claim submitted is a duplicate; the claim is
fraudulent; the provider improperly bills the claim; or the claim is submitted with a
billing code or diagnosis code that inaccurately or incorrectly resulted in
reimbursement or bypassed prior authorization requirements.
(B) If a prepaid inpatient health plan retroactively recovers a provider
payment that is equal to one thousand dollars or more, the prepaid inpatient health
plan shall work with the provider to develop a payment plan if the provider requests
a payment plan.
(q) Billing medicaid members. Notwithstanding any federal regulations or
the general prohibition of section 25.5-4-301 against providers billing medicaid
members, a provider may bill a medicaid member who is enrolled with a specific
medicaid PCCM or MCE and, in circumstances defined by the rules of the state
board, receives care from a medical provider outside that organization's network or
without referral by the member's PCCM;
(r) Marketing. In marketing coverage to medicaid members, all MCEs shall
comply with all applicable provisions of title 10 regarding health plan marketing.
The state board is authorized to promulgate rules concerning the permissible
marketing of medicaid managed care. The purposes of the rules must include but
not be limited to the avoidance of biased selection among the choices available to
medicaid members.
(s) Prescription drugs. All MCEs that have prescription drugs as a covered
benefit shall provide prescription drug coverage in accordance with the provisions
of section 25.5-5-202 (1)(a) as part of a comprehensive health benefit and with
respect to any formulary or other access restrictions:
(I) The MCE shall supply participating providers who may prescribe
prescription drugs for MCE enrollees with a current copy of such formulary or other
access restrictions, including information about coverage, payment, or any
requirement for prior authorization;
(II) The MCE shall provide to all medicaid members at periodic intervals, and
prior to and during enrollment upon request, clear and concise information about
the prescription drug program in language understandable to the medicaid
members, including information about such formulary or other access restrictions
and procedures for gaining access to prescription drugs, including off-formulary
products; and
(III) The MCE shall follow state department policies for prescribing any
prescription drugs that are not covered under the MCE contract;
(t) Each MCE must include the following statements prominently in the
enrollee handbook, on the state department's website, and on the MCE's
enrollment website:
(I) A statement indicating that the MCE is subject to the MHPAEA and that a
denial, restriction, or withholding of benefits for behavioral health services that are
covered under the medical assistance program could be a potential violation of that
act; and
(II) A statement directing the enrollee to contact the office of the
ombudsman for behavioral health access to care established pursuant to part 3 of
article 80 of title 27 if the enrollee wants further assistance pursuing action
regarding potential parity violations, which statement must include the telephone
number for the office and a link to the office's website.